Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Identifying barriers and facilitators of translating research evidence into clinical practice: A systematic review of reviews

Translating research into clinical practice is a global priority because of its potential impact on health services delivery and outcomes. Despite the ever-increasing depth and breadth of health research, most areas across the globe seem to be slow to translate relevant research evidence into clinical practice. Thus, this review sought to synthesise existing literature to elucidate the barriers and facilitators to the translation of health research into clinical practice. A systematic review of reviews approach was utilised. Review studies were identified across PubMed, Scopus, Embase, CINAHL and Web of Science databases, from their inception to 15 March 2021. Searching was updated on 30 March 2022. All retrieved articles were screened by two authors; reviews meeting the inclusion criteria were retained. Based on the review type, two validated tools were employed to ascertain their quality: A Measurement Tool to Assess Systematic Reviews-2 and International Narrative Systematic assessment. The framework synthesis method was adopted to guide the analysis and narrative synthesis of data from selected articles. Ten reviews met the inclusion criteria. The study revealed that the translation of new evidence was limited predominantly by individual-level issues and less frequently by organisational factors. Inadequate knowledge and skills of individuals to conduct, organise, utilise and appraise research literature were the primary individual-level barriers. Limited access to research evidence and lack of equipment were the key organisational challenges. To circumvent these barriers, it is critical to establish collaborations and partnerships between policy makers and health professionals at all levels and stages of the research process. The study concluded that recognising barriers and facilitators could help set key priorities that aid in translating and integrating research evidence into practice. Effective stakeholder collaboration and co-operation should improve the translation of research findings into clinical practice.

WHO/International Society of Hypertension risk prediction charts versus the UK Prospective Diabetes Study risk engine for cardiovascular risk assessment among patients with type 2 diabetes: a comparative study

BACKGROUND

Patients with type 2 diabetes are at increased risk of developing cardiovascular diseases, and assessment of cardiac risk is important for preventive strategies. We compared the performance of two cardiac assessment tools to predict 10-year cardiovascular risk.

METHODS

This was a retrospective study of patients with type 2 diabetes who attended two primary-health-care centres in the Gaza Strip from Sept 15 to Nov 15, 2019. We excluded patients who had any existing cardiovascular disease. 10-year cardiovascular risk assessment was done with two risk assessment tools: the WHO/International Society of Hypertension (WHO/ISH) risk prediction charts and the UK Prospective Diabetes Study (UKPDS) risk engine. We also assessed the need for prescribing statins based on the documented risk.

FINDINGS

Of 350 patients assessed, 200 were eligible for the study. WHO/ISH charts classified 135 (68%) patients as being at low of cardiac events and the UKPDS risk engine classified 100 (50%). WHO/ISH assigned 40 (20%) people to the low to moderate 10-year risk category compared with 52 (26%) assigned by the UKPDS risk engine. Agreement between the two tools was poor (p=0·01). 12 (6%) patients who were classified as being at very low 10-year cardiac risk by WHO/ISH were classified as being at very high risk when assessed by the UKPDS risk engine. Furthermore, 150 (75%) of individuals who were categorised as having low cardiac risk by WHO/ISH had higher LDL-cholesterol concentrations than the therapeutic target of 100 mg/dL. Meanwhile, the UKPD risk engine, which uses a higher number of parameters for assessment, identified these individuals as having moderate to high risk. Based on risk documented in the medical records, 33 patients needed statin therapy of whom 12 (36%) patients were receiving this treatment. Among the remaining 167 patients who did not need statin therapy, treatment was prescribed for 57 (34%).

INTERPRETATION

There is a significant discrepancy between the WHO/ISH risk charts and the UKPDS risk engine in assigning cardiac risk. Sensitivity in identifying patients with treatable levels of LDL cholesterol and diastolic blood pressure was low for both tools. Furthermore, a lack of clear local protocols led to incorrect or unnecessary prescribing. This study showed that there is a need to reconsider the use of assessment tools either by adding a new tool or by improving assessments with the current tools.

FUNDING

None.

Clinical audit as a quality improvement tool in the Gaza Strip: an audit of audits

BACKGROUND

Clinical audit plays a fundamental role in improving the quality of patient care and hence, is considered a cornerstone of clinical governance. This quality improvement tool is newly introduced in the health-care system of the Gaza Strip. Although the number of audits completed in Gaza has been increasing over the past few years, little evidence is available of subsequent quality improvements in practice.

METHODS

An online survey was used to collect information on the audit team, location, applied methods, outcomes, presentation of data, and reaudit. Medical students and health-care professionals who had conducted audits between 2015 and 2018 were invited to complete the survey from Oct 12 to Nov 2, 2018.

FINDINGS

Data on 62 audits were collected. Training in clinical governance was received by 55 auditors (89%) and a senior supervisor was available in 56 audits (90%). Audits were performed across different hospitals and specialties: 18 (29%) in obstetrics, 16 (26%) in medicine, and 11 (18%) in each of surgery and paediatrics, with six (10%) in other specialties. A clear trend of increasing numbers of audits was observed, with four (6%) having been done in 2015, 12 (19%) in 2016, 22 (35%) in 2017, and 24 audits (39%) in 2018. Students were involved in 46 audits (74%) whereas practising doctors were involved in only 29 audits (47%). 17 (27.4%) audits were done at more than one health-care facility and the remaining audits were done at one of 13 other main hospitals or community centres across the Gaza Strip. Clear standards were identified in 54 audits (90%) while eight audits (13%) reported not setting standards at all. Improvement of documentation was recommended in 44 audits (71%), development of national guidelines in 37 (60%), and staff training in 32 (52%). Only 32 audits (51.6%) were presented to the local staff. The audit cycle was completed in 13 projects (20.9%) with only seven of them reporting subsequent improvements in practice.

INTERPRETATION

A rise in the numbers of audits reflects a growing awareness of their key role in health care and patients' safety. However, completion of audit cycles and the actual implementation of recommendations are lagging. Therefore, more focused efforts supported by both clinical and administrative leaderships are needed to implement changes and ensure continuous evaluation of their effectiveness.

FUNDING

None.

Assessment of pain control among patients with cancer in hospitals of the Gaza Strip: a cross-sectional study

BACKGROUND

Poor control of cancer pain is a major public health problem worldwide. Many potential barriers can lead to suboptimal treatment of cancer pain. One such barrier is inadequate measurement and assessment of cancer-related pain control. This study aimed to assess current pain control and management for hospitalized adult patients with cancer in the Gaza Strip.

METHODS

A cross-sectional study was conducted from Dec 10, 2017, to April 25, 2018, in the Gaza Strip. The validated Brief Pain Inventory (BPI) questionnaire was translated into Arabic for data collection. The first section of the questionnaire described the patients' sociodemographic characteristics, the second evaluated the severity of cancer, and the third assessed the interference of pain with daily activities. A ten-point Likert scale was used to evaluate the magnitude of cancer pain and its impact on the patients' lifestyle. Participants were 12 years of age and older, and were patients with cancer who had been admitted to Al-Rantisi Hospital or European Gaza Hospital (the two cancer institutes available in the Gaza Strip), and who had no mental illness or disorder affecting pain perception. Convenience sampling was used to recruit eligible patients for face-to-face interviews to complete the questionnaire. The primary outcome was the median score of cancer pain control. Ethical approval was obtained from the Palestinian Ministry of Health and informed verbal consent was obtained from patients. Data were analysed with SPSS version 22.

FINDINGS

97 patients were assessed, of whom 75% (73 of 97) were eligible and were recruited. The sample size was decided based on the available cases in the included centres during study period. The median age was 49 years (IQR 37-60), 56% (41 of 73) were females, and 86% (63 of 73) were married. Most (81%; 59 of 73) had an educational level of high school or below, and 52% (38 of 73) were unemployed. 90% of patients (66 of 73) had cancer pain as a presenting symptom at diagnosis. 93% (68 of 73) had received painkillers (analgesics) within the past week, 74% (54 of 73) were using analgesics daily, and 43% (31 of 73) reported that they needed potent analgesics. 15% (11 of 73) reported concerns about analgesic addiction. The level of functional impairment owing to pain, as reported using the ten-point Likert scale, was highest for daily activities and routines (median 9·0, IQR 7·0-10·0) and least for social relationships (5·0, 0·0-9·0). There was no statistically significantly association between cancer-related pain and gender, educational level, or occupation.

INTERPRETATION

Most patients were taking analgesics but a large proportion reported the need for more potent or frequent doses of painkillers. In addition, pain had a significant effect on the patients' lifestyle. These findings indicate poor control of cancer pain. There is an urgent need to address the reasons for this, to alleviate pain and to improve quality of life.

FUNDING

None.

Long-Term Outcomes of the Knee and Hip Arthroplasties in Patients with Alkaptonuria

Alkaptonuria is a rare autosomal recessive metabolic disorder. It is characterized by the accumulation of homogentisic acid in the body due to a lack of enzymes that degrade it. Over time, it results in joint degeneration and eventually leads to ochronosis. Ochronosis refers to bluish-black discoloration of connective and other tissues within the body. In this study, we present 5 distinct cases diagnosed with alkaptonuria. They have undergone 8 total joint replacement surgeries (4 hips and 4 knees) within 8 years (2010-2018). All patients had an excellent outcome over several years. The follow-up period ranged from 2 to 10 years. Although none of the presented cases had intraoperative or postoperative adverse sequelae, we must take care when dealing with patients with ochronotic arthropathy. They carry a higher risk of complications than other patients with osteoarthritis disease. These complications include fractures due to fragile bone quality, muscle or tendon rupture, joint instability, and anesthesia-related complications. Total joint arthroplasty is a valid and safe option in the management of hip and knee ochronotic arthropathy.

A comparison between health research output and burden of disease in Arab countries: evidence from Palestine

BACKGROUND

Research conducted on conditions responsible for the greatest disease burden should be given the highest priority, particularly in resource-limited settings. The present study aimed to assess the research output in relation to disease burden in Palestine and to identify the conditions which are under- or over-investigated, if any.

METHODS

We searched PubMed and Scopus for reports of original research relevant to human health or healthcare authored by researchers affiliated with Palestinian institutions and published between January 2000 and December 2015. We categorised the condition studied in included articles using the Global Burden of Disease (GBD) taxonomy. Data regarding burden of disease (percentage of deaths and disability-adjusted life years (DALYs)) was obtained from the Palestine profile in the GBD study. We examined the degree of discordance between the observed number of published articles for each disease/condition with the expected number based on the proportion of disease burden of that disease/condition.

RESULTS

Our search identified 2469 potentially relevant records, from which 1650 were excluded following the screening of titles and abstracts. Of the remaining 819 full-text articles, we included 511 in our review. Communicable (infectious) diseases (n = 103; 20%) was the condition with the highest number of published studies. However, cancer (n = 15; 3%) and chronic respiratory diseases (n = 15; 3%) were the conditions with the lowest number of published studies. Research output was poorly associated with disease burden, irrespective of whether it was measured in terms of DALYs (rho = -0.116, P = 0.7) or death (rho = 0.217, P = 0.5). Cardiovascular disease, cancer, and maternal and neonatal deaths accounted for more than two-thirds of the total deaths in Palestine (67%), but were infrequently addressed (23%) in published articles.

CONCLUSIONS

There is evidence of research waste measured by a mismatch between the health burden of certain diseases/conditions and the number of published research reports on those diseases/conditions in Palestine. A national research priority-setting agenda should be developed to meet the local community's need for quality evidence to implement independent and informed health policies.

Inpatient management of community-acquired pneumonia at the European Gaza Hospital: a clinical audit

BACKGROUND

Disease severity scores such as CURB-65 are often used to guide the management of patients with community-acquired pneumonia. Early and adequate empirical antibiotic treatment reduces mortality. The aim of this study was to examine the severity assessment and management of patients presenting with community-acquired pneumonia at the European Gaza Hospital in the Gaza Strip and to compare this to the best available evidence.

METHODS

Medical records of all patients admitted to the European Gaza Hospital with a diagnosis of community-acquired pneumonia between Dec 1, 2015, and March 31, 2016, were reviewed retrospectively. Clinical practice was compared with recommendations for severity assessment and the management of community-acquired pneumonia, as reported in guidelines by the National Institute for Health and Care Excellence and the American Thoracic Society. Ethical approval was obtained from the General Directorate of Human Resources.

