A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus.

BACKGROUND: Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS: Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION: Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS: This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Scalable Route to Colloidal NixCo3-xS4 Nanoparticles with Low Dispersity Using Amino Acids.

The thiospinel group of nickel cobalt sulfides (NixCo3-xS4) are promising materials for energy applications such as supercapacitors, fuel cells, and solar cells. Solution-processible nanoparticles of NixCo3-xS4 have advantages of low cost and fabrication of high-performance energy devices due to their high surface-to-volume ratio, which increases the electrochemically active surface area and shortens the ionic diffusion path. The current approaches to synthesize NixCo3-xS4 nanoparticles are often based on hydrothermal or solvothermal methods that are difficult to scale up safely and efficiently and that preclude monitoring the reaction through aliquots, making optimization of size and dispersity challenging, typically resulting in aggregated nanoparticles with polydisperse sizes. In this work, we report a scalable "heat-up" method to colloidally synthesize NixCo3-xS4 nanoparticles that are smaller than 15 nm in diameter with less than 15% in size dispersion, using two inexpensive, earth-abundant sulfur sources. Our method provides a reliable synthetic pathway to produce phase-pure, low-dispersity, gram-scale nanoparticles of ternary metal sulfides. This method enhances the current capabilities of NixCo3-xS4 nanoparticles to meet the performance demands to improve renewable energy technologies.

Anatomical shoulder replacements in young patients: A systematic review and meta-analysis.

Introduction: Increasing numbers of young patients receive shoulder replacements. Greater information on outcomes is needed to inform implant choice. The aim of this study was to investigate the survivorship and clinical effectiveness of hemiarthroplasty and anatomical total shoulder arthroplasty (TSA) in patients younger than 65 years. Method: A systematic review was performed of MEDLINE, EMBASE, CENTRAL, The Cochrane Database of Systematic Reviews and National Joint Registry reports. The primary outcomes were implant survival and change in perioperative shoulder scores. Results: Meta-analysis of implant survivorship was performed of six studies reporting on 416 patients. Implant survival was 86.1% (72.1,100) at 10 years for hemiarthroplasty and 82.3% (64.6,100) for TSA. 20 year survival was 80.0% for hemiarthroplasty (72.5,87.4) and 75.0% (56.9,93.1) for TSA. Ten studies were included in the meta-analysis of shoulder scores, multiple instruments were used. The standardised mean difference between pre-operative and post-operative shoulder scores was 2.15 (1.95, 2.35) for TSA at 4.2-4.9 years, and 2.72 (1.98,3.47) for hemiarthroplasty at 3.8-6 years. Conclusion: Over 80% of shoulder replacements last more than 10 years, and 75% last more than 20 years. Significant improvements in shoulder scores are shown at all time points.

Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis.

INTRODUCTION: Identifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40% and 95% and is being increasingly adopted. The BioLIFT is an augmentation of the LIFT with an intersphincteric bioprosthetic mesh and has reported healing rates between 69% and 94%. Despite increased costs and potential complications associated with mesh, the evidence comparing healing rates between BioLIFT and LIFT is unknown. This study details the protocol for a systematic review and meta-analysis of BioLIFT and LIFT to compare outcomes associated with each procedure. METHODS AND ANALYSIS: MEDLINE, EMBASE and the Cochrane Database will be searched from inception using a search strategy designed by an information specialist. Randomised controlled trials, prospective and retrospective cohort studies, consecutive series, cross-sectional studies and case series with more than five patients will be included. Both comparative and single group studies will be included. The eligible population will be adult patients undergoing BioLIFT or LIFT for trans-sphincteric anal fistula. The primary outcome will be primary healing rate. Secondary outcomes will capture secondary healing rate and complications. Abstract, full text and data extraction will be completed independently and in duplicate by two reviewers. Study risk of bias will be assessed using Risk of Bias In Non-randomized Studies - of Interventions and the Risk of Bias (RoB 2.0) tool. Quality of evidence for outcomes will be evaluated using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis will be performed using a random-effects inverse variance model. Subgroup and sensitivity analyses will be explored in relation to complex fistula characteristics and patients who have undergone previous LIFT. Heterogeneity will be assessed using the I2 statistic. ETHICS AND DISSEMINATION: This review does not require research ethics board approval. This study will be completed in September 2022. The findings of this study will be disseminated through peer-reviewed international conferences and journals. PROSPERO REGISTRATION NUMBER: CRD42020127996.

