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IntroductionFemoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention.ProblemThe purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects., Methods: A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK)., Results: Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays., Conclusions and Relevance: The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids. HardsM, BrewerA, BessantG, LahiriS. Efficacy of prehospital analgesia with Fascia Iliaca Compartment Block for femoral bone fractures: a systematic review. Prehosp Disaster Med. 2018;33(3):299-307.

Study Objectives: To determine the effectiveness of serratus plane block performed under direct vision on postoperative pain after mastectomy., Design: We performed a retrospective study of elective breast surgery patients undergoing mastectomy over 6 months. We collected data on the outcomes for the pain score and use of analgesia in recovery, the use of analgesia and antiemetics overnight, and the pain score and mobilization status of the patient 1 day after the operation., Setting: Breast cancer is the most common cancer in women, and mastectomy is commonly performed as part of the management. A mastectomy can cause significant acute pain which progresses to chronic pain in 25% to 60% of women. Recent studies have suggested that a serratus plane block is a viable alternative to regional anesthetic techniques without the side effect profile and that injection of local anesthetic into serratus anterior provided predictable and effective anesthesia to the chest wall. Serratus blocks target the thoracic nerves more selectively than pectoral blocks, and local blocks can reduce the use of opiates postoperatively thereby lessening opiate-related side effects., Patients: Our sample included 16 patients who had received a serratus block and 11 patients who only had wound infiltration with levobupivacaine with adrenaline and clonidine., Intervention: Serratus plane block was conducted by injecting 50% of the totally available levobupivacaine 0.375% with adrenaline and clonidine deep to serratus anterior under direct observation., Main Results: No patients receiving a serratus block suffered severe pain in recovery or day 1 postoperatively. Patients receiving wound infiltration alone had 2 patients suffering severe pain in recovery and 3 patients suffering severe pain day 1 postoperatively., Conclusion: Serratus block provides effective regional anesthesia, suitable for mastectomies, and currently appears to be superior to wound infiltration alone. However, further data will need to be collected to support this finding., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aims: This study characterized UK primary care patients with Type 2 diabetes who initiated insulin treatment, and described the initial insulin regimens used, overall metabolic changes and health-care resource usage., Methods: A retrospective cohort study was performed using quality-checked patient data from The Health Improvement Network database. Eligible patients who initiated insulin for the first time between 2004 and 2006 were grouped into four cohorts according to the type of insulin regimen initiated. Data on patient characteristics, metabolic and clinical outcomes and health-care resource use were collected at baseline and during 6 months of follow-up., Results: In total, 4045 eligible adults [2269 male, 1776 female; mean age 62.6 ± 13.3 years; mean baseline HbA(1c) 82 ± 22 mmol/mol (9.6% ± 2.0%)] initiated insulin. Approximately half (52.4%) initiated insulin as basal insulin only, 41.6% as premixed only, 4.0% as basal-bolus and 2.1% as prandial insulin only. Among patients with ≥ 180 days follow-up (n=3815), the initial insulin regimen was not changed during follow-up in 75.1% of patients, while 13.7% discontinued, 7.0% switched and 4.7% intensified insulin therapy. The mean change in HbA(1c) was -14 mmol/mol (-1.3%, n=2881), with 17.3% of patients achieving an HbA(1c) of <53 mmol/mol (7%, n=3024). The mean weight change was +0.9 kg (n=2345)., Conclusions: Basal and premixed insulin were the most common types of insulin initiated and in most patients no changes were made to the initial regimen over 6 months. However, few patients achieved glycemic control targets., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Aims: To describe patients with Type 2 diabetes mellitus treated with basal insulin, with or without oral antidiabetics in UK primary care, and evaluate insulin treatment patterns and factors explaining changes in therapy., Methods: Retrospective analysis of patients with Type 2 diabetes within The Health Improvement Network UK primary care database. Patients receiving basal insulin between January and June 2006 were followed until July 2009., Results: Analysis included 3185 patients, mean age 65.6 years [standard deviation (SD) 12.4], 50.9% men, median diabetes duration 9.6 years, median basal insulin use 1.3 years, 86.5% had received oral antidiabetics in the previous 12 months. Mean follow-up was 2.9 years (SD 1.0), 59.8% patients maintained basal insulin throughout follow-up with a mean HbA(1C) of 69 mmol/mol (SD 19; 8.4%, SD 1.7) at baseline and 65 mmol/mol (SD 17; 8.1%, SD 1.6) during follow-up. During follow-up, 6.9% of patients discontinued, 19.3% intensified with and 14.1% switched to prandial or premixed insulin. Patients who intensified (prandial) had a mean HbA(1c) of 77 mmol/mol (SD 18; 9.2%, SD 1.6) before change and a mean HbA(1c) of 71 mmol/mol (SD 21; 8.6%, SD 2.0) at the end of the study. Those switching to premixed insulin had a mean HbA(1c) of 80 mmol/mol (SD 18; 9.5%, SD 1.7) before change and a mean HbA(1c) of 69 mmol/mol (SD 17; 8.5%, SD 1.5) at the end of the study. Increasing HbA(1c) and longer diabetes duration explained intensification and switch., Conclusions: The majority of patients had HbA(1c) above the 53 mmol/mol (< 7%) target at baseline and post-intensification/switch. The HbA(1c) levels were reduced by intensification/switch suggesting that insulin changes did have some impact. Most patients did not change insulin treatment despite having higher than recommended HbA(1c) levels. Reasons for not changing treatment in face of unsatisfactory clinical outcomes are unclear. Further research is warranted to explore barriers towards therapy change., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Purpose: To describe the use of 3 prostaglandin/timolol fixed combinations (FCs) in UK primary care, to summarize characteristics of recipients, and to assess 12-month persistence., Methods: This retrospective cohort study included first-time recipients of latanoprost/timolol FC, bimatoprost/timolol FC, or travoprost/timolol FC treated between April 1, 2007, and November 30, 2008, identified in The Health Improvement Network database, a large database of anonymized longitudinal electronic medical records of patients treated in UK primary care. Eligible patients were = 18 years old at the index date (date of first prescription). Persistence, defined as a gap =60 days between consecutive prescriptions, was assessed through 12 months post-index for each cohort (Cox proportional hazards models)., Results: A total of 2,015 patients were included: latanoprost/timolol FC, n = 898 (44.6%); bimatoprost/timolol FC, n = 733 (36.4%); travoprost/timolol FC, n = 384 (19.1%). The mean age was approximately 72 years across cohorts (p = 0.792). Glaucoma was the diagnosis for >90% of patients in each cohort. Twelve-month persistence was similar across treatments: latanoprost/timolol FC: 38.2%; bimatoprost/timolol FC: 38.6%; travoprost/timolol FC: 38.3% (p = 0.985). Mean time to therapy change for nonpersistent patients was also similar: 143.3 ± 89.8, 151.0 ± 87.9, and 151.8 ± 87.7 days, respectively (p = 0.095). Among persistent patients, additional therapy was prescribed for 36.2%, 41.7%, and 41.5% of patients, respectively. Among nonpersistent patients, 64.0%, 70.4%, and 69.2%, respectively, restarted the index therapy., Conclusions: The largest proportion of first-time recipients of prostaglandin/beta-blocker FC products treated in UK primary care was prescribed latanoprost/timolol FC. Twelve-month persistence was similar (<40%) across the 3 FCs evaluated.

