Pain after traumatic injury is common, yet few patients receive adequate pain relief. NHS paramedics have a limited formulary to treat severe pain. To estimate the cost-effectiveness of ketamine versus morphine for severe pain in acute traumatic injury. A cost-utility analysis was conducted based on data from a pragmatic, multicentre, randomised controlled trial (PACKMAN). The base-case analysis took the form of an intention-to-treat analysis conducted from a UK National Health Service (NHS) and personal social services (PSS) perspective and separately from a societal perspective. Costs (£ 2021–2022 prices) were collected prospectively over a 6-month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained and the incremental net monetary benefit (INMB) of ketamine in comparison to morphine. Sensitivity and pre-specified subgroup analyses explored uncertainty and heterogeneity in cost-effectiveness estimates. Participants (n = 416) were randomised to ketamine (n = 206) or morphine (n = 210) amongst whom complete data for the economic evaluation was available for 189 (45.4

OBJECTIVE:The objective of this study was to examine whether foot/ankle injury and injection contribute to the risk of foot/ankle OA in retired UK male professional footballers. METHODS:This was a case-control study among retired UK male footballers, in which cases reported General Practitioner-diagnosed foot/ankle OA or forefoot/ankle surgery after retirement, and controls reported neither. Injury was defined as significant foot/ankle injury with pain for most days over 3 months during their career. Injection was defined as injection of corticosteroids or other agents into foot/ankle joints during their career. Adjusted odds ratios (aORs) with 95% confidence interval (CIs) were calculated using logistic regression. Areas Under the Curve (AUCs) and 95% CIs were estimated to examine the contribution of injury and/or injection in the context of other available risk factors. RESULTS:Of 424 footballers studied, 63 had foot/ankle OA and 361 had neither. Cases had similar mean age (63.2 vs 63.0, P = 0.457) and BMI (27.7 vs 27.0, P = 0.240) to those of controls, but more foot/ankle injury (73.3% vs 42.5%, P < 0.001) and injections (75.0% vs 48.4%, P < 0.001), with aORs of 4.23 (95% CI 1.88-9.48) and 2.62 (95% CI 1.19-5.78), respectively. The AUC was 0.69 (95% CI 0.62-0.77) for injury, 0.74 (95% CI 0.66-0.81) for injury and injection, and 0.78 (95% CI 0.70-0.85) for all risk factors. Similar results were observed in footballers with ankle OA only. CONCLUSION:Injury was a major risk factor for foot/ankle OA in retired UK male professional footballers. The role of injection needs cautious interpretation due to potential confounding by indication.

Introduction The Major Trauma Triage Study (‘MATTS’) triage tool was designed to identify patients with major trauma who could benefit from expedited care in specialist major trauma centres (MTCs). We aimed to investigate the impact of the MATTS tool on major trauma triage decisions after implementation. Methods Consecutive patients were included in a multicentre, prospective cohort study conducted between 1 November 2021 and 15 May 2022 in six trauma networks served by West Midlands and Yorkshire Ambulance Services. Electronic data from ambulance service patient report forms were linked to data from the Trauma Audit and Research Network trauma registry. The accuracy of prehospital triage decisions (conveyance to an MTC with pre-alert) against a bespoke MATTS reference standard to define major trauma was calculated. This was compared with optimal undertriage/overtriage trade-off indicated by previous economic modelling. Additional analyses investigated theoretical triage tool accuracy based on recorded data irrespective of hospital destination, examined important injury subgroups, evaluated alternative reference standards and described triage tool use. Results In total, 38 010 injured patients were included, with 2.2% prevalence of major trauma. The MATTS triage tool demonstrated 55.3% sensitivity (95% CI 51.8% to 58.7%) and 94.3% specificity (95% CI 94.1% to 94.6%). There was evidence of triage tool use in a minority of patients (6.3%), with senior clinical advice sought in 9.3% of patients. Theoretical triage tool sensitivity was 51.1% (95% CI 47.6% to 54.5%) with specificity 93.6% (95% CI 92.7% to 94.4%). Agreement between the theoretical triage tool result and the observed triage decision was good (absolute agreement 90.4%, Gwet’s agreement coefficient 1 (AC1) statistic 0.89, 95% CI 0.89 to 0.89). Accuracy varied across different ages, mechanisms of injury subgroups and alternative reference standards for major trauma. Conclusions The MATTS triage tool achieved an appropriate undertriage/overtriage trade-off compared with previously established targets. However, documented adherence to MATTS was low. Dedicated training and further evaluation are necessary prior to national wider implementation.

Background:Paramedics frequently administer analgesic medications for pain following trauma. Morphine is the most commonly administered strong analgesic. However, it may not be the best option as it may lower blood pressure, depress respiration and there is a risk of dependency. Ketamine might be a better option. We sought to compare clinical and cost-effectiveness of paramedic administered ketamine and morphine in patients with severe pain following trauma. Methods:PACKMaN was a double-blinded, randomised controlled, superiority trial. Eligible patients were 16 years of age or over, had an acute injury, and articulated a pain score of 7 or greater on a 0-10 numeric rating score. We excluded pregnant patients, prisoners, those unable to articulate a pain score and anyone lacking capacity. The maximum dose of morphine was 20 mg while the maximum dose of ketamine was 30 mg. The trial drug was titrated to effect. The primary outcome was the Sum of Pain Intensity Difference score. Results:We randomised 449 participants: 219 (49%) received ketamine and 230 (51%) received morphine. The Sum of Pain Intensity Difference score was 3.5 (standard deviation 2.8) for ketamine and 3.4 (standard deviation 3.0) for morphine. We found no significant difference in efficacy between drugs (adjusted mean difference 0.1, 95% confidence interval -0.4 to 0.6; p = 0.7). Ketamine was more likely to achieve 'very much improvement' (odds ratio 1.58, 95% confidence interval 1.08 to 2.31; p = 0.019) and to do so more rapidly than morphine (hazard ratio 1.42, 95% confidence interval 1.09 to 1.84; p = 0.009). However, morphine was likely to last longer than ketamine (hazard ratio 1.28, 95% confidence interval 1.05 to 1.56; p = 0.013). There was no evidence of a significant difference in serious adverse events. Conclusion:Ketamine does not provide superior analgesia than morphine when treating acute severe trauma pain. Ketamine is a suitable alternative that is safe for use by paramedics. Limitations:Patients were required to provide verbal assent to participate, consequently we were only able to recruit patients who had capacity to understand what was being asked of them. It is also therefore probable that we were unable to recruit the most severely injured patients. These factors may limit generalisability of our results. Furthermore, we were unable to complete a planned sensitivity analysis to determine if there was a difference in treatment response between patients with more minor injuries and those who were more severely injured. Finally, we experienced a loss to follow-up at 3 and 6 months, so our findings for long term outcomes may have been underpowered. Future work:Future research should focus on identification of the optimal drug (or combination of drugs), dosing and drug route to achieve rapid control of pain. In addition, it would be valuable to explore the relationship between paramedic analgesia and the development of chronic pain. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128086.

OBJECTIVES:To examine whether retired male professional footballers have a higher risk of foot/ankle osteoarthritis (OA) and pain than general population male controls. METHODS:In this cross-sectional study, questionnaires for self-reported foot/ankle OA outcomes were posted to 878 footballers and 1060 controls, and subsequently a sample of responders per group underwent assessment for radiographic OA (ROA) irrespective of symptoms. ROA was defined using the La Trobe atlas when definite osteophyte (score ≥ 2) or definite joint space narrowing (score ≥ 2) was observed at any assessed foot/ankle joint. Symptomatic ROA (sROA) was defined as presence of ROA and pain in the same region of the foot for most days of the past month. Adjusted relative risks (aRRs) with 95% CI were calculated using robust Poisson regression. RESULTS:Questionnaires were completed by 468 footballers (53%) and 619 controls (58%), of whom 113 footballers and 319 controls underwent radiographic assessment. Compared with controls, footballers were more likely to: (i) report general practitioner-diagnosed foot/ankle OA (aRR 1.77; 95% CI: 1.22, 2.57), forefoot/ankle surgery (aRR 2.80; 95% CI: 2.04, 3.84), and current foot/ankle pain (aRR 1.33; 95% CI: 1.09, 1.62); and (ii) have foot/ankle ROA (aRR 1.04; 95% CI: 1.01, 1.07) and sROA (aRR 1.63; 95% CI: 1.21, 2.19). CONCLUSION:Retired male professional footballers were more likely to have self-reported and radiographic foot/ankle OA than general population male controls. The ankle appeared the joint most affected by OA in footballers compared with controls. Further study is needed in female footballers and to determine specific risk factors related to this increased risk.

