Lessons for the government from Miller I and the Scottish Continuity Bill Case

In the United Kingdom (UK), tensions between the executive and the judiciary reignited recently when the government launched a thinly veiled ‘attack’ on the courts in an ‘Independent Review of Administrative Law’ (IRAL). 1 Largely understood to have been triggered by the government’s defeats in the Miller cases,2 the IRAL seems intended to limit the availability of judicial review against the government. 3 This article revisits some (unpublished) arguments made by the author at the time of the Miller I judgment about its true driving force.4 It also considers a similar impulse in the Scottish Continuity Bill case5 that was considered around the same time.6 It argues that the Supreme Court’s procedural protections of EU-derived rights and the devolution settlement with Scotland in these cases represent a threat to the executive government. This is because these cases make it more difficult for the government to overcome the common law constitution without proper Parliamentary scrutiny

The Hughes external fixation device: studies of its biomechanical properties' effect on fracture healing and its clinical application

External skeletal fixation devices first appeared in clinical practice in the 1850's. Their use has mainly been confined to Europe although North American surgeons developed an interest in the 1930's. In the last few years, however, there has been a reawakening of interest in external fixation in North America and Great Britain leading to a proliferation of different external fixation devices.Although some experimental work has been done on the biomechanics of some of the more complex fixators very little is known about the optimal configuration of application of most devices. Additionally there is scanty information on the effect that external fixation has on bone healing.This thesis examines the Hughes unilateral external fixator from three aspects.1) Its biomechanica1 properties are examined and the stiffest mode of application defined. The effects of altering this configuration are shown. A comparison is made with the Hoffmann device.2) The effect of external fixation on bone healing is examined. A small fixator is used to immobilise rabbit tibial osteotomies and the effect on healing and bone blood flow compared with an osteotomy treated with a cast.3) A prospective study of the clinical use of the Hughes fixator is presented. An analysis is made of the use of the device in treating tibial fractures.Biomechanical study: This was undertaken using beech as a bone substitute. A jig was constructed so that different loads could be applied to a simulated fracture held by a Hughes fixator. It was found that the stiffest configuration of the Hughes occurred with the fixator bar close to the limb. The inner pin should be as close to the fracture as possible with the outer pin as far from the fracture as is practical. The effect of altering the location of the bar from a lateral to an antero-media 1 location as used on the tibia was to lower the stiffness, although only to the level of stiffness gained using a Hoffmann-Vida 1 double frame. The effect of altering the stiffest configuration was examined.Bone healing and blood flow study: New Zealand white rabbits were used to investigate bone healing and blood flow using a small external fixator designed for the experiment. Bilateral tibial osteotomies were made and one was stabilised with the small fixator with the contra-1atera1 osteotomy being treated in a long-leg cast. After a period of between one and ten weeks the rabbits were sacrificed but prior to this were injected with radioactive microspheres. Comparison of the blood flow in the two fracture sites showed a considerable increase in flow in the cast-treated leg after four weeks.A review of the histology showed that external fixation altered bone healing. The externally fixed leg showed less periosteal reaction but enhanced endochondral ossification and intra-medullary ossification.Clinical study: A three year prospective study of the use of the Hughes fixator was undertaken. The device was mainly used for the treatment of tibial fractures although humeral fractures and pelvic diastases were also treated. In addition a number of osteotomies and an arthrodesis were stabilised with the device.A study of the tibial fractures showed that the eventual outcome of the fracture was dependent on the initial reduction and the length of time tha

Damage to the Superficial Peroneal Nerve in Operative Treatment of Fibula Fractures: Straight to the Bone? Case Report and Review of the Literature

Ankle fractures are a significant part of the lower extremity trauma seen in the emergency department. Neurologic complications of ankle fracture surgery are infrequently described but account for significant morbidity. The risk of nerve injury is increased for the Blair and Botte type B pattern of the intermediate cutaneous dorsal nerve branch, crossing the distal fibula from posterior to anterior (at 5 to 7 cm from malleolar tip). This pattern is present in about 10% to 15% of patients. Injuries to the superficial peroneal nerve and its branches negatively influence the outcome. Early recognition and protection might reduce the incidence of superficial peroneal nerve injuries during open reduction and internal fixation of lateral malleolus fractures. We describe 2 surgically treated ankle fractures with superficial peroneal nerve branch (intermediate cutaneous dorsal nerve) involvement and review the current literature

Suprachiasmatic nucleus-dependent and independent outputs driving rhythmic activity in hypothalamic and thalamic neurons

