Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients.

BACKGROUND: Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. AIMS: To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. METHODS: This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates. RESULTS: Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender. CONCLUSION: Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.

A Portable Smart Fitness Suite for Real-Time Exercise Monitoring and Posture Correction.

Fitness and sport have drawn significant attention in wearable and persuasive computing. Physical activities are worthwhile for health, well-being, improved fitness levels, lower mental pressure and tension levels. Nonetheless, during high-power and commanding workouts, there is a high likelihood that physical fitness is seriously influenced. Jarring motions and improper posture during workouts can lead to temporary or permanent disability. With the advent of technological advances, activity acknowledgment dependent on wearable sensors has pulled in countless studies. Still, a fully portable smart fitness suite is not industrialized, which is the central need of today's time, especially in the Covid-19 pandemic. Considering the effectiveness of this issue, we proposed a fully portable smart fitness suite for the household to carry on their routine exercises without any physical gym trainer and gym environment. The proposed system considers two exercises, i.e., T-bar and bicep curl with the assistance of the virtual real-time android application, acting as a gym trainer overall. The proposed fitness suite is embedded with a gyroscope and EMG sensory modules for performing the above two exercises. It provided alerts on unhealthy, wrong posture movements over an android app and is guided to the best possible posture based on sensor values. The KNN classification model is used for prediction and guidance for the user while performing a particular exercise with the help of an android application-based virtual gym trainer through a text-to-speech module. The proposed system attained 89% accuracy, which is quite effective with portability and a virtually assisted gym trainer feature.

Identifying and Mitigating Phishing Attack Threats in IoT Use Cases Using a Threat Modelling Approach.

Internet of things (IoT) is a technology that enables our daily life objects to connect on the Internet and to send and receive data for a meaningful purpose. In recent years, IoT has led to many revolutions in almost every sector of our society. Nevertheless, security threats to IoT devices and networks are relentlessly disruptive, because of the proliferation of Internet technologies. Phishing is one of the most prevalent threats to all Internet users, in which attackers aim to fraudulently extract sensitive information of a user or system, using fictitious emails, websites, etc. With the rapid increase in IoT devices, attackers are targeting IoT devices such as security cameras, smart cars, etc., and perpetrating phishing attacks to gain control over such vulnerable devices for malicious purposes. In recent decades, such scams have been spreading, and they have become increasingly advanced over time. By following this trend, in this paper, we propose a threat modelling approach to identify and mitigate the cyber-threats that can cause phishing attacks. We considered two significant IoT use cases, i.e., smart autonomous vehicular system and smart home. The proposed work is carried out by applying the STRIDE threat modelling approach to both use cases, to disclose all the potential threats that may cause a phishing attack. The proposed threat modelling approach can support the IoT researchers, engineers, and IoT cyber-security policymakers in securing and protecting the potential threats in IoT devices and systems in the early design stages, to ensure the secure deployment of IoT devices in critical infrastructures.

A Framework for Malicious Traffic Detection in IoT Healthcare Environment.

The Internet of things (IoT) has emerged as a topic of intense interest among the research and industrial community as it has had a revolutionary impact on human life. The rapid growth of IoT technology has revolutionized human life by inaugurating the concept of smart devices, smart healthcare, smart industry, smart city, smart grid, among others. IoT devices' security has become a serious concern nowadays, especially for the healthcare domain, where recent attacks exposed damaging IoT security vulnerabilities. Traditional network security solutions are well established. However, due to the resource constraint property of IoT devices and the distinct behavior of IoT protocols, the existing security mechanisms cannot be deployed directly for securing the IoT devices and network from the cyber-attacks. To enhance the level of security for IoT, researchers need IoT-specific tools, methods, and datasets. To address the mentioned problem, we provide a framework for developing IoT context-aware security solutions to detect malicious traffic in IoT use cases. The proposed framework consists of a newly created, open-source IoT data generator tool named IoT-Flock. The IoT-Flock tool allows researchers to develop an IoT use-case comprised of both normal and malicious IoT devices and generate traffic. Additionally, the proposed framework provides an open-source utility for converting the captured traffic generated by IoT-Flock into an IoT dataset. Using the proposed framework in this research, we first generated an IoT healthcare dataset which comprises both normal and IoT attack traffic. Afterwards, we applied different machine learning techniques to the generated dataset to detect the cyber-attacks and protect the healthcare system from cyber-attacks. The proposed framework will help in developing the context-aware IoT security solutions, especially for a sensitive use case like IoT healthcare environment.