Growth dynamics and amorphous-to-crystalline phase transformation in natural nacre.

Biominerals, such as nacreous bivalve shells, are important archives of environmental information. Most marine calcifiers form their shells from amorphous calcium carbonate, hypothesised to occur via particle attachment and stepwise crystallisation of metastable precursor phases. However, the mechanism of this transformation, including the incorporation of trace elements used for environmental reconstructions, are poorly constrained. Here, using shells of the Mediterranean mussel, we explore the formation of nacre from the meso- to the atomic scale. We use a combination of strontium pulse-chase labelling experiments in aquaculture and correlated micro- to sub-nanoscale analysis to show that nacre grows in a dynamic two-step process with extensional and space-filling growth components. Furthermore, we show that nacre crystallizes via localised dissolution and reprecipitation within nanogranules. Our findings elucidate how stepwise crystallization pathways affect trace element incorporation in natural biominerals, while preserving their intricate hierarchical ultrastructure.

Using load sensing insoles to identify knee kinetic asymmetries during landing in patients with an Anterior Cruciate Ligament reconstruction.

BACKGROUND: Knee extension moment asymmetry is a known second anterior cruciate ligament injury risk factor in patients who have had an anterior cruciate ligament reconstruction. Traditionally, assessing asymmetries requires motion capture and force platforms which are expensive and occupy a large space. Wireless force sensing insoles could be a feasible surrogate. METHODS: Twenty-nine patients following anterior cruciate ligament reconstruction performed ten bilateral stop jumps while insole forces, ground reaction forces, and lower extremity kinematics were collected. Peak knee extension moment symmetry was computed using the kinematic and kinetic data, and peak impact force symmetry and impulse symmetry were computed using both the insole force data and vertical ground reaction force data. The relationship between outcomes was analyzed using Pearson correlation coefficients. Patients were classified as symmetric or asymmetric for each outcome based on an 85% symmetry cutoff. The resulting classifications were qualitatively compared across outcome measures. FINDINGS: Peak knee extension moment symmetry had a strong association with the force plate symmetry outcomes (r = 0.72-0.96, p < 0.001) and a moderate to strong association with insole symmetry outcomes (r = 0.67-0.77, p < 0.001). There was strong agreement between insole and force plate symmetry outcomes (r = 0.69-0.90, p < 0.001). Four patients were identified as symmetric when using the peak knee extension moment symmetry, five when using force plate data, and eight when using insole data. INTERPRETATION: Force sensing insoles could be used as a surrogate for knee extension moment asymmetry in patients who have had an anterior cruciate ligament reconstruction.

Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus.

BACKGROUND: Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking. OBJECTIVES: We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae. METHODS: Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method. RESULTS: Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded. CONCLUSIONS: Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking.

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

The potential impact of post-COVID symptoms in the healthcare sector.

