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Fractures: Appendices JQ National Clinical Guideline Centre 1 DRAFT FOR CONSULTATION Fractures (non-complex): assessment and management Fractures: diagnosis, management and follow-up of fractures Clinical guideline <...> Appendices J - Q August 2015 Draft for consultation Commissioned by the National Institute for Health and Care Excellence Fractures: Appendices J-Q Contents 1 Disclaimer Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer. Copyright National Clinical Guideline Centre, 2015 Funding National Institute for Health and Care Excellence National Clinical Guideline Centre, 2015 Fractures: Appendices J-Q Contents Contents Appendices .................................................................................................................................. 5 Appendix J: Forest plots ................................................................................................................. 5 Appendix K: Excluded clinical studies ........................................................................................... 53 Appendix L: Excluded economic studies ....................................................................................... 71 Appendix M:Cost-effectiveness analysis: Imaging of suspected scaphoid fractures .................... 73 Appendix N: Mapping of DRAFFT trial data to predict an EQ5D index score from a PRWE score .......................................................................................................................... 98 Appendix O: Qualitative study checklist ...................................................................................... 108 Appendix P: Research recommendations ................................................................................... 110 Appendix Q: NICE technical team ................................................................................................ 118 References ................................................................................................................................ 119 1 National Clinical Guideline Centre, 2015 4 Fractures: Appendices J-Q Forest plots 1 Appendices 2 3 Appendix J: Forest plots 4 J.1 Initial pain management and immobilisation 5 J.1.1 Initial pharmacological pain management 6 J.1.1.1 Intranasal Opioid versus Intravenous Opioid - Children Figure 1: Pain at 30 minutes (Final Score) Mean Difference Mean Difference Study or Subgroup Mean Difference SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Borland 2007 -4 6.12 100.0% -4.00 [-15.99, 7.99] Total (95% CI) 100.0% -4.00 [-15.99, 7.99] Heterogeneity: Not applicable -100 -50 0 50 100 Test for overall effect: Z = 0.65 (P = 0.51) Favours Intravenous Favours Intranasal 7 Figure 2: Pain Score at 30 minutes (Final Score) Intravenous Intranasal Mean Difference Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Furyk 2009 4.03 2.3 37 3.51 2.4 35 100.0% 0.52 [-0.57, 1.61] Total (95% CI) 37 35 100.0% 0.52 [-0.57, 1.61] Heterogeneity: Not applicable -10 -5 0 5 10 Test for overall effect: Z = 0.94 (P = 0.35) Favours Intravenous Favours Intranasal 8 Figure 3: Nausea Intranasal Intravenous Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Borland 2007 1 32 0 33 25.2% 3.09 [0.13, 73.19] Furyk 2009 0 35 1 37 74.8% 0.35 [0.01, 8.36] Total (95% CI) 67 70 100.0% 1.04 [0.15, 7.29] Total events 1 1 Heterogeneity: Chi² = 0.90, df = 1 (P = 0.34); I² = 0% 0.1 0.2 0.5 1 2 5 10 Test for overall effect: Z = 0.04 (P = 0.97) Favours Intranasal Favours Intravenous 9 Figure 4: Need for further analgesia Intranasal Intravenous Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Borland 2007 1 33 1 34 66.9% 1.03 [0.07, 15.80] Furyk 2009 1 35 0 37 33.1% 3.17 [0.13, 75.24] Total (95% CI) 68 71 100.0% 1.74 [0.24, 12.77] Total events 2 1 Heterogeneity: Chi² = 0.28, df = 1 (P = 0.60); I² = 0% 0.1 0.2 0.5 1 2 5 10 Test for overall effect: Z = 0.54 (P = 0.59) Favours Intranasal Favours Intravenous 10 National Clinical Guideline Centre, 2015 5 Fractures: Appendices J-Q Forest plots 1 J.1.1.2 Oral Codeine versus Oral Codeine (Children) Figure 5: Pain at 180 minutes (Change Score) Mean Difference Mean Difference Study or Subgroup Mean Difference SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Charney 2008 -0.4 0.15 100.0% -0.40 [-0.69, -0.11] Total (95% CI) 100.0% -0.40 [-0.69, -0.11] Heterogeneity: Not applicable -10 -5 0 5 10 Test for overall