Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Making finds matter: using charismatic objects, people power and digital technologies to build a better future for archaeological finds in Scotland

From enigmatic carved stone balls to the patched breeches of an 18th-century bog body, many archaeological finds from Scotland are, without doubt, fabulous. Through these objects and the practices they embody, we can imagine alternative ways of living and thinking, wonder at past peo-ple’s ingenuity and skill, and revisit significant moments in our own lives. Archaeological finds are also often fragile, scattered across diverse locations, and often difficult to access or find out about following their initial discovery. Only very few archaeological objects make it into museum displays where they can be widely enjoyed. In economically and socially challenging times, even these items can be hard to reach. Linking into wider moves to improve access to heritage collections in Scotland and across the UK, the Boundary Objects Project celebrated captivating archaeological objects from Scotland and the diverse sets of people involved in their discovery. Contemporary digital tech-nologies and the goodwill, skills and energy of a wide set of archaeological professionals, students and enthusiasts were harnessed in order to improve access to information to scattered digital re-cords relating to archaeological objects and sites, to raise the prominence of these items in existing community-led heritage initiatives, and to engage diverse audiences in actively enjoying them. This paper summarises work on the Boundary Objects Project – a collaboration between the universities of Reading and Manchester in partnership with Historic Environment Scotland (HES) and National Museums Scotland (NMS) – in the context of wider multi-stranded moves to build a better future for archaeological finds in and well beyond Scotland

Making finds matter: using charismatic objects, people power and digital technologies to build a better future for archaeological finds in Scotland

From enigmatic carved stone balls to the patched breeches of an eighteenth-century bog body, many archaeological finds from Scotland are, without doubt, fabulous. Through these objects and the practices they embody, we can imagine alternative ways of living and thinking, wonder at past peoples’ ingenuity and skill, and revisit significant moments in our own lives. Archaeological finds are also often fragile, scattered across diverse locations, and often difficult to access or find out about following their initial discovery. Only very few archaeological objects make it into museum displays where they can be widely enjoyed. In economically and socially challenging times, even these items can be hard to reach. Linking into wider moves to improve access to heritage collections in Scotland and across the UK, the Boundary Objects Project celebrated captivating archaeological objects from Scotland and the diverse sets of people involved in their discovery. Contemporary digital technologies and the good will, skills, and energy of a wide set of archaeological professionals, students and enthusiasts were harnessed in order to improve access to information to scattered digital records relating to archaeological objects and sites, to raise the prominence of these items in existing community-led heritage initiatives, and to engage diverse audiences in actively enjoying them. This paper summarises work on the Boundary Objects Project – a collaboration between the Universities of Reading and Manchester in partnership with Historic Environment Scotland (HES) and National Museums Scotland (NMS) – in the context of wider multi-stranded moves to build a better future for archaeological finds in and well beyond Scotland

Empagliflozin in Patients with Chronic Kidney Disease

Background The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. Methods We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m(2) of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m(2) with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to < 10 ml per minute per 1.73 m(2), a sustained decrease in eGFR of & GE;40% from baseline, or death from renal causes) or death from cardiovascular causes. Results A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P < 0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P=0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. Conclusions Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo