A simple index to predict healing in venous leg ulcers: a secondary analysis from four randomised controlled trials.

OBJECTIVE: To investigate whether the use of a simple baseline measurement predicts venous leg ulcer healing at 12 and 24 weeks. METHOD: This was a secondary analysis of a cohort of four randomised controlled trials (RCTs) of treatments adjuvant to compression. Self-reported ulcer duration, and measured ulcer length and width, to calculate estimated ulcer area, were used to obtain a Margolis index score. The score created three prognostic strata for likelihood to heal within 24 weeks, and the number of participants healed and time-to-healing were compared. RESULTS: There were a total of 802 participants across the four RCTs-408 (50.9%) in two 12-week trials and 394 (49.1%) in two 24-week trials. The mean age of participants was 63.7±17.6 years, and 372 were female (46.4%). The Margolis index score at baseline was 0 for 320 participants (predicted normal healing); 1 for 334 participants; and 2 for 148 participants (both 1 and 2 predicted slow-to-heal). Overall, 248 (77.5%) of those participants who scored 0 at baseline healed within 24 weeks, compared with 182 (54.5%) of participants who scored 1, and 30 (20.3%) participants who scored 2. The median time-to-healing was 40 (24-62) days, 57 (35-100) days and 86.5 (56-151) days, respectively. The area under the receiver operating characteristic curve was 0.69 and 0.77, respectively, for the 12 and 24 week trials. CONCLUSION: A simple baseline index identifies participants with normal or slow-to-heal wounds and could be used to demonstrate prognostic balance between treatment groups in trials. This approach could also be used in clinical practice to assist with managing expectations and for early identification of patients who may best benefit from adjuvant treatments.

Statins and venous leg ulcer healing: Secondary analysis of data from a cohort of three randomised controlled trials.

Adjuvants to compression are sought for treating venous ulceration. There is animal, observational and trial evidence that suggests statins increase venous ulcer healing. The objective of this study was to conduct secondary analyses investigating the association of statin use with healing in three randomised trials that recruited people with venous ulceration. The difference in healing rates was modest but higher in the statins group. Crude analyses found no significant difference between the groups, but when adjusted for the trial effect and potential confounders (age, diabetes, first ever ulcer, ulcer area and ulcer duration), significantly more participants healed among those taking statins. The analyses were robust to method of analysis (fixed effects or random effects models). A definitive trial is required to evaluate the effect of statins versus placebo on venous ulcer healing, but until then patients needing to take statins seem unlikely to be disadvantaged by this treatment.

Patient's experiences of endotracheal tubes and suction following cardiac surgery.

BACKGROUND: There is a growing body of evidence addressing the patient experience of intensive care, including patient reports that the presence of an endotracheal tube is bothersome and distressing, and that endotracheal suction is moderately to extremely painful. Yet there remains little information about the patient experience of the endotracheal tube and suction in those patients receiving planned short-term mechanical ventilation. AIMS AND OBJECTIVES: This study aimed to describe the patient experience of the endotracheal tube and suction, following mechanical ventilation in post-operative cardiac surgical patients. DESIGN: This qualitative study used inductive thematic analysis. Participants having planned cardiac surgery, anticipated to receive less than 12-hours mechanical ventilation, were approached pre-operatively and written consent provided. METHODS: Ten participants were recruited using purposive sampling. Semi-structured interviews were conducted between days four and six post-operatively. One researcher interviewed all participants; two researchers independently read, coded, and agreed themes. FINDINGS: None of the participants recalled endotracheal suction, while half had no recollection of the endotracheal tube. Three themes were identified; the experience of the endotracheal tube and extubation, the experience of emerging from sedation, and participants concerns about the future. The presence of the endotracheal tube was described as bothersome, whilst breathing through the tube and extubation were described as 'weird' and 'strange' but not painful. CONCLUSIONS: Knowledge of the patient experience can help inform nursing practice by improving pre and post-operative care planning. RELEVANCE TO CLINICAL PRACTICE: This study adds to the body of knowledge about the patient experience of the endotracheal tube and extubation. TRIAL REGISTRATION: Prospective registration with the Australian New Zealand Clinical Trials Registry. www.anzctr.org.au (ACTRN12616001515482).

Effect of Cardiac Surgery on Health-Related Quality of Life in Patients Aged 75 Years or Older: A Prospective Study.