Assessment of non-scholastic skills (non-clinical) in trainee residents.

Doctors are clinicians and are trained in clinical work. Many non-clinical qualities, apart from the ability to examine and treat, matter a lot in their professional success. Traditionally, knowing the book well or mastering the content of the curriculum was considered enough to succeed in a medical career, but recent recognition of having good communication skills in a physician has changed the medical curricula the world over. A recent look at the formative assessments done to see the on-job trainees during their residencies in various countries, like India, the United States and Turkey, has revealed that most trainees are overworked and find it difficult to cope with the demanding training requirements centred around mastering the clinical skills. The supervisors are also very busy. Non-scholastic abilities, like good emotional quotient and extracurricular activities that do not directly relate to things learnt from the book or the ward are being graded as very important for medical students because all these abilities are essential for a doctor not only to help the patients medically and psychologically, but also emotionally. He should be able to protect his self from care-provider's stresses. Personal qualities of a doctor are seen as important predictors of clinical performance in medicine. There are opportunities during training that the senior trainer can become a role model and impart non-scholastic skills most effectively. Supervisors must show their trainees how to behave with a patient. This change in attitude and behaviour has to be induced by performing these things in front of the trainee residents. The problem with non-scholastic skills, unlike the scholastic cognitive/psychomotor domains, is that these skills are quite elusive to routine assessments. However, lone reliance upon a final examination for assessing attitudes can be biased. If the behaviour of residents is to be tested in an exit examination they are likely to behave more consciously only to pass the examination, which is called the Hawthorne effect. No one can ensure that one behaves in a uniform manner in every social situation. Our responses may vary every day in the face of emerging challenges. Probably a balanced combination of formative plus summative assessment supplemented with a well-planned continuous internal assessment is the answer.

Increase in Penicillin and multidrug resistance in Streptococcus pneumoniae (1993-2016): Report from a tertiary care hospital laboratory, Pakistan.

OBJECTIVE: To determine the trend of resistance to antimicrobials in Streptococcus pneumoniae infections, and the impact of new Clinical and Laboratory Standards Institute guidelines on 1211 among meningeal isolates. METHODS: The descriptive observational retrospective study was conducted at the Aga Khan University Hospital laboratory in Karachi, and comprised Streptococcus pneumoniae isolation and antimicrobial susceptibility data over a period of 24 years, from 1993 to 2016, which was compared in terms of pre-2008 and post-2008 data, which was analysed using SPSS 19. RESULTS: Of the 7415 non-duplicate isolates identified, 4700(63.4%) were from male patients and 2,715(36.6%) were from female patients. The overall mean age of the patients was 38±27 years. Penicillin resistance in non-meningeal isolates during the two periods was not significantly different (p>0.05), but a significant rise in penicillin resistance in meningeal isolates was observed in the second period (p<0.05). High resistance rates were observed for co-trimoxazole, tetracycline and erythromycin, and an increased trend of multi-drug resistant strains was also noted from 1999 {n=35/317(11%)} to 2016 {n=110/314 (36%)}. CONCLUSIONS: The emergence of multi-drug resistant strains was evident. The spike in penicillin-resistant Streptococcus pneumoniae in meningeal isolates may have been due to the revised guidelines by the Clinical and Laboratory Standards Institute.

A Case with Purine Nucleoside Phosphorylase Deficiency Suffering from Late-Onset Systemic Lupus Erythematosus and Lymphoma.