BACKGROUND: The phenomenon of post-COVID syndrome (PCS) is evolving from an abstract array of non-specific symptoms to an identifiable clinical entity of variable severity. Its frequency and persistence have implications for service delivery and workforce planning. AIMS: This study was aimed to assess the prevalence of symptoms consistent with PCS and the subjective degree of recovery in a cohort of healthcare workers, focusing on those who have returned to work. METHODS: A study population of 1176 was surveyed when attending for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing. Two sub-groups were identified: those with known (i.e. diagnosed on PCR testing) and assumed (i.e. antibody evidence of previous infection) SARs-CoV-2 infection, at least 12 weeks prior to the study. Each group was asked about their subjective degree of recovery and the nature of their persistent symptoms. Results were analysed via excel and SPSS. RESULTS: In total, 144 employees showed PCR evidence of previous infection, with 139 of these being infected at least 12 weeks prior to the study. Of these 139, only 19% (n = 26) reported feeling 100% recovered, and 71% reported persistent symptoms. Of those with assumed SARS-CoV-2 infection (n = 78), 32 (41%) were truly asymptomatic since the commencement of the pandemic, while 46 (59%) described symptoms suggestive of possible infection at least 12 weeks prior to the study. Of this latter group, 23% (n = 18) also reported residual symptoms. CONCLUSIONS: PCS is prevalent among this group, including those not previously diagnosed with COVID-19. Its' frequency and duration present challenges to employers with regards to the management of work availability and performance.

A type VI acromioclavicular joint injury: subcoracoid dislocation in a patient with polytrauma.

The Rockwood type VI acromioclavicular joint injury describes subcoracoid dislocation of the distal end of the clavicle. This injury pattern is exceedingly rare, with only 12 cases described in the literature. Diagnosis can be challenging; it is often the result of a high-energy mechanism and patients frequently have other severe distracting injuries. We report the case of a 23-year-old man who presented to our department after falling from a fifth-floor balcony. Alongside multiple intra-abdominal and musculoskeletal injuries, the patient sustained a type VI acromioclavicular joint dislocation. This injury was not picked up on the initial clinical assessment or described in the initial radiology report, with the diagnosis only made upon subsequent repeat review of the imaging by the admitting team. Fortunately, this delay did not increase the time to the patient receiving appropriate treatment. Despite its rarity, awareness of this injury pattern and its association with polytrauma is essential to reduce the risk of the diagnosis being overlooked in the acute setting.

When infection isn't infection.

Following open reduction and internal fixation for a proximal humerus fracture a 71-year-old man re-presented with wound changes consistent with infection and elevated inflammatory markers. No significant improvement was seen with concomitant intravenous antibiotics and multiple debridement procedures. This case was further complicated by soft tissue breakdown at the site of a left thigh haematoma also requiring debridement. Surgical site infections represent the most common cause of morbidity postoperatively. This case highlights the importance of considering a number of differential diagnoses. A diagnosis of pyoderma gangrenosum prompted systemic corticosteroid therapy giving rapid clinical improvement.

Comparison of Ligation of the Intersphincteric Fistula Tract and BioLIFT for the Treatment of Transsphincteric Anal Fistula: A Retrospective Analysis.