FINDINGS

141 patients were admitted to the European Gaza Hospital with community-acquired pneumonia during the study period. Records of 41 patients were missing or could not be retrieved. The mean age of patients was 55·9 years (SD 20·2). Blood urea and nitrogen concentrations were not documented for 48 (48%) patients, and respiratory rate was not documented for 73 (73%) patients. The CURB-65 score was determined only for 12 (12%) patients. Microbiological testing was done only for two (2%) patients. Although 18 different antibiotic regimens were used, 81 (81%) patients received a β-lactam plus macrolide combination therapy, either given alone (49 [49%] patients) or with another antibiotic (32 [32%] patients), which is in line with the recommendations for patients admitted to hospital with community-acquired pneumonia. 43 (43%) patients received anti-viral drugs, and 41 (41%) patients received corticosteroids.

INTERPRETATION

Clinicians were poorly adherent to current standards of care in severity assessment and management of community-acquired pneumonia. Moreover, the broad range of antibiotic regimes used, without microbiological guidance, was inappropriate and will have increased the risk of antibiotic resistance. A local evidence-based clinical practice guideline should be developed and implemented. Furthermore, the documentation system should be improved to enhance the continuity of care and clinical auditing.

FUNDING

None.

Awareness and factors influencing breast reconstruction in the Gaza Strip: a cross-sectional study

BACKGROUND

Women are usually given two options after a mastectomy. They can either wear a prosthesis or have a breast reconstruction. Unfortunately, many women in the Gaza Strip are unaware of these options. The aim of this study was to shed light on the awareness and sociocultural factors in women who underwent mastectomy before choosing between options.

METHODS

In this cross-sectional study, we recruited patients who underwent mastectomy in the Gaza Strip. All participants completed a face-to-face questionnaire between Aug 1, 2015, and April 30, 2016. Verbal consent was obtained from all participants.

FINDINGS

173 women with a mean age 51 years (SD 10) were enrolled in this study. 90 (52%) women had low income, and 36 (21%) women had a first-degree relative with breast cancer. 133 (77%) women underwent radical mastectomy, and 29 (17%) women had breast-conserving surgery. 96 (55%) women had tried a breast prosthesis to gain confidence, and 72 (42%) women were unaware of the availability of breast reconstruction in the Gaza Strip. 161 (93%) women expressed a strong desire to have breast reconstruction surgery, whereas 12 (7%) women expressed no interest. The preference for breast reconstruction surgery was justified as a way of regaining positive attitudes from others (135 [84%] women), improving romance and satisfying their husbands (116 [72%]), and regaining self-confidence (37 [23%]). Being unconcerned about the physical appearance was the most common explanation for refusing breast reconstruction surgery (47 [29%] women), whereas 18 (11%) women had a fear of getting unsatisfactory results.

INTERPRETATION

When opting for breast reconstruction surgery, patients appear to be affected by prior knowledge, societal attitudes, body appearance, and romantic relationships. The findings suggest that assessing women's desires, goals, and expectations could help improve service delivery after mastectomy. Efforts should be made to spread knowledge and awareness of breast reconstruction options for women having a mastectomy in the Gaza Strip.

FUNDING

None.

The relation between health research output and burden of disease in Palestine: a systematic review

BACKGROUND

Highest priority should be given to research on conditions responsible for the greatest disease burden. This is particularly important in settings where resources are scarce. The aim of this study was to assess the association between research output and disease burden in the occupied Palestinian territory and to identify the conditions that are under-investigated or over-investigated, if any.

METHODS

We searched PubMed and Scopus for reports of original research relevant to human health or health care that was authored by researchers affiliated with Palestinian institutions and published between Jan 1, 2000, and Dec 31, 2015. We categorised the health condition studied in included articles using the Global Burden of Disease (GBD) taxonomy. Data about the burden of disease (percentage of deaths and disability-adjusted life-years [DALYs]) were obtained from the Palestine profile in the GBD study. We examined the degree of discordance between the observed number of published articles for each disease or health condition with the expected number based on the proportion of disease burden for that disease or health condition.