BACKGROUND: Purine nucleoside phosphorylase (PNP) deficiency accounts for about 4% of severe combined immunodeficiency diseases. PNP deficiency is a variable disease with recurrent infections and neurodevelopmental delay. Autoimmunity and malignancy can still occur in one-third of patients. METHODS: Case report. CASE PRESENTATION: An 8-year-old Saudi female who was apparently healthy presented at the age of 7 years with confirmed systemic lupus erythematosus (SLE) and lupus nephritis that were poorly controlled with conventional therapy. She also had frequent sinopulmonary and varicella infections. Preliminary immunological workup showed severe lymphopenia and depressed lymphocyte proliferation assay. The uric acid was within normal levels at 179 µmol/L (normal range, 150 to 350 µmol/L) 6 weeks after blood transfusion. Genetic study revealed a homozygous missense mutation c.265G>A in the PNP gene, resulting in a substitution of glutamic acid to lysine at amino acid 89 of the encoded protein (E89K). The PNP serum level was 798 nmol/h/mg (normal level 1354 ± 561 nmol/h/mg) 6 weeks after blood transfusion. Hematopoietic stem cell transplantation (HSCT) was planned from a matched unrelated donor; however, she developed an EBV and varicella meningoencephalitis. Atypical malignant cells suggestive of lymphoma were discovered, likely induced by EBV, and suspicious lesions were shown on brain MRI and PET scan. Unfortunately, she passed away before HSCT due to multiorgan failure. CONCLUSION: This report emphasizes the challenges in recognizing PNP deficiency in a patient suffering from SLE.

The Effect of Delayed Injection of Leukocyte-Rich Platelet-Rich Plasma Following Rotator Cuff Repair on Patient Function: A Randomized Double-Blind Controlled Trial.

PURPOSE: To investigate the effect of delayed application of leukocyte-rich platelet-rich plasma (PRP) on rotator cuff repair results as assessed by outcome scores and imaging at one year. METHODS: Patients with a symptomatic rotator cuff tear awaiting arthroscopic repair were approached to take part in the study. Final eligibility for the study was confirmed at the time of surgery. A total of 97 patients were randomized to an ultrasound guided injection of leukocyte-rich PRP or normal saline between 10 and 14 days postsurgery. A total of 87 patients completed clinical evaluation and underwent magnetic resonance imaging imaging at 1 year. Outcome scores included the American Shoulder and Elbow Score, Constant score, Western Ontario Rotator Cuff Index, and the Disabilities of the Arm, Shoulder and Hand Score. Structural integrity of the repair was assessed according to the Sugaya grading. Muscle fatty infiltration was assessed on magnetic resonance imaging using the Goutallier classification. RESULTS: At 1 year postsurgery, there was no significant difference between the treatment groups on any of the patient-reported outcome measures or Constant score. On postoperative imaging analysis, there was no difference in the retear rates (Sugaya 4 and 5) between the groups (21% in control group vs 15.3% in PRP group). Fatty infiltration on postoperative imaging was found to be significantly higher in the normal saline group compared with the PRP group (Kendall's tau-b P = .032). CONCLUSIONS: The delayed application of PRP postrotator cuff repair did not improve function as measured by patient-reported outcome measures and Constant score at 1 year postoperatively. LEVEL OF EVIDENCE: Level II, prospective randomized therapeutic trial.

Subjective quality of multiple choice questions used in undergraduate courses in orthopedics and other specialties.