BACKGROUND: Ligation of the intersphincteric fistula tract is a sphincter-preserving technique for the treatment of anal fistulas. The BioLIFT modification involves the placement of a biologic mesh in the intersphincteric plane. Advocates of this modification state improved healing rates, however evidence for this is lacking, and this approach costs significantly more. OBJECTIVE: The purpose of this study was to compare the healing rates of the ligation of the intersphincteric fistula tract with the BioLIFT. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a tertiary care hospital from April 2008 to April 2018. PATIENTS: All adult patients with transsphincteric anal fistulas were included. Patients were excluded if they had IBD, more than 1 fistula tract operated on simultaneously, or a previous attempt at repair. MAIN OUTCOME MEASURES: The primary outcome was primary healing of the fistula tract, and secondary outcomes included overall success, complications, and time to recurrence. RESULTS: There were 119 cases (75 ligation of the intersphincteric fistula tract and 44 BioLIFTs). One surgeon performed 84% of the BioLIFT cases. The primary healing rate was 75.0% versus 58.7% (p = 0.08), and the complication rate was 22.7% versus 17.3% (p = 0.48; BioLIFT vs ligation of intersphincteric fistula tract). After multivariate logistic regression, the BioLIFT had a significantly better healing rate (OR = 2.38 (95% CI, 1.01-5.62); p = 0.048). Median follow-up was 9 versus 29 weeks (BioLIFT vs ligation of intersphincteric fistula tract). Kaplan-Meier analysis demonstrated no difference in the time to recurrence (p = 0.48). LIMITATIONS: This study was limited by the retrospective nature, different lengths of follow-up, and varying case numbers between the surgeons. CONCLUSIONS: The BioLIFT modification is safe and effective for the treatment of anal fistulas but has a higher cost. This modification warrants additional prospective studies to establish its benefits over the ligation of the intersphincteric fistula tract procedure. See Video Abstract at http://links.lww.com/DCR/B139. COMPARACIÓN DE LIFT VERSUS BIOLIFT PARA EL TRATAMIENTO DE LA FÍSTULA ANAL TRANSFINTERÉRICA: UN ANÁLISIS RETROSPECTIVO: Ligadura del tracto de la fístula interesfintérica es una técnica para preservación del esfínter en el tratamiento de las fístulas anales. La modificación BioLIFT implica la colocación de una malla biológica en el plano interesfintérico. Protagonistas de la modificación mejoraron las tasas de curación, sin embargo, carecen evidencias definitivas y la técnica eleva costos significativamente.Comparar las tasas de curación de ligadura del tracto de la fístula interesfintérica con el BioLIFT.Estudio de cohorte retrospectivo.Hospital de atención de tercer nivel desde abril de 2008 hasta abril de 2018.Se incluyeron todos los pacientes adultos con fístulas anales transfinteréricas. Los pacientes fueron excluidos si tenían enfermedad inflamatoria intestinal, más de un tracto fistuloso operado simultáneamente o con un intento previo de reparación.El resultado principal fue la curación primaria del tracto fistuloso y los resultados secundarios incluyeron el éxito en general, las complicaciones y tiempo hasta recurrencia.Se registraron 119 casos (75 ligaduras del tracto de la fístula interesfintérica y 44 BioLIFT). Un cirujano realizó el 84% de los casos de BioLIFT. La tasa de curación primaria fue del 75.0% vs 58.7%, p = 0.08, y la tasa de complicaciones fue del 22.7% vs 17.3%, p = 0.48 comparando BioLIFT vs ligadura del tracto de la fístula interesfintérica. Después de la regresión logística multivariada, el BioLIFT tuvo una tasa de curación significativamente mejor (OR 2.38 [IC 95% 1.01-5.62], p = 0.048). La mediana de seguimiento fue de 9 vs 29 semanas (BioLIFT vs ligadura del tracto de la fístula interesfintérica). El análisis de Kaplan-Meier no demostró diferencias en el tiempo hasta la recurrencia (p = 0,48).Este estudio estuvo limitado por ser retrospectivo, las diferentes duraciones de seguimiento y el número variable de casos entre los cirujanos.La modificación BioLIFT es segura y efectiva para el tratamiento de las fístulas anales pero tiene un costo más alto. Esta modificación amerita más estudios prospectivos para establecer los beneficios sobre ligadura del tracto de la fístula interesfintérica. Consulte Video Resumen en hhttp://links.lww.com/DCR/B139.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic.

CLINICAL SCENARIO: A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful. MANAGEMENT QUESTION: What are the psychological impacts of SJS/TEN on this man's life? BACKGROUND: SJS and TEN have devastating outcomes for those affected. OBJECTIVES: To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario. METHODS: Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age. RESULTS: Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression. DISCUSSION AND RECOMMENDATION: The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial.