BACKGROUND: Health-related quality of life (HRQoL) of patients, aged 75 years or older, was measured before and at 12 weeks after cardiac surgery using a generic tool (SF12 version 2). METHODS: This was a single centre, prospective study of patients aged 75 years or older who had any type of cardiac surgery. The instrument was self-administered preoperatively and by interviewer administered via telephone at 12 weeks. RESULTS: Sixty-six (66) of the 81 participants approached were eligible and agreed to participate. Mean age was 79.2 years, 17 participants were female (25.8%), 56 participants were New Zealand European (84.8%) and the mean Euroscore II score was 4.0. Sixty (60) participants (90.9%) provided data at follow-up. All mean HRQoL domain scores significantly improved by 12 weeks after surgery. The pattern of gain was similar for ages 75-79 and 80 years and older. The changes in the physical and mental component summary (PCS, MCS) scores were statistically significant and the mean scores were proximate to or better than age group norms at 12 weeks. The number of patients with a PCS score at or above age group norms improved from 16.4% to 56.6% while the number of patients whose MCS scores were at or above age group norms improved from 55.7% to 81.6%. Health utility values also significantly improved. CONCLUSIONS: Cardiac surgery in older patients is associated with significantly improved physical and mental health-related quality of life at 12 weeks after procedure.

Adverse event reporting and trial registration in venous leg ulcer trials published since the 2001 CONSORT statement revision: A systematic review.

AIM: To be in accord with the Consolidated Standards of Reporting Trials (CONSORT) Statement, all important adverse events in randomised controlled trials (RCTs) should be reported, as well as trial registration. Neither concern has been investigated in venous leg ulcer trials. We therefore aimed to quantify and explore compliance with adverse event reporting and trials registration in RCTs that reported interventions for treating venous leg ulceration. MATERIALS AND METHODS: We searched the Cochrane Controlled Trials Register, Medline, Embase, and CINAHL for studies reported between 2001 and 2017. Included studies must have been described as randomised controlled trials evaluating any intervention in a VLU population. Data was then extracted by one author into a standard form and checked by a second author. RESULTS: We screened 3100 titles and identified 204 trials involving pharmaceuticals (82), medicated and non-medicated devices (102), organisational (5) or other interventions (15) published in 76 journals. Eighty-four trials reported adverse events (41.2%), while 18 reported no events occurred (8.8%) and 78 did not report adverse events (38.2%). Types of adverse events reported included all-cause (20.1%), ulcer-related only (38.2%), treatment-related only (11.3%) and serious adverse events only (1.0%). Only 38 trials were registered (18.6%). Trial registration was associated with reporting of any adverse events (Odds Ratio 3.0, 95%CI 1.1-7.9), as was the trial being a pharmaceutical trial (Odds Ratio 2.9, 95%CI 1.5-5.7) or a multicentre trial (Odds Ratio 4.2, 95%CI 2.2-8.1). CONCLUSION: Adverse event reporting in VLU trials is variable with about one third of trials not reporting on adverse events at all. Trials registration is a the modifiable factor associated with better reporting of adverse events. Journal editors could explore how they can promote trials registration to enhance better reporting of harms in VLU trials.

Rugby Fans in Training New Zealand (RUFIT-NZ): a pilot randomized controlled trial of a healthy lifestyle program for overweight men delivered through professional rugby clubs in New Zealand.