Objectives: The EyeGuide Focus system is a simple, portable, test of visual tracking with potential use for concussion screening. This study investigated the repeatability, reproducibility, distribution, and modifiers of EyeGuide Focus measurements in healthy elite Rugby players. Design: Cross sectional repeated measures study and controlled pre-test post-test sub-study. Methods: EyeGuide Focus testing was performed in a medical room at rest. Test-retest repeatability (within-subject standard deviation (Sw), coefficient of variation (CV), repeatability coefficient (RC)) and reliability intra-class correlation coefficient (ICC A,1) of 3 test results were evaluated. The distribution of best score across replicates was then examined using summary statistics, and the influence of subject characteristics investigated. A controlled pre-test post-test sub-study examined the effect of exercise on best EyeGuide Focus score using an analysis of covariance (ANCOVA). Results: A total of 769 elite male Rugby players underwent EyeGuide Focus testing. Repeated test scores demonstrated positively skewed distributions. Test-retest repeatability (Sw 1.46, CV 46.0 %, RC 2.85, natural log transformed data) and reliability (ICC 0.41, natural log transformed data) were low. The distribution of best EyeGuide Focus score was unaffected by previous concussion, eye conditions, or age. No learning or exercise effects were apparent in the controlled pre-test post-test sub-study (ANCOVA, n = 89, p = 0.69). Conclusions: EyeGuide Focus test-retest repeatability and reliability were low and could limit diagnostic accuracy. Best test score achieved across repeated measurements is a possible metric for operationalisation and future research is required to determine if this differs in patients with concussion compared to normal subjects. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of Sports Medicine Australia. This is an open access article under the CC BY license(http://creativecommons.org/licenses/by/4.0/).

Background:Paramedics frequently administer analgesic medications for pain following trauma. Morphine is the most commonly administered strong analgesic. However, it may not be the best option as it may lower blood pressure, depress respiration and there is a risk of dependency. Ketamine might be a better option due to speed of onset and favourable side-effect profile. We sought to compare clinical effectiveness of paramedic administered ketamine and morphine in patients with severe pain following trauma. Methods:PACKMaN was a double-blinded, randomised controlled, superiority trial, conducted in two regional ambulance services in the UK. Eligible patients were 16 years of age or over, had an acute injury, and articulated a pain score of 7 or greater on a 0-10 numeric rating score (NRS). We excluded pregnant patients, prisoners, those unable to articulate a pain score and anyone lacking capacity. The randomisation list prepared by the study programmer, utilised a permuted, unstratified, block randomisation system (variable size blocks) to achieve an overall ratio of 1:1 control (morphine): intervention (ketamine). Treatment packs were identical in appearance, apart from their unique sequential number. Individual participant randomisation occurred when the attending paramedic opened the treatment pack. The maximum available dose of morphine was 20 mg while the maximum available dose of ketamine was 30 mg. The treating paramedic administered the trial drug slowly, in regular small aliquots, via the intravenous (or intraosseous) route, titrating treatment until the patient reported adequate analgesia or requested that treatment stop due to undesired side effects. Timing of drug administration was not prespecified. The primary outcome was the Sum of Pain Intensity Difference (SPID) score on arrival to the hospital, calculated using patient reported NRS scores. Analysis was performed on an intention to treat basis. PACKMaN is registered with the International Clinical Trials Registry (ISRCTN14124474). Findings:PACKMaN recruited its first patient on 10/11/2021 and achieved its recruitment target on 16/05/2023. We randomised 449 participants: 219 (49%) received ketamine and 230 (51%) received morphine. The SPID score was 3.5 (SD 2.8) for ketamine and 3.4 (SD 3.0) for morphine. We found no significant difference in efficacy between drugs (adjusted mean difference 0.1, 95%CI -0.4 to 0.6, p = 0.74). There was no significant difference in the incidence of serious adverse events [4 (2%) ketamine; 8 (3%) morphine]. There were no treatment related deaths. Interpretation:Ketamine did not provide superior analgesia than morphine when used by paramedics to treat acute severe trauma pain. Unexpected adverse events occurred infrequently. Despite analgesia, many patients still experienced pain on arrival at hospital, highlighting the need for further research. Funding:PACKMaN was funded by the National Institute for Health and Care Research.