FINDINGS

We identified 2469 records and excluded 1650 records after screening titles and abstracts. We included 511 of the remaining 819 full-text articles in our review. Research output was poorly associated with disease burden, irrespective of whether measured in DALYs (ρ: -0·116; p=0·7) or death (0·217; p=0·5). Cardiovascular disease, maternal and neonatal health, and cancer accounted for 212 (67%) deaths per 100 000 population in the occupied Palestinian territory, but this was addressed in only 117 (23%) articles.

INTERPRETATION

We found evidence of research waste, as measured by a mismatch between the health burden of disease or health condition and the number of published research reports about that disease or condition in Palestine. National research priority setting should be developed to meet the local community's need of quality evidence in order to develop independent and informed health policies.

FUNDING

None.

Awareness, attitudes and knowledge about evidencebased medicine among doctors in Gaza: a crosssectional survey

Evidence-based medicine (EBM) has emerged as a strategy to integrate research evidence within clinical decision-making. We have explored awareness, knowledge and attitudes about EBM among doctors in the Gaza Strip. In 2014, we conducted a cross-sectional survey among doctors working in health centres in Gaza, using a 20 item, web-based self-administered questionnaire. Approximately two thirds of the respondents welcomed EBM in principle, and believed that it could improve patient care. However, they had a relatively low level of knowledge about EBM. The main barriers to EBM mentioned by respondents were lack of knowledge needed to practise EBM [n = 47 (35%)]; negative attitude among senior colleagues [n = 34 (25%)]; lack of relevant resources [n = 31 (23%)]; work overload [n = 27 (20%)]; and lack of institutional support [n = 248 (18%)]. Thus, there are personal and organisational barriers to its practice that need to be addressed.

The quality of reports of medical and public health research from Palestinian institutions: a systematic review

OBJECTIVE

Over the past decade, there has been an increase in reports of health research from Palestine, but no assessment of their quality. We have assessed the quality of reports of Palestinian health research and factors associated with it.

DESIGN

This is a systematic review.

INCLUSION CRITERIA

We searched Medline and Scopus for reports of original research relevant to human health or healthcare authored by researchers affiliated with Palestinian institutions and published between January 2000 and August 2015 inclusive.

OUTCOMES

We used international guidelines to assess report quality, classifying as adequate those with ≥50% of items completely addressed.

RESULTS

Of 2383 reports identified, 497 met our inclusion criteria. Just over half (264; 55%) of these were published after 2010. 354 (71%) of first authors were affiliated with Palestinian institutions; 261 (53%) reports had coauthors from outside Palestine. The majority of the reports in our study were inadequately reported (342; 69%), and none had adequately reported all items. Of 439 observational studies, 11 (2.5%) reports provided adequate descriptions of eligibility criteria and selection procedures; 35 (8%) reported efforts to address potential sources of bias; 50 (11.4%) reported the basis for the study sample size; and funding sources were mentioned in 74 reports (17%). Higher reporting quality was associated with international affiliation of the first author (prevalence ratio (PR) 1.6 (95% CI 1.2 to 2.1)), international collaboration (PR 2.9 (95% CI 1.7 to 5.0)), international funding (PR 1.9 (95% CI1.5 to 2.5)), publication after 2005 (PR 3.9 (95% CI 1.8 to 8.5)) and four or more coauthors (PR 1.5 (95% CI 1.1 to 2.1)).

CONCLUSION

Although the quality of reports of Palestinian research has improved in recent years, it remains well below an acceptable standard. International reporting guidelines should be used to guide research design and improve the quality of reports of research.

TRIAL REGISTRATION NUMBER

The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) registery (registration number: CRD42015027553).

Specialized stroke rehabilitation services in seven countries: Preliminary results from nine rehabilitation centers

BACKGROUND

There is a lack of defined levels of rehabilitation, indicating possibly random content and access to specialized services.

AIMS AND/OR HYPOTHESIS

The aim of the study was to perform a multinational descriptive study of specialized rehabilitation in persons with stroke, to elucidate what the different centers define as prerequisites for specialized rehabilitation, and to analyze whether these descriptions map to currently applied standards or constructs of specialized rehabilitation. A secondary aim was to look for similarities and differences between therapies and services for persons with stroke in the sub-acute stage in the different institutions.