BACKGROUND: Healthy lifestyle programs that are designed specifically to appeal to and support men to improve lifestyle behaviors and lose weight are needed. The Rugby Fans in Training-New Zealand (RUFIT-NZ) program is delivered by professional rugby clubs and inspired by the successful Football Fans In Training program (FFIT), a gender sensitized weight loss program for obese middle-aged men delivered by professional football clubs in Scotland. RUFIT-NZ required development and evaluation for feasibility. METHODS: To develop the intervention we reviewed content from the FFIT program and evidence-based physical activity, dietary and weight management guidelines, and undertook a series of focus groups and key informant interviews. We then evaluated the feasibility of the intervention in a two-arm, parallel, pilot randomized controlled trial in New Zealand. Ninety-six participants were randomized to either the 12-week RUFIT-NZ intervention (N = 49) or a control group (N = 47). The intervention was delivered through professional rugby clubs and involved physical activity training and classroom sessions on healthy lifestyle behaviors. Pilot trial outcomes included body weight, heart rate, blood pressure, cardiorespiratory fitness, and lifestyle behaviors. Feasibility was assessed by recruitment and retention rates, and acceptability of the intervention. RESULTS: At 12 weeks the mean difference in body weight was 2.5 kg (95% CI -0.4 to 5.4), which favored the intervention. Statistically significant differences in favor of the intervention group were also observed for waist circumference, resting heart rate, diastolic blood pressure, cardiorespiratory fitness, and the proportion of participants that were adherent to 3 or more healthy lifestyle behaviors. The intervention was considered feasible to test in a full trial given the good recruitment and retention rates, and positive feedback from participants. CONCLUSIONS: A pilot study of a healthy lifestyle intervention delivered via professional rugby clubs in New Zealand demonstrated positive effects on weight and physiological outcomes, as well as adherence to lifestyle behaviors. Feasibility issues in terms of recruitment, retention, and participant acceptability were assessed and findings will be used to inform the design of a definitive trial. TRIAL REGISTRATION: The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry ACTRN12616000137493 , 05/12/2016.

Study protocol: A randomized controlled trial assessing the avoidance of endotracheal suction in cardiac surgical patients ventilated for ≤ 12 hr.

AIMS: To assess the safety and efficacy of avoiding endotracheal suction in postoperative cardiac surgical patients mechanically ventilated for ≤ 12 hr. DESIGN: A prospective, single centre, single blind, non-inferiority, randomized controlled trial evaluating the safety and efficacy of avoiding suction in uncomplicated, postoperative, adult cardiac surgical patients mechanically ventilated for ≤ 12 hr. METHODS: Randomization will be performed on return to intensive care (ICU) with allocation to either usual postoperative care including suction or to usual care with no suction (intervention arm). The primary outcome is the ratio of partial pressure of oxygen (PaO2 ) to fraction of inspired oxygen (FiO2 ) (P/F) 6 hr after extubation. Pain assessments will be performed before, during and after endotracheal suction (ETS) and the patient experience will be investigated with a brief interview the following day. Ethics approval was received in October 2015. DISCUSSION: Endotracheal suction is performed as part of airway management but has potential complications and there is little robust evidence to guide practice. This study will add to the evidence base about the need and benefit of endotracheal suction in this patient cohort. IMPACT: As there is currently no published evidence about the safety of avoiding endotracheal suction. This study will provide the first evidence about avoidance of endotracheal suction in patients ventilated for less than 1 day. If non-inferior, the results have the capacity to change nursing practice by avoiding a potentially unnecessary procedure, it will build on the body of knowledge about the patient experience.

Endotracheal suction in intensive care: A point prevalence study of current practice in New Zealand and Australia.

BACKGROUND: Despite the evidence and available guidelines about endotracheal suction (ETS), a discrepancy between published guidelines and clinical practice persists. To date, ETS practice in the adult intensive care unit (ICU) population across New Zealand and Australia has not been described. OBJECTIVE: To describe ICU nurses' ETS practice in New Zealand and Australia including the triggers for performing endotracheal suction. METHODS: A single day, prospective observational, binational, multicentre point prevalence study in New Zealand and Australian ICUs. All adult patients admitted at 10:00 on the study day were included. MAIN OUTCOME MEASURES: In addition to patient demographic data, we assessed triggers for ETS, suction canister pressures, use of preoxygenation, measures of oxygenation, and ETS at extubation. RESULTS: There were 682 patients in the ICUs on the study day, and 230 were included in the study. Three of 230 patients were excluded for missing data. A total of 1891 ETS events were performed on 227 patients during the study day, a mean of eight interventions per patient. The main triggers reported were audible (n = 385, 63%) and visible (n = 239, 39%) secretions. Less frequent triggers included following auscultation (n = 142, 23%), reduced oxygen saturations (n = 140, 22%), and ventilator waveforms (n = 53, 9%). Mean suction canister pressure was -337 mmHg (standard deviation = 189), 67% of patients received preoxygenation (n = 413), and ETS at extubation was performed by 84% of nurses. CONCLUSION: Some practices were inconsistent with international guidelines, in particular concerning patient assessment for ETS and suction canister pressure.

Impact of venous leg ulceration on health-related quality of life: A synthesis of data from randomized controlled trials compared to population norms.

