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

Background: Anterior 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. Methods: We 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. Findings: Between 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. Interpretation: Surgical 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. Funding: The UK National Institute for Health Research Health Technology Assessment Programme

Cost-effectiveness of replacing versus discarding the nail in children with nail bed injury

Every year in the UK, around 10 000 children need to have operations to mend injuries to the bed of their fingernails. Currently, most children have their fingernail placed back on the injured nail bed after the operation. The NINJA trial found that children were slightly less likely to have an infection if the nail was thrown away rather than being put back, but the difference between groups was small and could have be due to chance. This study looked at whether replacing the nail is cost-effective compared with throwing it away. Using data from the NINJA trial, we compared costs, healthcare use, and quality of life and assessed the cost-effectiveness of replacing the nail. It was found that throwing the nail away after surgery would save the National Health Service (NHS) £75 (€85) per operation compared with placing the nail back on the nail bed. Changing clinical practice could save the NHS in England £720 000 (€819 000) per year

Use of ring-expanded diamino- and diamidocarbene ligands in copper catalyzed azide-alkyne "click" reactions

The two-coordinate ring-expanded N-heterocyclic carbene copper­(I) complexes [Cu­(RE-NHC)₂]⁺ (RE-NHC = 6-Mes, 7-<i>o</i>-Tol, 7-Mes) have been prepared and shown to be effective catalysts under neat conditions for the 1,3-dipolar cycloaddition of alkynes and azides. In contrast, the cationic diamidocarbene analogue [Cu­(6-MesDAC)₂]⁺ and the neutral species [(6-MesDAC)­CuCl]₂ and [(6-MesDAC)₂(CuCl)₃] show good activity when the catalysis is performed on water

Effectiveness of nail bed repair in children with or without replacing the fingernail : NINJA multicentre randomized clinical trial

Background Surgery for nail bed injuries in children is common. One of the key surgical decisions is whether to replace the nail plate following nail bed repair. The aim of this RCT was to assess the clinical effectiveness and cost-effectiveness of nail bed repair with fingernail replacement/substitution compared with repair without fingernail replacement. Methods A two-arm 1 : 1 parallel-group open multicentre superiority RCT was performed across 20 secondary-care hospitals in the UK. The co-primary outcomes were surgical-site infection at around 7 days after surgery and cosmetic appearance summary score at a minimum of 4 months. Results Some 451 children presenting with a suspected nail bed injury were recruited between July 2018 and July 2019; 224 were allocated to the nail-discarded arm, and 227 to the nail-replaced arm. There was no difference in the number of surgical-site infections at around 7 days between the two interventions or in cosmetic appearance. The mean total healthcare cost over the 4 months after surgery was €84 (95 per cent c.i. 34 to 140) lower for the nail-discarded arm than the nail-replaced arm (P < 0.001). Conclusion After nail bed repair, discarding the fingernail was associated with similar rates of infection and cosmesis ratings as replacement of the finger nail, but was cost saving

Light‐Induced Rearrangement of Thioether‐Substituted Phosphanide Ligands: Scope and Limitations of a Remarkable Isomerization

Treatment of the thioether‐substituted secondary phosphanes R2PH(C6H4‐2‐SR1) [R2=(Me3Si)2CH, R1=Me (1PH), iPr (2PH), Ph (3PH); R2=tBu, R1=Me (4PH); R2=Ph, R1=Me (5PH)] with nBuLi yields the corresponding lithium phosphanides, which were isolated as their THF (1–5Pa) and tmeda (1–5Pb) adducts. Solid‐state structures were obtained for the adducts [R2P(C6H4‐2‐SR1)]Li(L)n [R2=(Me3Si)2CH, R1=nPr, (L)n=tmeda (2Pb); R2=(Me3Si)2CH, R1=Ph, (L)n=tmeda (3Pb); R2=Ph, R1=Me, (L)n=(THF)1.33 (5Pa); R2=Ph, R1=Me, (L)n=([12]crown‐4)2 (5Pc)]. Treatment of 1PH with either PhCH2Na or PhCH2K yields the heavier alkali metal complexes [{(Me3Si)2CH}P(C6H4‐2‐SMe)]M(THF)n [M=Na (1Pd), K (1Pe)]. With the exception of 2Pa and 2Pb, photolysis of these complexes with white light proceeds rapidly to give the thiolate species [R2P(R1)(C6H4‐2‐S)]M(L)n [M=Li, L=THF (1Sa, 3Sa–5Sa); M=Li, L=tmeda (1Sb, 3Sb–5Sb); M=Na, L=THF (1Sd); M=K, L=THF (1Se)] as the sole products. The compounds 3Sa and 4Sa may be desolvated to give the cyclic oligomers [[{(Me3Si)2CH}P(Ph)(C6H4‐2‐S)]Li]6 ((3S)6) and [[tBuP(Me)(C6H4‐2‐S)]Li]8 ((4S)8), respectively. A mechanistic study reveals that the phosphanide–thiolate rearrangement proceeds by intramolecular nucleophilic attack of the phosphanide center at the carbon atom of the substituent at sulfur. For 2Pa/2Pb, competing intramolecular β‐deprotonation of the n‐propyl substituent results in the elimination of propene and the formation of the phosphanide–thiolate dianion [{(Me3Si)2CH}P(C6H4‐2‐S)]2−

Capital consumption: The transition to sustainable consumption and production in London

How can London reduce its consumption based carbon dioxide emissions by 90% by 2050? The Capital Consumption report has modelled one scenario, based on expert research, to show how this can be achieved in the city. This paper will present the findings of the report. Capital consumption aims to create an evidence base on the climate impacts of consumption in London, to provide a better understanding of the scale and breadth of action needed across all sectors to put London on a more sustainable footing, and to identify key opportunities for London to take effective action. The research is informative for anyone interested in sustainability and could be applied to other cities and regions. The report has the following characteristics: \u95 It models consumption based CO2 emissions and so takes into account the embodied carbon emissions of items consumed in London but manufactured elsewhere - such as consumer goods, construction materials and food \u95 It is London-specific and identifies opportunities for city-level action to catalyse change \u95 It considers CO2 savings through changes in both consumption and production \u95 It uses a carbon budgeting approach to define the desired reduction pathway The measures modelled in the report are stretching and ambitious, they are unlikely to be achieved by action only within London. As the supply chains and policy contexts influencing consumption in London are global in scope, responsibility for bringing about the measures must be shared between governments at all levels, businesses and consumers