BACKGROUND AND OBJECTIVE: Multiple Choice Questions (MCQs) can sample broad domains of knowledge efficiently and reliably. The MCQs of lower order C1(Cognitive Level1=Recall of knowledge) do not fulfill this purpose and those of higher cognitive order C2 (Cognitive Level2=Interpret) &C3(Cognitive Level3=Analyze) are better at assessing the problem solving capabilities of the student. Every good educational activity must be supported by quality examination to complete the objectives of a curriculum. The objective of the study was to evaluate MCQs presently being used in internal examinations of medical colleges in Lahore. METHODS: Papers consisting of MCQs from Orthopedics other specialties were collected in June 2019 from different medical colleges of Lahore and reviewed by a senior medical teacher without blinding and without his knowing the scores the students had been awarded before. Question statement, clinical scenarios, options and other mistakes were assessed in each item on predetermined criteria. Cognitive level of the item was determined if it was asking for a recall/identify/ analyze response. The results were tabulated and compared in two groups i.e. Miscellaneous and Orthopedics. RESULTS: Most of the items(total=589) in both groups were of C1 cognitive level though Orthopedics (229) were slightly better (χ2 = 49.882 P-Value = 0.000 (Statistically Significant). Miscellaneous group (360) was better in quality in making clinical scenarios (χ2 = 29.952 P-Value = 0.000 (Statistically Significant) and writing a question statement without confusion. Options were better written in both groups. A good percentage of items needed to be corrected for mistakes in spellings, grammar and segregation into under graduate level. CONCLUSIONS: The cognitive level of assessment tool s MCQs is quiet low in both groups especially clinical scenario construction can be improved. Mistakes in spellings, grammar and conceptual mediocrity is common in both groups.

A comparative study of functional outcome of treatment of intra articular fractures of distal radius fixed with percutaneous Kirschner's wires vs T-plate.

BACKGROUND & OBJECTIVE: Fractures of the distal radius are common with a variable prognosis in case of intra articular extension. The available options include Plaster, External fixation, Prefabricated Splintage using Ligamentotaxis, K-wire fixation, and open reduction internal fixation with T-plate without an as yet clear advantage of one over the others. If these fractures are allowed to collapse, radial shortening, angulation and articular incongruity may cause permanent deformity and loss of function. This limited small scale study was intended to compare the functional results of treatment of these fractures with a T plate and K-wires. METHODS: This was a prospective experimental study conducted at department of Orthopedics of PGMI/Lahore General Hospital, Lahore. Total 30 patients were included and randomized into two groups of 15 patients each. Group-A patients were treated with Krischner's wires and Group-B patients were treated with a T-Plate with open reduction. Informed consent was taken. Post operative follow up was done for 12 weeks for the outcome parameters (Green and O'Brien score). RESULTS: Mean age of patients in Group-A and B was 36.13±9.81 and 44.73±7.86 years respectively. In Group-A there were 10 male and 5 female patients and in Group-B there were 8 male and seven female patients respectively. In Group-A nine patients presented with Fernandez type-II and six patients presented with Fernandez type-III fracture. While in Group-B 10 patients presented with Fernandez type-II and five patients presented with Fernandez type-III fracture. Among Group-A patient's final outcome was excellent in 86.67% patients while in Group-B only 53.33% patients had excellent outcome at three months follow up. CONCLUSION: Percutaneous Kirschner's wires appeared to be more effective as compared to T-Plate fixation in terms of functional outcome for treating intra-articular distal radius fractures.

Occurrence of fungal microbial contamination in drinking water of megacity of Karachi (Pakistan) and their physico-chemical control.

The water quality in Karachi (Pakistan) is uncertain due to the occurrence of fungi and other microorganisms. A total of twenty-five water samples were collected from public places, educational institutes, hospitals, water supply systems and surface water of the canal of Karachi (Pakistan). The different fungal species including Acremonium sp., Alternaria alternata, Aspergillus flavus, A. fumigatus, A. sulphureus, Cladosporium sp., Fusarium sp., Clonostachys (Gliocladium) sp., Macrophomina phaseolina, Mucor racemosus, Paecilomyces sp. Penicillium chrysogenum, P. citrinum, P. commune, P. expansum, Rhizoctonia sp. and Stachybotrys sp. were isolated from these drinking water samples. However, the bacteria, microalgae and some other microorganisms were present in low concentrations. The reason for fungi infection and production of mycotoxicity depends upon various factors and the availability of their nutrients in filtration plants. The major threats to human health are fungal mycotoxicity which is responsible for carcinogenic and other lethal diseases. Mostly, the genus Aspergillus was dominated and isolated with a maximum of 88-98% of occurrence in the different samples of drinking water by the direct plate-spread method. For the control of fungi, various Physico-chemical coagulation treatments were used, but Potassium alum, clay pot, and hot water treatment disinfected effectively 69-70% removal of the fungi and its spore or mycelia from the water. In addition, it is concluded that drinking water purifications such as chlorination, filtration and lime did not eliminate thermophilic fungal spores or mycelia including Penicillium, Paecilomyces and Mucor from the water.