Background: Relative leg length is frequently used as a biomarker of childhood nutrition in epidemiological studies, but evidence is lacking. We examined the association between supplemental nutrition in pregnancy and childhood and relative proportions of components of height in adolescence., Methods: In a community trial of nutritional supplementation, villages from adjacent administrative areas were selected to serve as intervention (n = 15) and control (n = 14) arms. In the intervention villages, balanced protein-calorie supplementation (2.51 MJ, 20 g protein) was offered daily to pregnant women and their offspring until the age of 6 years. Children born in the trial were re-examined 15 years later to assess components of height., Results: A total of 1165 adolescents (intervention: 654, 49% of trial participants; control: 511, 41% of trial participants) aged 13-18 years were examined. Supplemented children were 10 mm taller [95% confidence interval (CI): 1.4 to 18.7 mm], but almost all of the increase was in trunk length (9 mm, 95% CI: 2.6 to 15.4 mm). The age- and gender-adjusted β-coefficients for the association of nutritional supplementation with relative trunk, leg and lower leg lengths (expressed as standard deviation scores) were 0.26 (95% CI: 0.11 to 0.42), 0.08 (95% CI: -0.03 to 0.19) and 0.03 (95% CI: -0.08 to 0.15) respectively, thereby unsupportive of cephalocaudal gradient in growth., Conclusions: In this nutritional supplementation trial in an undernourished population, we were unable to confirm relative leg length as a biomarker of childhood nutrition. Alternative explanations may underlie the reported associations between childhood conditions and relative leg length.

Objectives: Varenicline is a licensed smoking cessation medication in the EU, USA and many other countries worldwide. This study was designed to assess its effectiveness in a UK general practice setting., Methods: The main outcome measure was the rate of smoking cessation, defined as the seven-day point prevalence after six months from starting varenicline. Varenicline users were identified from records in The Health Improvement Network (THIN) database. A questionnaire on smoking cessation was sent to patients who commenced treatment close to the selection date (six months prior to the date of questionnaire dispatch)., Results: The response rate was 26.4%: 193 responses were received. Ninety percent had previously attempted to stop smoking and 87.4% had used nicotine replacement therapy during the previous attempt to stop smoking. The overall smoking cessation rate was 49.5%. There was a strong association between the duration of varenicline treatment and smoking cessation. Patients who reported using varenicline for 9-12 weeks were 11 times more likely to stop smoking than those who completed less than two weeks of treatment. There was some evidence that patients with a longer history of smoking were less likely to stop. No association was observed between smoking cessation and: previous number of cigarettes smoked per day; number of previous attempts to stop smoking; or motivations for stopping., Conclusions: Varenicline appeared to be a useful pharmacological aid to smoking cessation in a general practice setting. The observed effectiveness was similar to the efficacy estimates from previously reported clinical trials. However, the response rate was lower than expected and responders tended to be older, more likely to suffer from chronic obstructive pulmonary disease and to live in more affluent areas than non-responders. Responses were self-reported and not clinically validated therefore recall bias may be an issue.