Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK

Aims The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care. Methods A two-round, modified Delphi study was conducted online. An advisory group of children’s orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to ‘Exercises’, ‘Physical activity’, ‘Education/information sharing’, ‘Input from other services’, and ‘Monitoring assessments’. The survey was shared with clinicians who regularly treat children with Perthes’ disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as ‘points to consider’. Results A total of 40 participants took part in the first round, of whom 31 completed the second round. A total of 87 statements were generated by the advisory group and included in the first round, at the end of which 31 achieved consensus and were removed from the survey, and an additional four statements were generated. A total of 60 statements were included in the second round and 45 achieved the threshold for consensus from both rounds, with three achieving the threshold for ‘points to consider’. The recommendations predominantly included self-management, particularly relating to advice about exercise and education for children with Perthes’ disease and their families. Conclusion Children’s orthopaedic specialists have reached consensus on recommendations for non-surgical treatment in Perthes’ disease. These statements will support decisions made in clinical practice and act as a foundation to support clinicians in the absence of robust evidence. The dissemination of these findings and the best way of delivering this care needs careful consideration, which we will continue to explore

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

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome

Human impact on the environment in the Annecy Petit Lac Catchment, Haute-Savoie: A documentary approach

It is axiomatic that mountain environments are particularly vulnerable to changes in patterns of human use, over both long and medium terms, but also over quite short periods of critical activity. This paper uses archaeological and documentary records to look at the human impact on one such montane environment, the pre-alps of Savoy, over the long-term, from pre-history up to the pre-modern period. The use and modification of landscape is estimated at the level of the Annecy Petit Lac hydrological catchment taking into account spatial differences in land use in the uplands, mid-slope and plain. Land use patterns and nutrient balance are reconstructed for specific periods in time between 1561 and 1892. Results from this study demonstrate that seven main phases of human activity have left their traces in the environmental record during the historical period through to the pre-modern period. Of these the 1730-1770s and 1840-1860s stand out as two discernible periods of heightened environmental pressures at higher altitudes, which manifest themselves as discernable lowland environmental problems, such as flooding, increased erosion and declining soil fertility

Family household structures and inheritance in Savoy 1561-1975

Supported by grant number HR-6875 from the Social Science Research CouncilAvailable from British Library Lending Division - LD:9349.083(11) / BLDSC - British Library Document Supply CentreSIGLEGBUnited Kingdo

Forestry and flooding in the Annecy Petit Lac Catchment, Haute-Savoie 1700-2000

Upland environments are particularly vulnerable to the stresses of climate change. The strength and persistence of such forces are not easy to measure and hence comparison of climate impacts with anthropogenic impacts has remained problematic. This paper attempts to demonstrate the nature of human impact on forest cover and flooding in the Annecy Petit Lac Catchment in pre-Alpine Haute Savoie, France, between 1730 and 2000. Local documentary sources and a pollen record provided a detailed history of forest cover and management, making it possible to plot changes in forest cover against local and regional precipitation records, and their individual and combined impacts on flooding. A main period of large-scale, uniform and rapid deforestation in the catchment was identified in the early nineteenth century, but sub-catchment patterns of reforestation and regeneration have varied up to the present. The period of deforestation was accompanied by demographic expansion and regional scale exogenous forces, such as small scale industrial development, foreign occupation, war, caveats and laws, acting alongside local scale endogenous forces and land fragmentation, agricultural crisis, and the desire for pasture. These all produced conflict between individual needs and those of communities and resulted in localised changes in forest cover. Joint phases of deforestation and flooding are more evident in individual second order tributaries than the whole catchment, but there appears to be no obvious or simple causal link between forest cover change, climate anomalies and flooding

Meteorological and land use controls on past and present hydro-geomorphic processes in the pre-alpine environment: an integrated lake-catchment study at the Petit Lac d'Annecy, France

A wide range of environmental records is integrated in order to reconstruct the mechanisms of flooding and sediment transport within the 170 km2 Petit Lac catchment, Annecy, France, over time scales of 10-1 to 102 years. These records include sequential lake sediment trap samples and cores, floodplain stratigraphies, dated landform assemblages, hydro-meteorological records, and documented histories of river channel and land-use change. Mineral magnetic measurements are used as the basis for classifying catchment sediment sources and tracing sediment movements through time. Records of magnetic susceptibility for monthly sediment trap samples (1998-99) track seasonal discharge, peaking in winter and spring. Magnetic records in lake sediment cores are compared against and tuned to precipitation records to provide dated proxy records for past discharge spanning sub-annual to decadal time scales back to 1826. Calculated sediment accumulation rates in lake sediment cores are used as proxies for time-averaged catchment sediment load. Analysis of the results reveals that climate and land-use controls on the hydrological and sediment system are complex and vary according to the time scale of observation. In general, cycles of agricultural expansion and deforestation appear to have been the major cause of shifts in the sediment system through the late Holocene. Deforestation in the 18th century may have caused a number of high-magnitude flood and erosion events. As the time scale of observation becomes shorter, changes in climate and hydro-meteorological conditions become progressively more important. Since the mid-19th century, smoothed records of discharge roughly follow annual precipitation; this is in contrast to sediment load, which follows the trend of declining land-use pressures. Episodic erosion events during this recent period seem to be linked to geomorphic evidence for slope instability in the montane and sub-alpine zones, triggered by intense summer rainfall. At the annual scale, changes in seasonal rainfall become paramount in determining sediment movement to downstream locations. The study demonstrates that the connections between forcings and responses span a four-dimensional array of temporal and spatial scales, with strong evidence for dominantly nonlinear forcing-response mechanisms