Venous insufficiency is the most common cause of leg ulceration, but the impact of venous leg ulceration on health-related quality of life has not been adequately assessed. This study compared data from randomized controlled trials to population norms obtained from a large national population survey. We combined the baseline Short Form-36 (SF-36) version 1 data from two New Zealand randomized controlled trials that recruited participants with VLU and compared the pooled data to the population scores obtained from the New Zealand Health Survey using general linear regression to adjust for age, sex, and ethnicity differences between the cohorts. Baseline SF-36 scores obtained from 618 trial participants were compared to the SF-36 scores obtained from the 12,529 participants in the New Zealand Health Survey. Participants with VLU had significantly lower crude SF-36 scores across all eight SF-36 domains, but there was interaction between age and group. Adjusted mean differences for participants aged 65 years or younger were -25.8, -32.1, -21.2, -9.6, -7.6, -23.9, -21.5, and -9.3, respectively, for Physical Functioning, Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, and Mental Health whereas the adjusted mean differences for older participants were -15.7, -23.8, -13.8, -0.3 (nonsignificant), -4.6, -15.3, -21.2, and -6.6. This study is the first to compare a VLU population to norms from a general population survey and the first to show VLU interacts with age creating stronger impact in younger patients compared their age cohort. Younger patients may have need of more pastoral care as a consequence.

Low-dose aspirin as an adjuvant treatment for venous leg ulceration: study protocol for a randomized controlled trial (Aspirin4VLU).

AIM: The aim of this study was to determine the effect of low-dose aspirin on venous leg ulcer healing when used in addition to compression. BACKGROUND: The mainstay of treatment for venous leg ulcers is compression therapy and there are few adjuvant treatments to accelerate healing. DESIGN: Pragmatic, community-based, double-blind, randomized trial. METHODS: Participants with venous leg ulcers will receive either 150 mg aspirin or placebo daily for up to 24 weeks. Participants will receive background treatment with compression therapy (system of choice guided by participant and/or clinical preference) delivered through district nursing services. The primary outcome will be time-to-healing. Secondary outcomes will include proportion healed at 24 weeks, change in ulcer area, change in health-related quality of life, adherence, efficacy of blinding and adverse events. The trial was funded in June 2014. DISCUSSION: The trial commenced in March 2015 and is successfully recruiting. The trial is one of three trials that will contribute to an individual participant data meta-analysis to be undertaken at the York Trials Centre. TRIAL REGISTRATION: Registered 5 June 2014 ClinicalTrials.gov NCT02158806. Protocol version 1·1, 14 April 2015.

Honey as a topical treatment for wounds.