Characteristic scapular and rib changes on chest radiographs of children with ADA-deficiency SCIDS in the first year of life.

BACKGROUND: We describe radiographic changes in the ribs and scapulae seen in the first 6 months of life in children with ADA (adenosine deaminase) deficiency severe combined immundeficiency syndrome (SCIDS). We suggest that these changes are reversible with appropriate enzyme replacement therapy. OBJECTIVE: The purpose of this study was to describe characteristic rib and scapular radiographic changes in infants with ADA-deficiency SCIDS. MATERIALS AND METHODS: This was a retrospective review of chest radiographs of nine children with ADA-deficiency SCIDS performed in the first year of life by two experienced pediatric radiologists. A control cohort of unaffected children was used for comparison. RESULTS: All children with ADA-deficiency SCIDS manifested unusual scapular spurring and anterior rib cupping. None of the control children manifested these changes. CONCLUSION: Characteristic and reversible scapular and rib changes in the correct clinical setting should suggest an early diagnosis of ADA deficiency, prompting appropriate diagnostic and therapeutic measures.

Promoting and supporting breastfeeding in a protracted emergency setting-Caregivers' and health workers' perceptions from North-East Nigeria.

Background: Breastfeeding (BF) should be protected, promoted, and supported for all infants in humanitarian settings. The re-establishment of exclusive BF is also a central part of the management of acutely malnourished infants under 6 months (<6 m). Médecins Sans Frontières (MSF) runs a nutrition project in Maiduguri, a protracted emergency setting in North-East Nigeria. This study aimed to explore caregivers' (CGs) and health workers' (HWs) perceptions of BF practice, promotion, and support among CGs with infants <6 m in this setting. Methods: We conducted a qualitative study using in-depth interviews and focus group discussions combined with non-participant observations. Participants included CGs of young infants enrolled in MSF nutritional programs or who attended health promotion activities in a displacement camp. MSF HWs were involved at different levels in BF promotion and support. Data were collected involving a local translator and analyzed using reflexive thematic analysis directly from audio recordings. Results: Participants described how feeding practices are shaped by family, community, and traditional beliefs. The perception of breastmilk insufficiency was common and led to early supplementary feeding with inexpensive but unsuitable products. Participants often linked insufficient breastmilk production with poor maternal nutrition and stress, in a context shaped by conflict and food insecurity. BF promotion was generally well received but could be improved if tailored to address specific barriers to exclusive BF. Interviewed CGs positively valued BF support received as part of the comprehensive treatment for infant malnutrition. One of the main challenges identified was the length of stay at the facility. Some participants perceived that improvements in BF were at risk of being lost after discharge if CGs lacked an enabling environment for BF. Conclusion: This study corroborates the strong influence of household and contextual factors on the practice, promotion, and support of BF. Despite identified challenges, the provision of BF support contributes to improvements in BF practice and was positively perceived by CGs in the studied setting. Greater attention should be directed toward providing support and follow-up for infants <6 m and their CGs in the community.

Comparison of machine learning techniques for the identification of human activities from inertial sensors available in a mobile device after the application of data imputation techniques.

Human activity recognition (HAR) is a significant research area due to its wide range of applications in intelligent health systems, security, and entertainment games. Over the past few years, many studies have recognized human daily living activities using different machine learning approaches. However, the performance of a machine learning algorithm varies based on the sensing device type, the number of sensors in that device, and the position of the underlying sensing device. Moreover, the incomplete activities (i.e., data captures) in a dataset also play a crucial role in the performance of machine learning algorithms. Therefore, we perform a comparative analysis of eight commonly used machine learning algorithms in different sensor combinations in this work. We used a publicly available mobile sensors dataset and applied the k-Nearest Neighbors (KNN) data imputation technique for extrapolating the missing samples. Afterward, we performed a couple of experiments to figure out which algorithm performs best at which sensors' data combination. The experimental analysis reveals that the AdaBoost algorithm outperformed all machine learning algorithms for recognizing five different human daily living activities with both single and multi-sensor combinations. Furthermore, the experimental results show that AdaBoost is capable to correctly identify all the activities presented in the dataset with 100% classification accuracy.