effect: Z = 2.67 (P = 0.008) Favours Oxycodeine Favours Codeine 2 3 Figure 6: Nausea Oxycodone Codeine Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Charney 2008 1 51 1 56 100.0% 1.10 [0.07, 17.10] Total (95% CI) 51 56 100.0% 1.10 [0.07, 17.10] Total events 1 1 Heterogeneity: Not applicable 0.1 0.2 0.5 1 2 5 10 Test for overall effect: Z = 0.07 (P = 0.95) Favours Oxycodone Favours Codeine 4 5 J.1.1.3 Oral NSAIDs versus Oral Codeine (Children) Figure 7: Pain at 60 minutes (Changes Score) Oral NSAIDs Oral Codeine Mean Difference Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Clark 2007 -29 25.26 58 -7 3.61 50 100.0% -22.00 [-28.58, -15.42] Total (95% CI) 58 50 100.0% -22.00 [-28.58, -15.42] Heterogeneity: Not applicable -50 -25 0 25 50 Test for overall effect: Z = 6.56 (P < 0.00001) Favours Oral NSAIDs Favours Oral Codeine 6 Figure 8: Nausea Oral NSAIDs Oral Codeine Peto Odds Ratio Peto Odds Ratio Study or Subgroup Events Total Events Total Weight Peto, Fixed, 95% CI Peto, Fixed, 95% CI Koller 2007 0 22 0 22 Not estimable Total (95% CI) 22 22 Not estimable Total events 0 0 Heterogeneity: Not applicable 0.01 0.1 1 10 100 Test for overall effect: Not applicable Favours Oral NSAIDs Favours Oral Codeine 7 Figure 9: Need for further analgesia 8 National Clinical Guideline Centre, 2015 6 Fractures: Appendices J-Q Forest plots 1 J.1.1.4 Oral NSAIDs versus Oral Paracetamol (Children) Figure 10: Pain at 60 minutes (Change Score) Oral NSAIDs Oral Paracetamol Mean Difference Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Clark 2007 -29 25.26 58 -14 18.21 51 100.0% -15.00 [-23.20, -6.80] Total (95% CI) 58 51 100.0% -15.00 [-23.20, -6.80] Heterogeneity: Not applicable -50 -25 0 25 50 Test for overall effect: Z = 3.59 (P = 0.0003) Favours Oral NSAIDs Favours Oral Paracetamol 2 Figure 11: Nausea Oral NSAIDs Oral Paracetamol Peto Odds Ratio Peto Odds Ratio Study or Subgroup Events Total Events Total Weight Peto, Fixed, 95% CI Peto, Fixed, 95% CI Shepard 2009 2 29 0 43 100.0% 12.41 [0.72, 213.59] Total (95% CI) 29 43 100.0% 12.41 [0.72, 213.59] Total events 2 0 Heterogeneity: Not applicable 0.5 0.7 1 1.5 2 Test for overall effect: Z = 1.73 (P = 0.08) Favours Oral NSAIDs Favours Oral Paracetamol 3 Figure 12: Delayed Union Oral NSAIDs Oral Paracetamol Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Shepard 2009 0 29 0 43 Not estimable Total (95% CI) 29 43 Not estimable Total events 0 0 Heterogeneity: Not applicable 0.1 0.2 0.5 1 2 5 10 Test for overall effect: Not applicable Favours Oral NSAIDs Favours Oral Paracetamol 4 Figure 13: Need for further analgesia at 2 hours Oral NSAIDs Oral Paracetamol Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Shepard 2009 4 29 3 43 100.0% 1.98 [0.48, 8.19] Total (95% CI) 29 43 100.0% 1.98 [0.48, 8.19] Total events 4 3 Heterogeneity: Not applicable 0.1 0.2 0.5 1 2 5 10 Test for overall effect: Z = 0.94 (P = 0.35) Favours Oral NSAIDs Favours Oral Paracetamol 5 Figure 14: Need for further analgesia at 48 hours Oral NSAIDs Oral Paracetamol Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Shepard 2009 2 29 2 43 100.0% 1.48 [0.22, 9.94] Total (95% CI) 29 43 100.0% 1.48 [0.22, 9.94] Total events 2 2 Heterogeneity: Not applicable 0.1 0.2 0.5 1 2 5 10 Test for overall effect: Z = 0.41 (P = 0.68) Favours Oral NSAIDs Favours Oral Paracetamol 6 7 J.1.1.5 Oral Codeine versus Oral Paracetamol (Children) Figure 15: Pain at 60 minutes (Change Score) Oral Codeine Oral Paracetamol Mean Difference Mean Difference Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Clark 2007 -7 3.61 50 -14 18.21 51 100.0% 7.00 [1.90, 12.10] Total (95% CI) 50 51 100.0% 7.00 [1.90, 12.10] Heterogeneity: Not applicable -100 -50 0 50 100 Test for overall effect: Z = 2.69 (P = 0.007) Favours Oral Codeine Favours Oral Paracetamol National Clinical Guideline Centre, 2015 7 Fractures: Appendices J-Q Forest plots 1 2 J.1.1.6 Oral Opioid versus Intravenous Opioid (Children) Figure 16: Pain at 30 minutes (Final Score) Mean Difference Mean Difference Study or Subgroup Mean Difference SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Mahar 2007 -10.94 4.94 100.0% -10.94 [-20.62, -1.26] Total (95% CI) 100.0% -10.94 [-20.62, -1.26] Heterogeneity: Not applicable -50 -25 0 25 50 Test for overall effect: Z = 2.21 (P = 0.03) Favours Oral Opioid Favours IV Opiod 3 Figure 17: Pain at 60 minutes (Final Score) Mean Difference
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