BACKGROUND: Honey is a viscous, supersaturated sugar solution derived from nectar gathered and modified by the honeybee, Apis mellifera. Honey has been used since ancient times as a remedy in wound care. Evidence from animal studies and some trials has suggested that honey may accelerate wound healing. OBJECTIVES: The objective of this review was to assess the effects of honey compared with alternative wound dressings and topical treatments on the of healing of acute (e.g. burns, lacerations) and/or chronic (e.g. venous ulcers) wounds. SEARCH METHODS: For this update of the review we searched the Cochrane Wounds Group Specialised Register (searched 15 October 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 9); Ovid MEDLINE (1946 to October Week 1 2014); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 13 October 2014); Ovid EMBASE (1974 to 13 October 2014); and EBSCO CINAHL (1982 to 15 October 2014). SELECTION CRITERIA: Randomised and quasi-randomised trials that evaluated honey as a treatment for any sort of acute or chronic wound were sought. There was no restriction in terms of source, date of publication or language. Wound healing was the primary endpoint. DATA COLLECTION AND ANALYSIS: Data from eligible trials were extracted and summarised by one review author, using a data extraction sheet, and independently verified by a second review author. All data have been subsequently checked by two more authors. MAIN RESULTS: We identified 26 eligible trials (total of 3011 participants). Three trials evaluated the effects of honey in minor acute wounds, 11 trials evaluated honey in burns, 10 trials recruited people with different chronic wounds including two in people with venous leg ulcers, two trials in people with diabetic foot ulcers and single trials in infected post-operative wounds, pressure injuries, cutaneous Leishmaniasis and Fournier's gangrene. Two trials recruited a mixed population of people with acute and chronic wounds. The quality of the evidence varied between different comparisons and outcomes. We mainly downgraded the quality of evidence for risk of bias, imprecision and, in a few cases, inconsistency.There is high quality evidence (2 trials, n=992) that honey dressings heal partial thickness burns more quickly than conventional dressings (WMD -4.68 days, 95%CI -5.09 to -4.28) but it is unclear if there is a difference in rates of adverse events (very low quality evidence) or infection (low quality evidence).There is very low quality evidence (4 trials, n=332) that burns treated with honey heal more quickly than those treated with silver sulfadiazine (SSD) (WMD -5.12 days, 95%CI -9.51 to -0.73) and high quality evidence from 6 trials (n=462) that there is no difference in overall risk of healing within 6 weeks for honey compared with SSD (RR 1.00, 95% CI 0.98 to 1.02) but a reduction in the overall risk of adverse events with honey relative to SSD. There is low quality evidence (1 trial, n=50) that early excision and grafting heals partial and full thickness burns more quickly than honey followed by grafting as necessary (WMD 13.6 days, 95%CI 9.82 to 17.38).There is low quality evidence (2 trials, different comparators, n=140) that honey heals a mixed population of acute and chronic wounds more quickly than SSD or sugar dressings.Honey healed infected post-operative wounds more quickly than antiseptic washes followed by gauze and was associated with fewer adverse events (1 trial, n=50, moderate quality evidence, RR of healing 1.69, 95%CI 1.10 to 2.61); healed pressure ulcers more quickly than saline soaks (1 trial, n= 40, very low quality evidence, RR 1.41, 95%CI 1.05 to 1.90), and healed Fournier's gangrene more quickly than Eusol soaks (1 trial, n=30, very low quality evidence, WMD -8.00 days, 95%CI -6.08 to -9.92 days).The effects of honey relative to comparators are unclear for: venous leg ulcers (2 trials, n= 476, low quality evidence); minor acute wounds (3 trials, n=213, very low quality evidence); diabetic foot ulcers (2 trials, n=93, low quality evidence); Leishmaniasis (1 trial, n=100, low quality evidence); mixed chronic wounds (2 trials, n=150, low quality evidence). AUTHORS' CONCLUSIONS: It is difficult to draw overall conclusions regarding the effects of honey as a topical treatment for wounds due to the heterogeneous nature of the patient populations and comparators studied and the mostly low quality of the evidence. The quality of the evidence was mainly downgraded for risk of bias and imprecision. Honey appears to heal partial thickness burns more quickly than conventional treatment (which included polyurethane film, paraffin gauze, soframycin-impregnated gauze, sterile linen and leaving the burns exposed) and infected post-operative wounds more quickly than antiseptics and gauze. Beyond these comparisons any evidence for differences in the effects of honey and comparators is of low or very low quality and does not form a robust basis for decision making.

The effect of active video games by ethnicity, sex and fitness: subgroup analysis from a randomised controlled trial.

BACKGROUND: The prevention and treatment of childhood obesity is a key public health challenge. However, certain groups within populations have markedly different risk profiles for obesity and related health behaviours. Well-designed subgroup analysis can identify potential differential effects of obesity interventions, which may be important for reducing health inequalities. The study aim was to evaluate the consistency of the effects of active video games across important subgroups in a randomised controlled trial (RCT). FINDINGS: A two-arm, parallel RCT was conducted in overweight or obese children (n=322; aged 10-14 years) to determine the effect of active video games on body composition. Statistically significant overall treatment effects favouring the intervention group were found for body mass index, body mass index z-score and percentage body fat at 24 weeks. For these outcomes, pre-specified subgroup analyses were conducted among important baseline demographic (ethnicity, sex) and prognostic (cardiovascular fitness) groups. No statistically significant interaction effects were found between the treatment and subgroup terms in the main regression model (p=0.36 to 0.93), indicating a consistent treatment effect across these groups. CONCLUSIONS: Preliminary evidence suggests an active video games intervention had a consistent positive effect on body composition among important subgroups. This may support the use of these games as a pragmatic public health intervention to displace sedentary behaviour with physical activity in young people.

What is the incidence of patients with palliative care needs presenting to the Emergency Department? a critical review.