A decentralized hybrid computing consumer authentication framework for a reliable drone delivery as a service.

The thriving adoption of drones for delivering parcels, packages, medicines, etc., is surging with time. The application of drones for delivery services results in faster delivery, fuel-saving, and less energy consumption. Giant companies like Google, Amazon, Facebook, etc., are actively working on developing, testing, and improving drone-based delivery systems. So far, a lot of work has been done for improving the design, speed, operating range, security of the delivery drones, etc. However, very limited work has been done to ensure a complete and reliable last-mile delivery from the merchant's store to the hands of the actual customer. To ensure a complete and reliable last-mile delivery, a drone must authenticate the consumer before dropping the package. Therefore, in this work, we propose a consumer authentication (Consumer-Auth) hybrid computing framework for drone delivery as a service to make sure that the parcel is perfectly delivered to the intended customer. The proposed Consumer-Auth framework enables a drone to reach the exact destination by using the GPS coordinates of the customer autonomously. After reaching the exact location, the drone waits for the customer to come to the specific pinned location then it starts a two-factor consumer authentication process, i.e., one-time password (OTP) verification and face Recognition. The experimental results manifest the effectiveness of the proposed Consumer-Auth framework to ensure a complete and reliable drone-based last-mile delivery.

Sonographic measurements for spleen size in healthy Saudi children and correlation with body parameters.

BACKGROUND: Ultrasound is commonly the first-line imaging modality for assessing the visceral organ dimensions without any risk of radiation. An abnormal size of the spleen may indicate disease, but the evaluation is challenging because of the normal size changes with age. In addition, published normal value charts for children may vary by population and methods. OBJECTIVES: Determine normal growth curves for splenic length in relationship to sex, age, body weight, height, body mass index, and body surface area of healthy children in Saudi Arabia. DESIGN: A retrospective review of ultrasonography images SETTING: Tertiary referral hospital SUBJECTS AND METHODS: We included all normal ultrasonography exams of splenic length (from full-term neonates to 16 years of age) performed between 2003 and 2018. The greatest longitudinal distance of the spleen from the dome to the tip (splenic length) measured at the hilum in the coronal plane was obtained by ultrasonography. MAIN OUTCOME MEASURES: The relationship between the longitudinal length of the spleen and sex, age, height, weight, body mass index, and body surface area. SAMPLE SIZE: 1028 healthy children RESULTS: Height had the most significant correlation with the length of the spleen (P<.001). There was a consistent difference in splenic length according to sex. The spleen was longer in males than in females in children older than 2 years. In terms of splenic growth according to age, our data showed a statistically significant correlation between the ages of 0-24 months and 2-16 years. There was a significant difference between cases from Saudi Arabia, the United States (P=.023) and India (P=.045). CONCLUSION: We developed scatter plots between splenic lengths and body parameters among Saudi children for children from 0 day to 24 months and children from 2 years to 16 years for reference. LIMITATION: Retrospective study. Ultrasound techniques in patient positioning, and cursor placement differed from other studies, which can affect measurements of splenic length. CONFLICTS OF INTEREST: None.

A review of informed consent and how it has evolved to protect vulnerable participants in emergency care research.

