BACKGROUND Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservativemanagement group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, −4.1 percentage points; 95% confidence interval [CI], −8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of −9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of −11.0 percentage points (95% CI, −18.4 to −3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events.

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Objective: To determine the proportion of alcohol‐related presentations to emergency departments (EDs) in Australia and New Zealand, at a single time point on a weekend night shift. Design, setting and participants: A point prevalence survey of ED patients either waiting to be seen or currently being seen conducted at 02:00 local time on 14 December 2013 in 106 EDs in Australia and New Zealand. Main outcome measures: The number of ED presentations that were alcohol‐related, defined using World Health Organization ICD‐10 codes. Results: At the 106 hospitals (92 Australia, 14 New Zealand) that provided data, 395 (14.3%; 95% CI, 13.0%–15.6%) of 2766 patients in EDs at the study time were presenting for alcohol‐related reasons; 13.8% (95% CI, 12.5%–15.2%) in Australia and 17.9% (95% CI, 13.9%–22.8%) in New Zealand. The distribution was skewed left, with proportions ranging from 0 to 50% and a median of 12.5%. Nine Australian hospitals and one New Zealand hospital reported that more than a third of their ED patients had alcohol‐related presentations; the Northern Territory (38.1%) and Western Australia (21.1%) reported the highest proportions of alcohol‐related presentations. Conclusions: One in seven ED presentations in Australian and New Zealand at this 02:00 snapshot were alcohol‐related, with some EDs seeing more than one in three alcohol‐related presentations. This confirms that alcohol‐related presentations to EDs are currently underreported and makes a strong case for public health initiatives.

The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

Background: There are currently no studies assessing effectiveness of subdissociative intranasal (IN) ketamine as the initial analgesic for adult patients in the ED. Objective: The study aims to examine the effectiveness of sub-dissociative IN ketamine as a primary analgesic agent for adult patients in the ED. Method: This is a prospective, observational study of adult ED patients presenting with severe pain (≥6 on 11-point scale at triage). IN ketamine dose was 0.7 mg/kg, with secondary dose of 0.5 mg/kg at 15 min if pain did not improve. After 6 months, initial dose was increased to 1.0 mg/kg with the same optional secondary dose. Primary outcomes: The primary outcomes are change in VAS rating at 30 min; percentage of patients reporting clinically significant reduction in VAS (≥20 mm) at 30 min; dose resulting in clinically significant pain reduction. Results: Of the 72 patients available for analysis, median age was 34.5 years and 64% were men. Median initial VAS rating was 76 mm (interquartile

Objective: Compare pain relief from non-opioid, codeine and oxycodone analgesic regimens in adults with moderate pain from limb injury. Method: Double-blind, randomised, controlled, non-inferiority trial. Three regimens of six tablets, each included 2 × 500 mg paracetamol and 2 × 200 mg ibuprofen with 2 × 100 mg thiamine (non-opioid), 2 × 30 mg codeine (codeine) or 2 × 5 mg oxycodone tablets (oxycodone). Primary outcome: difference in mean visual analogue scale (VAS) change between groups at 30 min, with a limit of inferiority of 13. Secondary outcomes included mean change in VAS rating from baseline to 30 min for each group, patient satisfaction, need for additional analgesia and adverse events. Pain ratings taken at 60 and 90 min for patients still in ED are described. Results: Of 182 patients randomised, non-opioid, codeine and oxycodone numbers were 61, 62 and 59. Differences (95% CI) between groups at 30 min were as follows: non-opioid versus codeine À2.6 (À8.8 to 3.6); non-opioid versus oxycodone À2.7 (À9.3 to 3.9); codeine versus oxycodone 0.1 (À6.6 to 6.4). Mean VAS reductions for non-opioid, codeine and oxycodone were À13.5, À16.1 and À16.2 mm, respectively. Satisfaction with analgesia was reported by 77.6% (64.7-87.5), 81.0% (67.2-89.0) and 73.6% (59.7-84.7) and adverse events by 3.3% (0.4-11.3), 1.6% (0.4-8.7) and 16.9% (8.4-29.0), respectively. Mean VAS reductions at 60 and 90 min were as follows: À23.2 and À18.7 mm for non-opioid; À30.7 and À33.3 mm for codeine; and À26.1 and À31.7 mm for oxycodone. Conclusion: At 30 min, analgesic effects of non-opioid, codeine and oxycodone groups were non-inferior.

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