BackgroundInitial ED assessment can use early warning scores to identify and prioritise patients who need time-critical treatment. We aimed to determine the accuracy of the National Early Warning Score version 2 (NEWS2) for predicting the need for time-critical treatment.MethodsWe undertook a single-centre retrospective observational cohort study. We randomly selected 4000 adults who attended a tertiary hospital ED in England from 1 January 2022 to 31 December 2022 and had NEWS2 routinely recorded on electronic patient records. The first NEWS2 and vital signs were extracted from electronic records. Research nurses selected cases that received a potentially time-critical treatment. Two independent clinical experts then determined whether time-critical treatment was or should have been received using an expert consensus derived list of interventions. We used receiver operating characteristic analysis and calculated sensitivity and specificity at predefined thresholds to evaluate the accuracy of NEWS2 for predicting need for time-critical intervention and, as a secondary outcome, mortality at 7 days.ResultsAfter excluding 10 patients who received their intervention before NEWS2 recording, 164/3990 (4.1%) needed time-critical treatment and 71/3990 (1.8%) died within 7 days. NEWS2 predicted need for time-critical treatment with a c-statistic of 0.807 (95% CI 0.765 to 0.849) and death within 7 days with a c-statistic of 0.865 (95% CI 0.813, 0.917). NEWS2>4 predicted need for time-critical treatment with sensitivity of 51.8% (95% CI 44.2%, 59.3%) and positive predictive value of 25.8% (95% CI 21.3%, 30.7%). 37 of the 45 patients needing emergency surgery, antibiotics for open fractures, insulin infusion or manipulation of limb-threatening injuries had NEWS2≤4. Patients with NEWS2>4 who did not need time-critical treatment frequently scored maximum points on NEWS2 for their respiratory rate, conscious level or receiving supplemental oxygen.ConclusionNEWS2 has limited accuracy for predicting need for time-critical treatment. We have identified time-critical interventions that frequently have low NEWS2 scores and NEWS2 parameters than may overestimate need for time-critical intervention.Trial registration numberResearch Registry 10450

Introduction: Previous research establishes that patients often experience inadequate pain relief following acute traumatic injury. The aim of this secondary analysis of data from the PACKMaN trial is to explore the contributing factors and impact of sub-optimal pain relief on short to long term outcomes. Methods: PACKMaN was a randomised controlled trial comparing ketamine and morphine when used by paramedics treating severe pain following trauma. We dicotomised all patients into two groups, those who reported moderate to severe pain (NRS pain score ) at hospital arrival and those who reported mild pain at hospital arrival (NRS pain score < four), irrespective of which treatment they had received. We explore the contributing factors to analgesic efficacy, hospital, short (3 month) and long-term (6 month) pain outcomes. Results: Final pain score was available in 446 (99%) participants. In our analysis population 175 (39%) had a final pain score below 4 and 271 (61%) had a final pain score of 4 or above. Significant differences were found in the Sum of Pain Intensity Difference (SPID), Total Pain Relief (TOTPAR) scores, percentage of maximum dose in milligrams, patient global impression of change, time to perceptible analgesia, time to meaningful analgesia, and duration of analgesia, participants being admitted to hospital in the adjusted analysis, and both short and long-term pain outcomes on the brief pain inventory. Conclusion: Participants still experiencing moderate to severe pain at hospital arrival report greater pain severity scores at both 3- and 6-months post randomisation as well as higher pain interference scores. Trial Registration: ISRCTN14124474 ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial EudraCT 2020-000154-10 ISRCTN14124474 ### Clinical Protocols ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was provided by the West of Scotland Research Ethics Committee (20/WS/0126). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data from the PACKMaN study will be available upon request from the Warwick Clinical Trials Unit (WCTU) Data Sharing Committee 6 months after the publication of the funder report. All applications will be assessed by according to WCTU Standard Operating Procedures available at: https://warwick.ac.uk/fac/sci/med/research/ctu/ctuintranet/qa/sop/sop153\_sharingdata\_v4.0.pdf. An application form to access data can be obtained from WCTUDataAccess{at}warwick.ac.uk, which should be submitted to the corresponding author in the first instance. Any data shared will be anonymised - no identifiable data will be available. There is no fixed end-date for data availability. [https://warwick.ac.uk/fac/sci/med/research/ctu/ctuintranet/qa/sop/sop153\_sharingdata\_v4.0.pdf][1] [1]: https://warwick.ac.uk/fac/sci/med/research/ctu/ctuintranet/qa/sop/sop153_sharingdata_v4.0.pdf