A vulnerable participant in research lacks capacity to consent or may be exposed to coercion to participate. Capacity may be temporarily impaired due to loss of consciousness, hypoxia, pain and the consumption of alcohol or elicit substances.To advance emergency care, providing life-threatening measures in life-threatening circumstances, vulnerable patients are recruited into research studies. The urgent need for time-critical treatment conflicts with routine informed consent procedures.This article reviews ethical considerations and moral obligations to safeguard these participants and preserve their autonomy.A particular focus is given to research methodology to waive consent, and the role of ethics committees, research audits, research nurses and community engagement.Research on the acutely unwell patient who lacks capacity is possible with well-designed research trials that are led by investigators who are sufficiently trained, engage the community, gain ethical approval to waive consent and continuously audit practice. Cite this article: EFORT Open Rev 2020;5:73-79. DOI: 10.1302/2058-5241.5.180051.

Sonographic measurements for kidney length in normal Saudi children: correlation with other body parameters.

BACKGROUND: Ultrasonography provides a quick assessment of visceral organ dimensions without any risk of radiation. Since many diseases can affect the kidney size, having a reliable reference for kidney length in children is valuable for clinical assessment. OBJECTIVE: Establish normal growth curves for renal length in relation to sex, age, body weight, height, body mass index and body surface area of healthy children in Saudi Arabia. DESIGN: Retrospective review of ultrasonography images. SETTING: Tertiary referral hospital. PATIENTS AND METHODS: We included all normal ultrasonography exams of renal length from full-term neonates to children ≤14 years old performed between 2003 and 2018. Data was collected retrospectively from the electronic archive and patient records. MAIN OUTCOME MEASURES: Relationship between the longitudinal length of both kidneys and age, height, weight, body mass index and body surface area. SAMPLE SIZE: 950 patients. RESULTS: The left kidneys were longer than the right kidneys ( P<.001). Height had the most significant correlation with kidney length (R2=0.829, P<.001 for right kidney; R2=0.831, P<.001 for left kidney). There was a consistent difference in kidney length by sex. Both kidneys were longer in males than females ( P=.031, right kidney:, P=.015, left kidney). In terms of renal growth by age, our data showed a statistically significant difference before and after 24 months of age. There was no significant difference between populations from Saudi Arabia, Hong Kong ( P=.485) and Australia ( P=.99), but the difference between Saudi and American children was significant ( P<.001). However, we did not have the data from those studies for direct comparison. The correlation plots of renal length versus age for all four countries were similar. CONCLUSION: The tables and correlation plots generated from this study should be useful to radiology departments in assessing conditions in children ≤14 years of age that lead to changes in renal size. LIMITATIONS: Retrospective, and there were differences in ultrasonographic techniques for patient positioning and cursor placement that can affect the reproducibility of measurements of renal length. CONFLICT OF INTEREST: None.

A pilot study to assess the safety and radiological performance of a new low-profile locking plate for high tibial osteotomy.

BACKGROUND: We report the first results of a new low-profile titanium locking plate for fixation of opening wedge high tibial osteotomy (OWHTO). Short spacer plates have been associated with a high hardware complication rate, whilst fixed angle locking plates have been associated with a high incidence of soft tissue irritation. This plate aims to achieve stable fixation whilst maintaining a low profile, allowing space for combined procedures. METHODS: All patients undergoing OWHTO with the Activmotion plate were retrospectively reviewed. Patients were allowed to progress to full weight bearing after two weeks. Radiographic assessment included the medial proximal tibial angle (MPTA) and posterior tibial slope at six weeks and then three monthly until union. All complications were recorded. RESULTS: Thirty-seven patients with 40 OWHTOs were included in the study. The mean MPTA increased from 85.2 preoperatively to 91.9 postop. Tibial slope changed from 5.2 to 4.2°. The correction was sustained until union with no loss of correction in the MPTA (median change 0.0, 95% CI for median (-0.25, 0.4)) or tibial slope (mean increase 0.32, 95% CI (-0.02, 0.67)). CONCLUSIONS: In this pilot study the Activmotion plate raised no safety concerns with regard to implant related adverse events or loss of initial correction. Early rehabilitation with immediate partial weight bearing was possible and all cases proceeded to osteotomy union with the exception of one case that needed to undergo bone grafting with implant retention. Premature removal of the implant was necessary in four cases due to symptomatic hardware irritation.