The Waiting Game: A Primary Care Intervention to Improve Access to Specialist Care to Patients with Osteoarthritis

Osteoarthritis (OA) commonly presents in the knee, contributing to pain and impairment in those affected. Given appropriate candidacy, surgical treatment for end-stage knee OA such as total knee replacement (TKR) and high tibial osteotomy (HTO) are highly successful with negligible risk. Just as the population has aged over the past decade, so too has the demand for surgical treatment of OA increasing wait times across Canada. Cipriano et al. identified that wait times for TKR in Ontario are longer than clinically appropriate. Several North American studies have demonstrated that general practitioner referrals to specialists do not result in subsequent surgery. Targeting increasing the proportion of referrals that result in a surgical booking has the potential to decrease the wait for initial consult, an important piece of the wait time continuum for knee OA

The development and validation of a multivariable model to predict whether patients referred for total knee replacement are suitable surgical candidates at the time of initial consultation

Background: In previous studies, 50%-70% of patients referred to orthopedic surgeons for total knee replacement (TKR) were not surgical candidates at the time of initial assessment. The purpose of our study was to identify and cross-validate patient self-reported predictors of suitability for TKR and to determine the clinical utility of a predictive model to guide the timing and appropriateness of referral to a surgeon. Methods: We assessed pre-consultation patient data as well as the surgeon\u27s findings and post-consultation recommendations. We used multivariate logistic regression to detect self-reported items that could identify suitable surgical candidates. Results: Patients\u27 willingness to undergo surgery, higher rating of pain, greater physical function, previous intra-articular injections and patient age were the factors predictive of patients being offered and electing to undergo TKR. Conclusion: The application of the model developed in our study would effectively reduce the proportion of nonsurgical referrals by 25%, while identifying the vast majority of surgical candidates (\u3e 90%). Using patient-reported information, we can correctly predict the outcome of specialist consultation for TKR in 70% of cases. To reduce long waits for first consultation with a surgeon, it may be possible to use these items to educate and guide referring clinicians and patients to understand when specialist consultation is the next step in managing the patient with severe osteoarthritis of the knee

A Thin Skin Calorimeter (TSC) for Quantifying Irradiation During Large-scale Fire Testing

This paper details a novel method for quantifying irradiation (incident radiant heat flux) at the exposed surface of solid elements during large-scale fire testing. Within the scope of the work presented herein, a type of Thin Skin Calorimeter (TSC) was developed intending for a practical, low cost device enabling the cost-effective mass production required for characterising the thermal boundary conditions during multiple large-scale fire tests. The technical description of the TSC design and a formulation of the proposed calibration technique are presented. This methodology allows for the quantification of irradiation by means of an a posteriori analysis based on a temperature measurement from the TSC, a temperature measurement of the gas-phase in the vicinity of the TSC and a correction factor defined during a pre-test calibration process. The proposed calibration methodology is designed to account for uncertainties inherent to the simplicity of the irradiation measurement technique, therefore not requiring precise information regarding material thermal and optical properties. This methodology is designed and presented so as to enable adaption of the technique to meet the specific requirements of other experimental setups. This is conveyed by means of an example detailing the design and calibration of a device designed for a series of large-scale experiments as part of the ‘Real Fires for the Safe Design of Tall Buildings’ project

X-ray micro-tomography and pore network modeling of single-phase fixed-bed reactors.

A three-dimensional (3D) irregular and unstructured pore network was built using local topological and geometrical properties of an isometric bead pack imaged by means of a high-resolution X-ray computed micro-tomography technique. A pore network model was developed to analyze the 3D laminar/inertial(non-Darcy) flows at the mesoscopic (pore level) and macroscopic (after ensemble-averaging) levels. The non-linear laminar flow signatures were captured at the mesoscale on the basis of analogies with contraction and expansion friction losses. The model provided remarkably good predictions of macroscopic frictional loss gradient in Darcy and non-Darcy regimes with clear-cut demarcation using channel-based Reynolds number statistics. It was also able to differentiate contributions due to pore and channel linear losses, and contraction/expansion quadratic losses. Macroscopic mechanical dispersion was analyzed in terms of retroflow channels, and transverse and longitudinal Péclet numbers. The model qualitatively retrieved the Péclet-Reynolds scaling law expected for heterogeneous networks with predominance of mechanical dispersion. Advocated in watermark is the potential of pore network modeling to build a posteriori constitutive relations for the closures of the more conventional macroscopic Euler approaches to capture more realistically single-phase flow phenomena in fixed-bed reactor applications in chemical engineering