From Springer Nature via Jisc Publications RouterHistory: received 2020-05-29, registration 2020-09-17, accepted 2020-09-17, pub-electronic 2020-09-30, online 2020-09-30, collection 2020-12Publication status: PublishedFunder: Biotechnology and Biological Sciences Research Council; doi: http://dx.doi.org/10.13039/501100000268; Grant(s): BB/N007115/1Abstract: Background: Daily variations in mammalian physiology are under control of a central clock in the suprachiasmatic nucleus (SCN). SCN timing signals are essential for coordinating cellular clocks and associated circadian variations in cell and tissue function across the body; however, direct SCN projections primarily target a restricted set of hypothalamic and thalamic nuclei involved in physiological and behavioural control. The role of the SCN in driving rhythmic activity in these targets remains largely unclear. Here, we address this issue via multielectrode recording and manipulations of SCN output in adult mouse brain slices. Results: Electrical stimulation identifies cells across the midline hypothalamus and ventral thalamus that receive inhibitory input from the SCN and/or excitatory input from the retina. Optogenetic manipulations confirm that SCN outputs arise from both VIP and, more frequently, non-VIP expressing cells and that both SCN and retinal projections almost exclusively target GABAergic downstream neurons. The majority of midline hypothalamic and ventral thalamic neurons exhibit circadian variation in firing and those receiving inhibitory SCN projections consistently exhibit peak activity during epochs when SCN output is low. Physical removal of the SCN confirms that neuronal rhythms in ~ 20% of the recorded neurons rely on central clock input but also reveals many neurons that can express circadian variation in firing independent of any SCN input. Conclusions: We identify cell populations across the midline hypothalamus and ventral thalamus exhibiting SCN-dependent and independent rhythms in neural activity, providing new insight into the mechanisms by which the circadian system generates daily physiological rhythms

Primary hemiarthroplasty for treatment of proximal humeral fractures

Background: Primary hemiarthroplasty of the shoulder is used to treat complex proximal humeral fractures, although the reported functional results following this method of treatment have varied widely. The aim of this study was to prospectively assess the prosthetic survival and functional outcomes in a large series of patients treated with shoulder hemiarthroplasty for a proximal humeral fracture. By determining the factors that affected the outcome, we also aimed to produce models that could be used clinically to estimate the functional outcome at one year following surgery.Methods: A thirteen-year observational cohort study of 163 consecutive patients treated with hemiarthroplasty for a proximal humeral fracture was performed. Twenty-five patients died or were lost to follow-up in the first year after treatment, leaving 138 patients who had assessment of shoulder function with use of the modified Constant score at one year postinjury.Results: The overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. The overall median modified Constant score was 64 points at one year, with a typically good score for pain relief (median, 15 points) and poorer scores, with a greater scatter of values, for function (median, 12 points), range of motion (median, 24 points), and muscle power (median, 14 points). Of the factors that were assessed immediately after the injury, only patient age, the presence of a neurological deficit, tobacco usage, and alcohol consumption were significantly predictive of the one-year Constant score (p &lt; 0.05). Of the factors that were assessed at six weeks postinjury, those that predicted the one-year Constant score included the age of the patient, the presence of a persistent neurological deficit, the need for an early reoperation, the degree of displacement of the prosthetic head from the central axis of the glenoid seen radiographically, and the degree of displacement of the tuberosities seen radiographically.Conclusions: Primary shoulder hemiarthroplasty performed for the treatment of a proximal humeral fracture in medically fit and cooperative adults is associated with satisfactory prosthetic survival at an average of 6.3 years. Although the shoulder is usually free of pain following this procedure, the overall functional result, in terms of range of motion, function, and power, at one year varies. A good functional outcome can be anticipated for a younger individual who has no preoperative neurological deficit, no postoperative complications, and a satisfactory radiographic appearance of the shoulder at six weeks. The results are poorer in the larger group of elderly patients who undergo this procedure, especially if they have a neurological deficit, a postoperative complication requiring a reoperation, or an eccentrically located prosthesis with retracted tuberosities.<br /

Impact of the PROFHER trial findings on surgeons' clinical practice : An online questionnaire survey

OBJECTIVES: To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice. METHODS: A questionnaire was piloted with six orthopaedic surgeons using a 'think aloud' process. The final questionnaire contained 29 items and was distributed online to surgeon members of the British Orthopaedic Association and British Elbow and Shoulder Society. Descriptive statistics summarised the sample characteristics and fracture treatment of respondents overall, and grouped them by whether they changed practice based on PROFHER trial findings. Free-text responses were analysed qualitatively for emerging themes using Framework Analysis principles. RESULTS: There were complete responses from 265 orthopaedic and trauma surgeons who treat patients with proximal humeral fractures. Around half (137) had changed practice to various extents because of PROFHER, by operating on fewer PROFHER-eligible fractures. A third (43) of the 128 respondents who had not changed practice were already managing patients non-operatively. Those who changed practice were more likely to be younger, work in a trauma unit rather than a major trauma centre, be specialist shoulder surgeons and treat fewer PROFHER-eligible fractures surgically. This group gave higher scores when assessing validity and applicability of PROFHER. In contrast, a quarter of the non-changers were critical, sometimes emphatically, of PROFHER. The strongest theme that emerged overall was the endorsement of evidence-based practice. CONCLUSION: PROFHER has had an impact on surgeons' clinical practice, both through changing it, and through underpinning existing non-operative practice. Although some respondents expressed reservations about the trial, evidence from such trials was found to be the most important influence on surgeons' decisions to change practice.Cite this article: L. Jefferson, S. Brealey, H. Handoll, A. Keding, L. Kottam, I. Sbizzera, A. Rangan. Impact of the PROFHER trial findings on surgeons' clinical practice: An online questionnaire survey. Bone Joint Res 2017;6:590-599. DOI: 10.1302/2046-3758.610.BJR-2017-0170