Background:Lateral ligament ankle sprains are the single most common sports injury.Objective:To determine the functional outcome of the ankle joint after a moderate or severe inversion injury, comparing standard treatment with an elastic support bandage against an Aircast ankle brace.Design:Prospective, randomised controlled trial.Setting:Two accident and emergency departments.Method:Fifty patients presenting consecutively were randomised into two equal groups: one group was treated with an elastic support bandage and the other with an Aircast ankle brace. All patients were given a standardised advice sheet referring to rest, ice, compression, and elevation. Patients were reviewed after 48–72 hours, 10 days, and one month.Primary outcome measure:Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method (maximum score 90).Secondary outcome measure:The difference in ankle girth (swelling) and pain score at 10 days.Results:Seventeen patients in the elastic support bandage group (six defaulted, two excluded) and 18 patients in the Aircast ankle brace group (six defaulted, one excluded) completed the study. There were no significant differences between the two groups at presentation in terms of age (mean 35.3 and 32.6 years respectively), sex, dominant leg, left or right ankle injured, previous injury, time to presentation (median three and four hours respectively), difference in ankle girth (mean 14.5 and 14.3 mm respectively), and pain scores (mean 6.2 and 5.8 respectively). The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic bandage group at 10 days (mean 50v35, p  =  0.028, 95% confidence interval (CI) 1.7 to 27.7) and one month (mean 68v55, p  =  0.029, 95% CI 1.4 to 24.8) (Student’sttest). There was no difference between the groups in the secondary outcome measures (swelling, p  =  0.09; pain, p  =  0.07). When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors, the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days (p  =  0.009) and one month (p  =  0.024).Conclusion:The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage.

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The use of cannabis in our society is a common problem and the subject of much medical and political debate. We present a case in which a 17‐year‐old male regular cannabis user developed a large swollen uvula (uvulitis) and partial upper airway obstruction after smoking cannabis. Symptoms resolved with the administration of corticosteroids and antihistamines.

Naltrexone is a long acting opioid receptor antagonist used in controlled opioid withdrawal drug programmes. When taken by an opioid dependent patient an acute withdrawal reaction will be precipitated. The case is presented where a known opioid drug misuser inadvertently ingested naltrexone in conjunction with heroin resulting in severe agitation, requiring heavy sedation followed by general anaesthesia to enable investigation and management of his clinical condition. N altrexone is a long acting opioid receptor antagonist used in drug rehabilitation programmes to maintain opioid abstinence. However, when consumed in conjunction with an opioid substance, prolonged opioid withdrawal will be precipitated resulting in unpredictable and life threatening medical consequences. We present a case where a known drug misuser consumed naltrexone in conjunction with heroin. CASE REPORTA 39 year old man presented to the accident and emergency department having taken up to three, 50 mg tablets of naltrexone and having smoked an unknown quantity of heroin. He was known to be an injecting drug user and to suffer from epilepsy. No other recreational drugs, alcohol, or prescribed medications were known to have been consumed. On arrival he was extremely agitated being restrained by four police officers. He was confused, sweating, with episodes of profuse projectile diarrhoea and vomiting. Glasgow Coma Scale was 12 (spontaneous eye opening, localising to pain, and using inappropriate speech). Pupils were dilated but reactive to light. Heart rate was regular at 180 beats/minute and respiratory rate 40 breaths/minute. Blood pressure, oxygen saturation, blood glucose, and temperature were normal. There was no evidence of head injury and no history of seizure. Urea, electrolytes, full blood count, and arterial blood gas measurements were normal. Initial attempts at sedation using a combination of titrated intravenous midazolam and droperidol were unsuccessful. After receiving a total of 20 mg midazolam and 15 mg droperidol he continued to be confused, agitated, and increasingly violent. An urgent CT head scan was arranged to exclude any intracranial pathology. To expedite this he was anaesthetised and ventilated. Rapid sequence induction of anaesthesia was carried out using 200 mg propofol, and 100 mg suxamethonium. Anaesthesia was maintained with a propofol infusion and incremental paralysis with atracurium.CT of his brain was normal. A lumbar puncture was performed while the patient was still anaesthetised. This showed no abnormality. The patient was extubated four hours after induction and transferred to the medical high dependency unit for observation. Further episodes of agitation occurred overnight requiring additional sedation with intravenous midazolam. The following morning he took his own discharge. Retrospectively urine toxicology screen confirmed the presence of cannabinoids, benzodiazepines, and opioids.

Objective: To determine the impact of a newly opened prison on an accident and emergency (A&E) department. Method: A new category B prison opened in April 1999, the first privately run prison in Scotland and the third largest in population. All prisoners referred to the A&E department for treatment were identified prospectively during the first year after the opening of the prison. Results: 99 prisoners and four members of staff attended during the one year period. Ages ranged from 18-64 years with a mean age of 29.8 years. Presentations were as a result of deliberate self harm (22%), injury after violence (18%), sports injury (15%), surgical condition (15%), medical illness (13%), accidental injury (9%), ENT problem (2%), and miscellaneous (6%). Thirty seven prisoners (35.6%) were admitted to the hospital. Further review at outpatient clinics was arranged for 15 prisoners. One prisoner died, the result of suicide by hanging. The remaining prisoners were returned to the prison for further management by the prison medical and nursing team. Twelve prisoners re-attended a total of 37 times, ranging from twice to a maximum of eight visits. Some 42.3% of attendances were during "working hours" (09.00-17.00) and 57.7% attended "out of hours" (17.00-09.00). Twenty four referrals (23.1%) were deemed inappropriate by the prison medical team on retrospective review. Sixteen of these occurred "out of hours". Forty one prisoners (39.4%) were known to have a history of injecting drug misuse. Including re-attenders, 59 presentations (56.7%) to the A&E department had a history of injecting drug misuse. Of these 41 prisoners, 11 (26.8%) were hepatitis C positive, with eight of these having a positive polymerase chain reaction test. No prisoners had HIV and only one prisoner was hepatitis B positive. Conclusion: The opening of the prison resulted in only a slight increase in the workload of the A&E department. A significant proportion of prisoners were admitted to the hospital highlighting the practical and logistical problems of managing people restrained and in custody. Most cases can be safely referred back to the prison. Increased input is required from the prison medical team when dealing with deliberate self harm, frequent attenders, and "out of hours" referrals. All A&E staff must be aware of the increased risk of hepatitis C infection when dealing with a confined prison population.A ll accident and emergency (A&E) departments have to treat patients who are physically restrained, either in police custody or from a local prison. These patients are sent for treatment either by the police officer in charge at the local police station, the police casualty surgeon, or by the medical and nursing members of the prison healthcare team. Management of these patients present a number of problems to medical and nursing staff and may disrupt the normal routine of the department.The opening of a new prison in April 1999 within the catchment area of Crosshouse Hospital, Kilmarnock, Scotland, gave a unique opportunity to study the impact...