BACKGROUND: Given the context of ageing populations globally, there are a growing number of patients with chronic conditions, some of whom are in the final stages of their disease trajectory, presenting to Emergency Departments. AIM: The aim was to estimate the incidence of patients with palliative care needs presenting to the department. METHODS: Three databases (MEDLINE, CINAHL and Embase) were systematically searched up to August 2012. The reference lists of included articles were searched as well as Google and Google Scholar. Only studies in English were included. Two reviewers independently reviewed studies at the abstract and full-body stages. A critical review using systematic methods was undertaken as statistical analysis could not be done because of a lack of information. RESULTS: Only 10 of 1427 identified records met the inclusion criteria. Different definitions of palliative care were evident. One article provided an incidence density for patients with non-small cell lung cancer, and we calculated the mean presentations to be 52.5 per 100 person-months. Two articles focussed on patients known to palliative care services; we estimated that 2.5 in 1000 Emergency Department visits were made by these patients. The review demonstrated that the studies were so different it was not possible to compare the data. CONCLUSION: There is an absence of evidence regarding the incidence of patients with palliative care needs presenting to the Emergency Department. Further research needs to be undertaken in this area to ensure both clinicians and policymakers have sufficient information for service provision.

Honey as a topical treatment for wounds.

BACKGROUND: Honey is a viscous, supersaturated sugar solution derived from nectar gathered and modified by the honeybee, Apis mellifera. Honey has been used since ancient times as a remedy in wound care. Evidence from animal studies and some trials has suggested that honey may accelerate wound healing. OBJECTIVES: The objective was to determine whether honey increases the rate of healing in acute wounds (e.g. burns, lacerations) and chronic wounds (e.g. skin ulcers, infected surgical wounds). SEARCH METHODS: For this first update of the review we searched the Cochrane Wounds Group Specialised Register (searched 13 June 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5); Ovid MEDLINE (2008 to May Week 5 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 12 June 2012); Ovid EMBASE (2008 to 2012 Week 23); and EBSCO CINAHL (2008 to 8 June 2012). SELECTION CRITERIA: Randomised and quasi-randomised trials that evaluated honey as a treatment for any sort of acute or chronic wound were sought. There was no restriction in terms of source, date of publication or language. Wound healing was the primary endpoint. DATA COLLECTION AND ANALYSIS: Data from eligible trials were extracted and summarised by one review author, using a data extraction sheet, and independently verified by a second review author. MAIN RESULTS: We identified 25 trials (with a total of 2987 participants) that met the inclusion criteria, including six new trials that were added to this update. In acute wounds, three trials evaluated the effect of honey in acute lacerations, abrasions or minor surgical wounds and 12 trials evaluated the effect of honey in burns. In chronic wounds, two trials evaluated the effect of honey in venous leg ulcers, and single trials investigated its effect in infected post-operative wounds, pressure injuries, cutaneous Lieshmaniasis, diabetic foot ulcers and Fournier's gangrene. Three trials recruited people into mixed groups of chronic or acute wounds. Most trials were at high or unclear risk of bias. In acute wounds, specifically partial-thickness burns, honey might reduce time to healing compared with some conventional dressings (WMD -4.68 days, 95%CI -4.28 to -5.09 days), but, when compared with early excision and grafting, honey delays healing in partial- and full-thickness burns (WMD 13.6 days, 95% CI 10.02 to 17.18 days). In chronic wounds, honey does not significantly increase healing in venous leg ulcers when used as an adjuvant to compression (RR 1.15, 95% CI 0.96 to 1.38), and may delay healing in cutaneous Leishmaniasis when used as an adjuvant to meglumine antimoniate compared to meglumine antimoniate alone (RR 0.72, 95% CI 0.51 to 1.01). AUTHORS' CONCLUSIONS: Honey dressings do not increase rates of healing significantly in venous leg ulcers when used as an adjuvant to compression. Honey may delay healing in partial- and full-thickness burns in comparison to early excision and grafting, and in cutaneous Leishmaniasis when used as an adjuvant with meglumine antimoniate. Honey might be superior to some conventional dressing materials, but there is considerable uncertainty about the replicability and applicability of this evidence. There is insufficient evidence to guide clinical practice in other types of wounds, and purchasers should refrain from providing honey dressings for routine use until sufficient evidence of effect is available.

Evaluating the effects of triage education on triage accuracy within the emergency department: An integrative review.