Designing the Macrocyclic Dimension in Main Group Chemistry

Outside the confines and well-established domain of organic chemistry, the systematic building of large macromolecular arrangements based on non-carbon elements represents a significant and exciting challenge. Our aim in the past two decades has been to develop robust synthetic methods to construct new types of main group architectures in a methodical way, principles of design that parallel those used in the organic arena. This concept article addresses the fundamental thermodynamic and kinetic problems involved in the design and synthesis of main group macrocycles and looks to future developments of macromolecules in this area, as well as new applications in coordination chemistry.ERC. Grant Number: 291280 EU. Grant Number: RYC-2015-1903

Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda

Background: Longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce.Objectives: To investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values.Results: Symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ß = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ß = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ß = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ß = -1.67, 95% CI -3.19 to -0.15), close to death (ß = -1.38, 95% CI -2.70 to -0.06), and being in the host country >= 2 years (ß = -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ß = 2.11, 95% CI 0.58-3.65), and lack of shelter (ß = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ß = -1.36, 95% CI -2.67 to -0.05). Conclusion: Many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories.</p

Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Background: In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. Methods: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation &lt;92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg–800 mg (depending on weight) given intravenously. A second dose could be given 12–24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). Findings: Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76–0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12–1·33; p&lt;0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77–0·92; p&lt;0·0001). Interpretation: In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids. Funding: UK Research and Innovation (Medical Research Council) and National Institute of Health Research

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

Background: Many patients with COVID-19 have been treated with plasma containing anti-SARS-CoV-2 antibodies. We aimed to evaluate the safety and efficacy of convalescent plasma therapy in patients admitted to hospital with COVID-19. Methods: This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]) is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. The trial is underway at 177 NHS hospitals from across the UK. Eligible and consenting patients were randomly assigned (1:1) to receive either usual care alone (usual care group) or usual care plus high-titre convalescent plasma (convalescent plasma group). The primary outcome was 28-day mortality, analysed on an intention-to-treat basis. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936. Findings: Between May 28, 2020, and Jan 15, 2021, 11558 (71%) of 16287 patients enrolled in RECOVERY were eligible to receive convalescent plasma and were assigned to either the convalescent plasma group or the usual care group. There was no significant difference in 28-day mortality between the two groups: 1399 (24%) of 5795 patients in the convalescent plasma group and 1408 (24%) of 5763 patients in the usual care group died within 28 days (rate ratio 1·00, 95% CI 0·93–1·07; p=0·95). The 28-day mortality rate ratio was similar in all prespecified subgroups of patients, including in those patients without detectable SARS-CoV-2 antibodies at randomisation. Allocation to convalescent plasma had no significant effect on the proportion of patients discharged from hospital within 28 days (3832 [66%] patients in the convalescent plasma group vs 3822 [66%] patients in the usual care group; rate ratio 0·99, 95% CI 0·94–1·03; p=0·57). Among those not on invasive mechanical ventilation at randomisation, there was no significant difference in the proportion of patients meeting the composite endpoint of progression to invasive mechanical ventilation or death (1568 [29%] of 5493 patients in the convalescent plasma group vs 1568 [29%] of 5448 patients in the usual care group; rate ratio 0·99, 95% CI 0·93–1·05; p=0·79). Interpretation: In patients hospitalised with COVID-19, high-titre convalescent plasma did not improve survival or other prespecified clinical outcomes. Funding: UK Research and Innovation (Medical Research Council) and National Institute of Health Research