METHODS

Descriptive data of the collaborating centers regarding structure and processes of services were recorded and compared with the British Society of Rehabilitation Medicine and Specialized Services National Definitions sets.

RESULTS

Comparisons of the definitions showed that all centers admitted severely disabled persons with stroke, in need of complex rehabilitation, and provided high levels of physical services, with specialized equipment and facilities. However, funding, size, university affiliation, quality accreditation, staffing levels, specialist training, cognitive and vocational services, coordination of the professional teams, admission procedures, time and type of therapies, estimated length of stay, and follow-up procedures differed between the centers.

CONCLUSION

This multinational study of specialized stroke rehabilitation centers shows that a universal definition of specialized rehabilitation is possible, even in quite different countries and settings, in terms of general principles. There were however differences in structures and procedures, which may influence patients' outcomes, indicating a need for refinement of the definitions to be globally applicable.

Interventions for treating phosphorus burns

BACKGROUND

Phosphorus burns are rarely encountered in usual clinical practice and occur mostly in military and industrial settings. However, these burns can be fatal, even with minimal burn area, and are often associated with prolonged hospitalisation.

OBJECTIVES

To summarise the evidence of effects (beneficial and harmful) of all interventions for treating people with phosphorus burns.

SEARCH METHODS

In October 2013 for this first update we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library);Ovid OLDMEDLINE; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL and Conference Proceedings Citation Index - Science (CPCI-S). We did not apply any methodological filters or restrictions on the basis of study design, language, date of publication or publication status.

SELECTION CRITERIA

Any comparisons of different ways of managing phosphorus burns including, but not restricted, to randomised trials.

DATA COLLECTION AND ANALYSIS

We found two non-randomised comparative studies, both comparing patients treated with and without copper sulphate.

MAIN RESULTS

These two comparative studies provide no evidence to support the use of copper sulphate in managing phosphorus burns. Indeed the small amount of available evidence suggests that it may be harmful.

AUTHORS' CONCLUSIONS

First aid for phosphorus burns involves the common sense measures of acting promptly to remove the patient's clothes, irrigating the wound(s) with water or saline continuously, and removing phosphorus particles. There is no evidence that using copper sulphate to assist visualisation of phosphorus particles for removal is associated with better outcome, and some evidence that systemic absorption of copper sulphate may be harmful. We have so far been unable to identify any other comparisons relevant to informing other aspects of the care of patients with phosphorus burns. Future versions of this review will take account of information in articles published in languages other than English, which may contain additional evidence based on treatment comparisons.

Interventions for treating phosphorus burns

BACKGROUND

Phosphorus burns are rarely encountered in usual clinical practice and occur mostly in military and industrial settings. However, these burns can be fatal, even with minimal burn area, and are often associated with prolonged hospitalisation.

OBJECTIVES

To summarise the evidence of effects (beneficial and harmful) of all interventions for treating people with phosphorus burns.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 30 September 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid OLDMEDLINE (1947 to 1965); Ovid MEDLINE (1950 to September Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 29 September 2011); Ovid EMBASE (1980 to 2011 Week 38); EBSCO CINAHL (1982 to 23 September 2011) and Conference Proceedings Citation Index - Science (CPCI-S) (1990 to 30 September 2011).

SELECTION CRITERIA

Any comparisons of different ways of managing phosphorus burns including, but not restricted, to randomised trials.

DATA COLLECTION AND ANALYSIS

We found two non-randomised comparative studies, both comparing patients treated with and without copper sulphate.

MAIN RESULTS

These two comparative studies provide no evidence to support the use of copper sulphate in managing phosphorus burns. Indeed the small amount of available evidence suggests that it may be harmful.

AUTHORS' CONCLUSIONS

First aid for phosphorus burns involves the common sense measures of acting promptly to remove the patient's clothes, irrigating the wound(s) with water or saline continuously, and removing phosphorus particles. There is no evidence that using copper sulphate to assist visualisation of phosphorus particles for removal is associated with better outcome, and some evidence that systemic absorption of copper sulphate may be harmful. We have so far been unable to identify any other comparisons relevant to informing other aspects of the care of patients with phosphorus burns. Future versions of this review will take account of information in articles published in languages other than English, which may contain additional evidence based on treatment comparisons.