IntroductionSmooth pursuit eye movements may be affected by head impacts. The EyeGuide Focus system is a simple, portable, test of visual tracking. This study investigated the diagnostic accuracy of EyeGuide measurements for detection of concussion during elite Rugby matches.MethodsA prospective diagnostic case-control study was performed in the elite 2021/2022 United Rugby Championship competition. The study population comprised consecutive players identified with match-related head impact events during the World Rugby Head Injury Assessment process, randomly chosen uninjured players, and players with match-related musculoskeletal injuries. The index test was blinded EyeGuide assessment performed by independent assessors. The reference standard was concussion diagnosed by the team doctor. Distributions of EyeGuide scores were compared between concussed and non-concussed players and receiver operator characteristic curves constructed.ResultsEyeGuide testing was performed in 262 cases, comprising 55 concussed players and 207 non concussed players (33 head impact events, 97 uninjured controls, and 79 musculoskeletal injury controls). The distributions of EyeGuide score were similar between concussed and non-concussed cases (medians 20,120 Vs 21,522, p = 0.3; difference -1,402, 95% CI -5,332-3,865). The c-index for the receiver operating characteristic curve was 0.46 (95% CI 0.36-0.55).ConclusionsEyeGuide Focus scores did not appear to discriminate between concussed and non-concussed players in a cohort of elite Rugby players.

Objectives: To evaluate if the tackler correctly adhering, or not, to four different instructions of legal front-on oneon-one torso tackles altered the tackler and/or ball carrier peak inertial head kinematics. Design: Controlled laboratory study. Methods: Fifteen rugby-code players measured with three-dimensional optoelectronic motion capture performed two tackle instructions from the Australian National Rugby League coaching manual on under (Dominant National Rugby League) and over (SmotherNational Rugby League) the ball tackles, and two novel variants of these (under, Dominant, Torso Stick; over, Smother, Pop, Lock). A series of mixed general linear models identified if the tackler adhering (n = 455), or not (n = 139) to the tackle instructions altered peak inertial head kinematics. Results: The tackler's peak inertial head kinematics did not significantly change whether or not they adhered to each of the tackle instructions. When the tackler did adhere to the instructions, the ball carrier sustained a lower peak inertial head kinematics (p < 0.01) in the Smother National Rugby League tackle but higher peak inertial head kinematics in the Smother, Pop, Lock. Conclusions: The ball carriers' inertial head kinematics but not the tacklers were increased when the tackler adhered to this study's variants of the over and under the ball tackle instructions, suggesting that the tacklers were more effective in their tackle performance than the traditional tackle instructions when adhering to the tackle instruction. Greater adherence to the under the ball instructions suggests that the over the ball instruction is a more challenging technique to learn. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of Sports Medicine Australia. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