INTRODUCTION: Triage accuracy can affect patient outcomes. Education to ensure nurses provide the most accurate triage scores is paramount for patient safety.The objective was to investigate whether ongoing triage education increases triage accuracy, knowledge or behaviour. METHOD: An integrative review was conducted by searching five databases to identify studies that included triage-based education. A systematic search strategy was completed followed by analysis with critical appraisal using the Critical Appraisal Skills Programme, a TIDieR Checklist and thematic analysis. FINDINGS: Four thousand five hundred seventy-six studies were retrieved, with 34 studies selected for inclusion. Thirty-one studies were quantitative, and three were mixed methods. 18 out of 34 studies showed improvement in triage accuracy. Seven showed increased knowledge. Six studies showed no improvement in triage accuracy. Sixteen studies assessed triage behaviour and showed improvement post-intervention, with five showing no changes. Only three studies compared interventions. Fifty-three opportunities for changes to triage accuracy, knowledge or behaviour were found, 41 showed improvements. CONCLUSION: Triage education interventions can improve accuracy, knowledge and behaviour, but whether improvements are sustained needs further research.

Incidence and predictors of new-onset atrial fibrillation after cardiac surgery at Auckland City Hospital.

AIM: To describe the incidence, ethnic differences in incidence, and predictors of post-operative atrial fibrillation (POAF) after cardiac surgery in a New Zealand hospital. METHOD: Analysis of registry data on 1,630 adults without previous atrial fibrillation having coronary artery bypass grafting and/or valve surgery was used to determine the incidence of POAF. Univariate analysis identified risk factors and stepwise logistic regression was used to create the most parsimonious model to predict POAF. RESULTS: Overall POAF incidence was 29% (n=465) and differed by surgery type (25% after isolated coronary artery bypass surgery (CABG) vs 42% after combined CABG+valve). Incidence was highest in Maori (35%) and NZ/Other Europeans (32%). Maori and Pasifika with POAF were on average ten years younger than NZ/Other Europeans. Independent risk factors were age (OR 1.05, 95%CI 1.04-1.06), body mass index (OR 1.04, 95%CI 1.02-1.06), history of heart failure (OR 2.08, 95%CI 1.47-2.95), and valve surgeries (isolated valve OR 1.51, 95%CI 1.16-1.95; CABG+valve OR 1.59, 95%CI 1.11-2.28), but the model had poor discrimination (AUC 0.67). CONCLUSION: POAF in a New Zealand hospital occurs at comparable rates to international settings. Risk models using routinely measured factors offer poor predictive accuracy, meaning risk stratification is unlikely to adequately inform targeted POAF prevention in clinical practice.

Active video games: the mediating effect of aerobic fitness on body composition.

BACKGROUND: Increased understanding of why and how physical activity impacts on health outcomes is needed to increase the effectiveness of physical activity interventions. A recent randomized controlled trial of an active video game (PlayStation EyeToy™) intervention showed a statistically significant treatment effect on the primary outcome, change from baseline in body mass index (BMI), which favored the intervention group at 24 weeks. In this short paper we evaluate the mediating effects of the secondary outcomes. OBJECTIVE: To identify mediators of the effect of an active video games intervention on body composition. METHODS: Data from a two-arm parallel randomized controlled trial of an active video game intervention (n = 322) were analyzed. The primary outcome was change from baseline in BMI. A priori secondary outcomes were considered as potential mediators of the intervention on BMI, including aerobic fitness (VO2Max), time spent in moderate-to-vigorous physical activity (MVPA), and food snacking at 24 weeks. RESULTS: Only aerobic fitness at 24 weeks met the conditions for mediation, and was a significant mediator of BMI. CONCLUSION: Playing active video games can have a positive effect on body composition in overweight or obese children and this effect is most likely mediated through improved aerobic fitness. Future trials should examine other potential mediators related to this type of intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Website: http://www.anzctr.org.au. Study ID number: ACTRN12607000632493.

Pentoxifylline for treating venous leg ulcers.

