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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.

Liquid-liquid extraction is a commonly used technique to separate metals and is a process that has particular relevance to the nuclear industry. There has been a drive to use environmentally friendly ligands composed only of carbon, hydrogen, nitrogen, and oxygen. One example is the i-SANEX process that has been developed to separate minor actinides from spent nuclear fuel. The underlying science of such processes, is, however, both complex and intriguing. Recent research indicates that the liquid phases involved are frequently structured fluids with a hierarchical organization of aggregates. Effective flow-sheet modeling of such processes is likely to benefit from the knowledge of the fundamental properties of these phases. As a stepping stone toward this, we have performed molecular dynamics simulations on a metal free i-SANEX system composed of the ligand

Background The world has been turned upside down by COVID19. For so many, working lives have changed, roles have been adapted or learnt at lightning speed and working outside your 'comfort zone' has become part of the 'new normal'. Conversion of a PICU to an adult COVID ITU allowed both adult teams and paediatricians to work closely together and provide a chance to see how each other functions. And invaluably, an opportunity to learn from each other. This reflective piece looks at the key learning points taken from each team. Objectives To highlight the main learning points that were gained from both paediatric and adult teams during conversion of a PICU to an adult COVID ITU. Learning points applicable not only to working during the COVID-19 pandemic but that transcend to other aspects of paediatric and adult medical practice. Methods Reflection from both paediatric and adult medical staff who worked together during the COVID-19 pandemic in a PICU turned adult ITU. Results Key themes were found after discussion. Handover, communication with patients and relatives, attachment to patients and teamwork were the main areas where the largest learning points were seen. Upon reflection there were ways in which both the adult and paediatric doctors' practice had changed and influenced their future practice. Conclusions There is vast amounts of learning that can be taken from joint adult and paediatric working. Not just whilst managing adult COVID ITU patients during a pandemic but practices that can be translated into every day working lives. Perhaps more cross covering and working more closely with our adult colleagues, especially during the teenage transition years can improve not only patient care but working lives of future paediatricians. With ideals for future practice suggesting paediatricians may be looking after young adults very much over the age of 18 perhaps this is the time to be learning from experiences like these and introduce more parallel working between adult and paediatric colleagues.

HKB-Verletzungen werden in der Regel durch ein direktes Trauma des flektierten Knies verursacht und sind deutlich seltener als VKB-Rupturen. Das Wissen um die optimale physiotherapeutische Behandlung ist daher oft nicht präsent. Die britischen Kniespezialisten Richard Norris und Daniel Massey schaffen mit diesem physiopraxis-Refresher Abhilfe.

Moral relativism is an attractive position, but also one that it is difficult to formulate. In this paper, we propose an alternative way of formulating moral relativism that locates the relativity of morality in the property that makes moral claims true. Such an approach, we believe, has significant advantages over other possible ways of formulating moral relativism. We conclude by considering a few problems such a position might face.

An Environmental Protection Agency-funded project was the material flow analysis of naphthalene-containing products in an effort to eliminate, reduce, or replace the sources of naphthalene. The project analysis began with manufacturers who use naphthalene-containing products in their processes. It identifies the basic characteristics of naphthalene as a common polynuclear aromatic hydrocarbon, which is released to the environment. Included are likely sources of naphthalene emissions and releases as they were identified for further investigation. This paper, which is the sequel to IMECE 2005-82808, highlights a secondary objective of the project: to document the approach used in identifying the naphthalene flow from the raw material to its various products. This secondary objective was to show how process, product, and quantity data can best be gathered. Within the project, there were several means to collect data, some that have worked better than others. The purpose of this objective was to provide the framework of a proven approach to generating the material flow so that it can be followed for other priority chemicals that populate the EPA list.Copyright © 2006 by ASME