ObjectivesConcussion is a common injury in rugby union ('rugby') and yet its diagnosis is reliant on clinical judgment. Oculomotor testing could provide an objective measure to assist with concussion diagnosis. NeuroFlex (R) evaluates oculomotor function using a virtual-reality headset. This study examined differences in NeuroFlex (R) performance in clinician-diagnosed concussed and not concussed elite male rugby players over three seasons.MethodsNeuroFlex (R) testing was completed alongside 140 head injury assessments (HIAs) in 122 players. The HIA is used for suspected concussion events. Of these 140 HIAs, 100 were eventually diagnosed as concussed, 38 were not concussed (2 were unclear) Eight of the 61 NeuroFlex (R) metrics were analysed as they were comparable at all time points. These eight metrics, from three oculomotor domains (vestibulo-ocular reflex, smooth pursuit and saccades), were tested for their ability to distinguish between concussed and not concussed players using mean difference / odds ratios and corresponding 95% confidence intervals (CI's). General and generalised linear mixed models, accounting for baseline test performance, were used to determine any meaningful differences in concussed and not concussed players. The diagnostic accuracy of these differences was provided by the area under the receiver operating curve (AUC).ResultsOnly one of the eight metrics (number of saccades, smooth pursuit domain) had clear differences in performance between concussed and not concussed players at the HIA during the match (odds ratio: 0.76, 95%CI: 0.54-0.98) and after 48 hours (0.74, 95%CI: 0.52-0.96). However, the direction of this difference was contrary to clinical expectations (concussed performed better than not concussed) and the AUC for this outcome was also poor (0.52).ConclusionNeuroFlex (R) was unable to distinguish between concussed and not concussed players in this elite male cohort. Future research could study other cohorts, later time points before return to play, and the tool's role in rehabilitation.

Introduction: Major trauma centre (MTC) care has been associated with improved outcomes for injured patients. English ambulance services and trauma networks currently use a range of triage tools to select patients for bypass to MTCs. A standardised national triage tool may improve triage accuracy, cost-effectiveness and the reproducibility of decision-making.Methods: We conducted an expert consensus process to derive and develop a major trauma triage tool for use in English trauma networks. A web-based Delphi survey was conducted to identify and confirm candidate triage tool predictors of major trauma. Facilitated roundtable consensus meetings were convened to confirm the proposed triage tool’s purpose, target diagnostic threshold, scope, intended population and structure, as well as the individual triage tool predictors and cut points. Public and patient involvement (PPI) focus groups were held to ensure triage tool acceptability to service users.Results: The Delphi survey reached consensus on nine triage variables in two domains, from 109 candidate variables after three rounds. Following a review of the relevant evidence during the consensus meetings, iterative rounds of discussion achieved consensus on the following aspects of the triage tool: reference standard, scope, target diagnostic accuracy and intended population. A three-step tool comprising physiology, anatomical injury and clinical judgement domains, with triage variables assessed in parallel, was recommended. The triage tool was received favourably by PPI focus groups.Conclusions: This paper presents a new expert consensus derived major trauma triage tool with defined purpose, scope, intended population, structure, constituent variables, variable definitions and thresholds. Prospective evaluation is required to determine clinical and cost-effectiveness, acceptability and usability.

Background Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.Methods A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.Results The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.Conclusions Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Abstract Background Opioids kill more people than any other class of drug. Naloxone is an opioid antagonist which can be distributed in kits for peer administration. We assessed the feasibility of implementing a Take-home Naloxone (THN) intervention in emergency settings, as part of designing a definitive randomised controlled trial (RCT). Methods We undertook a clustered RCT on sites pairing UK Emergency Departments (ED) and ambulance services. At intervention sites, we recruited emergency healthcare practitioners to supply THN to patients presenting with opioid overdose or related condition, with recruitment across 2019–2021. We assessed feasibility of intervention implementation against four predetermined progression criteria covering site sign up and staff training; identification of eligible patients; issue of THN kits and Serious Adverse Events. Results At two intervention sites, randomly selected from 4, 299/687 (43.5%) clinical staff were trained (ED1 = 107, AS1 = 121, ED2 = 25, AS2 = 46). Sixty THN kits were supplied to eligible patients (21.7%) (n: ED1 = 36, AS1 = 4, ED2 = 16, AS2 = 4). Across sites, kits were not issued to eligible patients on a further 164 occasions, with reasons reported including: staff forgot (n = 136), staff too busy (n = 15), and suspected intentional overdose (n = 3), no kit available (n = 2), already given by drugs nurse (n = 4), other (n = 4). Staff recorded 626 other patients as ineligible but considered for inclusion, with reasons listed as: patient admitted to hospital (n = 194), patient absconded (n = 161) already recruited (n = 64), uncooperative or abusive (n = 55), staff not trained (n = 43), reduced consciousness level (n = 41), lack of capacity (n = 35), patient in custody (n = 21), other (n = 12). No adverse events were reported. Conclusion Staff and patient recruitment were low and varied widely by site. This feasibility study did not meet progression criteria; a fully powered RCT is not planned. Trial Registration ISRCTN13232859 (Registered 16/02/2018).