BACKGROUND: Healing of venous leg ulcers is improved by the use of compression bandaging but some venous ulcers remain unhealed, and some people are unsuitable for compression therapy. Pentoxifylline, a drug which helps blood flow, has been used to treat venous leg ulcers. OBJECTIVES: To assess the effects of pentoxifylline (oxpentifylline or Trental 400) for treating venous leg ulcers, compared with a placebo or other therapies, in the presence or absence of compression therapy. SEARCH METHODS: For this fifth update we searched the Cochrane Wounds Group Specialised Register (searched 20 July 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2010 to July Week 2 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 19, 2012); Ovid EMBASE (2010 to 2012 Week 28); and EBSCO CINAHL (2010 to July 13 2012). SELECTION CRITERIA: Randomised trials comparing pentoxifylline with placebo or other therapy in the presence or absence of compression, in people with venous leg ulcers. DATA COLLECTION AND ANALYSIS: One review author extracted and summarised details from eligible trials using a coding sheet. One other review author independently verified data extraction. MAIN RESULTS: No new trials were identified for this update. We included twelve trials involving 864 participants. The quality of trials was variable. Eleven trials compared pentoxifylline with placebo or no treatment. Pentoxifylline is more effective than placebo in terms of complete ulcer healing or significant improvement (RR 1.70, 95% CI 1.30 to 2.24). Pentoxifylline plus compression is more effective than placebo plus compression (RR 1.56, 95% CI 1.14 to 2.13). Pentoxifylline in the absence of compression appears to be more effective than placebo or no treatment (RR 2.25, 95% CI 1.49 to 3.39).More adverse effects were reported in people receiving pentoxifylline (RR 1.56, 95% CI 1.10 to 2.22). Nearly three-quarters (72%) of the reported adverse effects were gastrointestinal. AUTHORS' CONCLUSIONS: Pentoxifylline is an effective adjunct to compression bandaging for treating venous ulcers and may be effective in the absence of compression. The majority of adverse effects were gastrointestinal disturbances.

Review article: Ankle intra-articular haematoma block for reduction of unstable ankle fractures in the emergency department: An integrative review.

A review was conducted to assess the efficacy and safety of the intra-articular haematoma block (IAHB) for manipulation of ankle fractures in ED. Any study investigating the success of IAHB for ankle fracture reduction published in English was sought. Seven databases were searched. The Cochrane Risk of Bias tool was used to quality assess the included studies. Three studies met the inclusion criteria (n = 436 patients). Just one study was a randomised controlled trial (n = 42). The two non-randomised studies that included the majority of patients were assessed as at high overall risk of bias. The studies reported no significant difference in the overall rate of successful reduction or patient-reported pain scores between IAHB and procedural sedation groups. A subgroup analysis in one study suggested timelier reduction by 51.4 min (P = 0.01) for fractures involving subluxation when using IAHB, but that more patients with dislocation were reduced on first attempt when using procedural sedation compared to IAHB (74.0% vs 54.8%, P < 0.01). No adverse events were reported from using IAHB, although no study measured events such as joint sepsis or chondrolysis. Findings suggest that IAHB might be safe and effective but the evidence is very limited. High-quality research is required before IAHB can be considered a routine alternative. However, IAHB could be considered in situations where the risk of procedural sedation outweighs the likely very low risk of chondrolysis.

Trial registration and time to publication in a retrospective cohort of publicly funded randomised controlled trials in New Zealand 1999-2017.

OBJECTIVES: To determine how quickly randomised controlled trials funded by the Health Research Council of New Zealand (HRC) were registered and published, and whether time to publication differed by trial result. DESIGN: We created a retrospective cohort of trials offered funding from 1999 to 2017 by seeking lists of candidate studies using the Official Information Act 1982. These lists were supplemented by searching the HRC's online research repository and an open-access database on Figshare. One investigator searched for trial registrations and for dissemination using electronic databases, university websites and ResearchGate. One investigator extracted data from the obtained studies and a second investigator independently corroborated the data entry from a 10% random sample. RESULTS: We identified 258 trials that were offered funding, 252 trials were conducted and 229 (90.9%) were registered, 179 prospectively by the date of the final search (24 March 2022). Overall, 236 trials were completed by the date of the last search and in 209 (88.6%) trials the results had been disseminated, 200 (84.7%) of which were by journal publication. We obtained the results for 214 trials, 91 (42.5%) of which were positive, 120 (56.1%) of which were null and 3 (1.4%) of which were negative. Median time to publication was 22.7 months for positive trials and 21.5 months for combined null or negative trials (log rank test p=0.83). Median time since trial completion in the trials that had not been published was 43.6 months (IQR 17.1-108.2 months). CONCLUSIONS: Between 1999 and 2017, almost 9 out of every 10 HRC-funded trials had been registered and a similar proportion of completed trials had been published with no difference in time to publication based on type of result. However, only a slim majority of trials had published within the 2-year time frame set by the WHO.