BACKGROUND: Patient satisfaction in consenting is a major pillar of clinical governance and healthcare quality assessment. The purpose was to observe the effect of using 3D anatomical models of knee and shoulder joints on patient satisfaction during informed consent in the largest single-blinded randomised controlled trial in this field. METHODS: 52 patients undergoing elective knee or shoulder surgery were randomised into two groups when being consented. The intervention group (n = 26) was shown an anatomical model of the knee/shoulder joint while the control group (n = 26) was given only a verbal explanation without a model. Patients rated their satisfaction on the validated Medical Interview Satisfaction Scale (MISS-26) questionnaire. Semi-structured interviews were analysed for specific themes to determine key factors that influenced patient satisfaction. The mean score ±SD were calculated with significance set at p < 0.05. RESULTS: There was a significant difference in the overall satisfaction between the control and intervention cohorts (MISS-26 score 4.33 [86.6%] ± 0.646 vs 4.70 [94.0%] ± 0.335 respectively, 7.4% improvement, 8.5% difference, p = 0.01). Behavioural criteria showed a 13% increase in satisfaction (p = 0.02). Semi-structured interviews determined that the factors influencing satisfaction included the surgeon's interpersonal manner, the use of the visual aid and seeing the consultant surgeon in clinic. All patients in the intervention cohort identified factors contributing to their satisfaction, whereas a fifth of the control cohort claimed nothing at all made them feel satisfied. CONCLUSION: Anatomical models as visual aids significantly increased patient satisfaction during the consenting process and played an integral part of the surgeon's explanation. Patients exposed to anatomical models also claimed to be more satisfied with the surgeon's inter-personal skills. This study recommends the use of anatomical models, which are both cost-effective and easily implementable, during explanation and consent for orthopaedic procedures.

The critical size of a defect in the glenoid causing anterior instability of the shoulder after a Bankart repair, under physiological joint loading.

AIMS: Patients with recurrent anterior dislocation of the shoulder commonly have an anterior osseous defect of the glenoid. Once the defect reaches a critical size, stability may be restored by bone grafting. The critical size of this defect under non-physiological loading conditions has previously been identified as 20% of the length of the glenoid. As the stability of the shoulder is load-dependent, with higher joint forces leading to a loss of stability, the aim of this study was to determine the critical size of an osseous defect that leads to further anterior instability of the shoulder under physiological loading despite a Bankart repair. PATIENTS AND METHODS: Two finite element (FE) models were used to determine the risk of dislocation of the shoulder during 30 activities of daily living (ADLs) for the intact glenoid and after creating anterior osseous defects of increasing magnitudes. A Bankart repair was simulated for each size of defect, and the shoulder was tested under loading conditions that replicate in vivo forces during these ADLs. The critical size of a defect was defined as the smallest osseous defect that leads to dislocation. RESULTS: The FE models showed a high risk of dislocation during ADLs after a Bankart repair for anterior defects corresponding to 16% of the length of the glenoid. CONCLUSION: This computational study suggests that bone grafting should be undertaken for an anterior osseous defect in the glenoid of more than 16% of its length rather than a solely soft-tissue procedure, in order to optimize stability by restoring the concavity of the glenoid.

Do Diagnostic and Procedure Codes Within Population-Based, Administrative Datasets Accurately Identify Patients with Rectal Cancer?

BACKGROUND: Procedural and diagnostic codes may inaccurately identify specific patient populations within administrative datasets. PURPOSE: Measure the accuracy of previously used coding algorithms using administrative data to identify patients with rectal cancer resections (RCR). METHODS: Using a previously published coding algorithm, we re-created a RCR cohort within administrative databases, limiting the search to a single institution. The accuracy of this cohort was determined against a gold standard reference population. A systematic review of the literature was then performed to identify studies that use similar coding methods to identify RCR cohorts and whether or not they comment on accuracy. RESULTS: Over the course of the study period, there were 664,075 hospitalizations at our institution. Previously used coding algorithms identified 1131 RCRs (administrative data incidence 1.70 per 1000 hospitalizations). The gold standard reference population was 821 RCR over the same period (1.24 per 1000 hospitalizations). Administrative data methods yielded a RCR cohort of moderate accuracy (sensitivity 89.5%, specificity 99.9%) and poor positive predictive value (64.9%). Literature search identified 18 studies that utilized similar coding methods to derive a RCR cohort. Only 1/18 (5.6%) reported on the accuracy of their study cohort. CONCLUSIONS: The use of diagnostic and procedure codes to identify RCR within administrative datasets may be subject to misclassification bias because of low PPV. This underscores the importance of reporting on the accuracy of RCR cohorts derived within population-based datasets.