Background Opioids kill more people than any other class of drug. Naloxone is an opioid antagonist which can be distributed in kits for peer administration. We aimed to determine feasibility of undertaking a definitive randomised controlled trial (RCT) of Take-home Naloxone (THN) in emergency settings. Methods Using individual-level-routine health records (2015-21) we tested feasibility of developing a discriminant function to identify people at high-risk of fatal opioid poisoning for outcome comparisons. We undertook a clustered RCT on paired UK Emergency Department (ED) and ambulance service sites. At intervention sites, we recruited practitioners to administer THN to patients presenting with opioid overdose or related condition during ta 1year recruitment period, 2019 – 21. We assessed feasibility of intervention and trial methods against predetermined progression criteria. Results Within routine health records on the population of Wales (~3,200,000), we identified 1,105 adult deaths from opioid poisoning, of whom 307 (27.8%) had no ED or drugs service contacts in the year before death. At a predicted probability threshold of 0.0003, a discriminant function based on demographics and recent healthcare contacts identified 809 opioid related deaths within 1 year (sensitivity 74.7%) in 989,151 people, missing 274 cases. Lowering the threshold to 0.0002 increased sensitivity to 86.1% but included a further 608,191 non-cases; raising it to 0.0004 reduced sensitivity to 65.4% and inclusion of non-cases to 646,750. At two intervention sites, randomly selected from 4: 299/687 (43.5%) clinical staff were trained; 60/277 eligible patients (21.7%) were supplied with a THN kit and no adverse events were reported. Conclusion With a low incidence of opioid-related death and significant proportion with no contact with ED or drug services in the year before death, the numbers needed to reach a reasonable sensitivity was very high. This study did not meet progression criteria, a fully powered trial is not planned. Trial Registration ISRCTN13232859 (Registered 16/02/2018)

Background: Professional football is a risk factor for knee OA, but it is unclear whether it is also a risk factor for foot/ankle OA. Objectives: To compare the prevalence of foot/ankle outcomes (pain, GP-diagnosed OA, radiographic OA (ROA), and surgery) between male retired professional footballers and general population control men. Methods: A postal questionnaire was sent to 878 footballers and 1060 controls who participated in our previous knee OA study. Pain was defined as “current” (in the past month) and as “ever” (lasting ≥3 months in the past). GP-diagnosed OA and foot/ankle surgery were self-reported. Socioeconomic status in deciles was obtained according to post code. Foot and ankle radiographs were undertaken in those who indicated willingness to have radiographs. ROA was assessed using the La Trobe atlas and defined as osteophyte (OP) ≥2 or joint space narrowing (JSN) ≥2. The adjusted relative risk (aRR) with 95% confidence intervals (CI) were calculated using Poisson regression model on self-reported outcomes and foot/ankle ROA prevalence between groups. Results: 468 footballers (53%) and 619 controls (58%) completed the questionnaire. Of these, 113 footballers and 319 controls completed the radiographic assessment. Footballers were 4 years younger and had higher socioeconomic status than controls (Table 1). Compared to controls, footballers were more likely to have current foot/ankle pain (aRR 1.32, 95% CI 1.03-1.68), GP-diagnosed foot/ankle OA (aRR 1.79, 95%CI 1.18-2.71), and forefoot/ankle surgery (aRR 2.82, 95% CI 1.94-4.09), but not ever foot/ankle pain (Table 2). Prevalence of foot/ankle ROA did not differ between groups as defined but was significantly different when both OP and JSN ≥2 (i.e., definite OP plus definite JSN) was used to define ROA. The ankle was the most common joint affected by OA in footballers over controls. Both foot/ankle injury and injection were reported more commonly in footballers than controls. Injuries and injections correlated with each other, and the most commoninjection was corticosteroid. Conclusion: Professional footballers were more likely to have foot/ankle OA than controls in their post-retirement. Injury and injection were both associated with an increased risk of foot/ankle OA. Further research on preventing injury and reducing injections is needed. Keywords: osteoarthritis; foot/ankle; footballers. REFERENCES: NIL. Acknowledgements: The Football Association (FA), Professional Footballers’ Association (PFA) and Versus Arthritis provided financial support for the study. We are grateful to the footballers and control men in the East- Midlands who participated in the study. Disclosure of Interests: None declared.Table 1Characteristics of study population.FootballersControlsp-valueQuestionnaires, n468619Age (years), mean (SD)63.27 (10.4)68.42 (9.2)<0.001a*Body mass index (kg/m2), mean (SD)27.16 (3.2)26.81 (4.1)0.124aSocioeconomic status, mean (SD)7.50 (2.4)6.59 (3.0)<0.001a*Charlson Comorbidity Index, mean (SD)1.07 (2.0)1.33 (2.2)0.048a*SF-36 components summary, mean (SD)Physical components72.02 (21.6)69.25 (23.9)0.046a*Mental components77.98 (19.2)77.27 (20.3)0.559aFoot/ankle injury, n (%)190/425 (44.7)112/598 (18.7)<0.001b*Foot/ankle injections, n (%)221/416 (53.1)36/576 (6.2)<0.001b*Gout, n (%)56/486 (12.0)70/619 (11.3)0.737bPattern 3 finger ratio (2D<4D), n (%)300/452 (66.3)373/598 (62.3)0.181bHallux valgus, n (%): Current118/454 (25.9)159/607 (26.1)0.941bConstitutional (aged 20 years)27/428 (6.3)39/568 (6.9)0.710bFlat foot, n (%)39/443 (8.8)55/600 (9.1)0.840bBody pain, n (%)103/468 (22.0)177/619 (29.0)0.014b*a = Independent sample T-test. b= Chi-Square test.SD: Standard deviation. Table 2Prevalence of foot/ankle OA between footballers and controls.Prevalence, n (%)FootballersControlsaRR1 (95% CI)Self-reported Outcomes, n468619Current foot/ankle pain150/429 (35.0)150/574 (26.0)1.32 (1.03 - 1.68)*Ever foot/ankle pain ≥3 months133/438 (30.0)160/590 (27.0)1.15 (0.89 - 1.48)GP-diagnosed foot/ankle OA55/424 (13.0)47/581 (8.0)1.79 (1.18 - 2.71)*Surgery forefoot/ ankle103/426 (24.1)47/595 (7.9)2.82 (1.94 - 4.09)**Major risk factorsInjury190/425 (44.7)112/598 (18.7)2.27 (1.77 - 2.93)**Injection221/416 (53.1)36/576 (6.2)8.13 (5.68 - 11.63)*** p<0.05. ** p<0.001.1 aRR = Adjusted Rlative Risk: for age, socioeconomic status, and Charlson Comorbidity Index.

Concussions in contact sports are challenging for athletes, health professionals and sporting bodies to prevent, detect and manage. Design of interventions for primary prevention, early recognition of concussion and continuing to improve postconcussion management are essential for protecting athletes and promoting brain health. Over the last decade, there have been advancements in video technology for analysing head impact events and improvements in the clinical management of concussions. This study protocol describes how researchers, clinicians and staff from the Australasian National Rugby League (NRL) have brought these advancements together and developed a database of videos with head impact events and clinical outcomes. The intended outputs from this work will enhance the understanding of head impact events in NRL, from biomechanical and gameplay factors to concussion and return to play outcomes. Publishing this protocol increases the transparency of this large-scale effort to better identify head impacts and their relationship to concussions and player movement behaviour to contextualise these variables to generate new knowledge and support the reproducibility of these emerging findings. Between 2017 and 2023, over 5250 head contact cases were recorded in the database, from which >1700 head injury assessments were performed, and >600 concussions were diagnosed. Future studies using these data are planned to inform both primary and secondary injury prevention initiatives, such as risk analysis and prediction of game scenarios that result in concussion, as well as investigation of features and factors that help to inform the duration of recovery and return to play.