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There is a lack of prospective evidence to guide surgeons when making recommendations about the appropriate timing of surgical intervention for ruptured anterior cruciate ligament (ACL), activity modifications to reduce the risk of secondary injury before surgery, and the short- and long-term risks associated with delayed ACL reconstruction. This study aimed to determine whether longer wait times are associated with a prolonged decrease in quality of life and an increased incidence of secondary joint injury after ACL rupture.We recruited 53 patients who presented between 2013 and 2017 at a single sports medicine minor injury clinic with a suspected acute ACL rupture, based on clinical examination; ACL rupture was confirmed on magnetic resonance imaging. Patients were randomly allocated to undergo early reconstruction (12 wk after injury) or reconstruction after a regular wait time (≥ 12 wk). We compared scores on the ACL quality of life measure (ACL-QOL) and the incidence of secondary knee injury at baseline and at surgery between the 2 groups. Participants also completed the Tegner scale (level of activity) at the time of consent and within 7 days before surgery.Twenty-eight patients were randomly assigned to the early surgery group and 25 patients to the regular wait time group. There was no difference in mean age between the 2 groups. There were no between-group differences in mean ACL-QOL score at the time of injury (28.5 [standard deviation (SD) 12.5] v. 28.5 [SD 12.6]) or at surgery (34.9 [SD 17.5] v. 38.0 [SD 17.5]). The mean wait time was significantly longer in the regular wait time group than in the early surgery group (29.6 wk [SD 13.2 wk] v. 10.6 wk [SD 5.1 wk],Wait time for ACL reconstruction may affect patients' quality of life, as it remained diminished for a longer period when surgery was delayed. A low activity level during the waiting period was observed in both groups; this low activity level may be one reason why no between-group differences in the incidence of secondary injury were observed. The findings suggest that patients with a limited activity level during the waiting period have a low risk of secondary injuries.

Project Wingman is a novel initiative conceived early in the COVID-19 pandemic by two airline captains and a psychologist, which brings airline style lounges, staffed by volunteer air crew to NHS Trusts. The aim was to boost morale by providing airline style customer service for staff while on breaks. Over 50 lounges were opened across the NHS, staffed by up to 5000 volunteers. In this pilot study of one large Trust, we surveyed staff who visited the Wingman lounge. 100 completed questionnaires were used as an end point. All staff felt that the lounge was beneficial during COVID. 62% reported that they would visit the lounge even it was not attended by aircrew. 57% felt their wellbeing had suffered during the pandemic. A national study would be useful to assess the impact of the Wingman Lounges, but our pilot study highlights the importance of staff wellbeing and the value of taking breaks while at work. Many of the lessons learned in supporting colleagues during the pandemic could be used and adapted to help future wellbeing initiatives and aid retention of staff across the NHS.

Objectives: The provision of high-quality personal protective equipment (PPE) has been a critical challenge during the COVID-19 pandemic. We evaluated an alternative strategy, mass deployment of a powered air-purifying respirator (PeRSo), in a large university hospital.Methods: We performed prospective user feedback via questionnaires sent to healthcare workers (HCWs) issued PeRSos, economic analysis, and evaluated the real-world impact.Results: Where paired responses were available, PeRSo was preferred over droplet precautions for comfort, patient response, overall experience, and subjective feeling of safety. For all responses, more participants reported the overall experience being rated “Very good” more frequently for PeRSo. The primary limitation identified was impairment of hearing. Economic simulation exercises revealed that the adoption of PeRSo within ICU is associated with net cost savings in the majority of scenarios and savings increased progressively with greater ITU occupancy. In evaluation during the second UK wave, over 3,600 respirators were deployed, all requested by staff, which were associated with a low staff absence relative to most comparator hospitals.Conclusions: Health services should consider a widespread implementation of powered reusable respirators as a safe and sustainable solution for the protection of HCWs as SARS-CoV-2 becomes an endemic viral illness.

Multidisciplinary team (MDT) meetings are widely used throughout medicine and dentistry, bringing together expertise and different opinions across many disciplines to benefit patient care. Depending on the cancer site and specialties involved, some MDTs can last for several hours, especially if there are many complex patients to discuss. However, concentration and attention can vary and distraction is almost inevitable with separate conversations between MDT members and the ever-increasing use of smartphones. The role of human factors (HF) in contributing to error is well known in high-risk activities including medicine and surgery. Surprisingly, while there is increasing awareness of their importance by medical and dental professionals to enhance patient safety, to our knowledge nothing to date has been published about the possible effect and role of HF at MDTs. Here we provide a brief HF overview and focus on the factors at an MDT that could lead to distraction, providing suggestions (including some from aviation) for possible ways to enhance and improve discussion during these often-long meetings. It is hoped that this paper will generate some thought and discussion around the current "normal" MDT practice in head and neck and other specialties and challenge colleagues to embrace HF and safety principles in a just and learning culture.

Bulk density is a key property of anode grade petroleum coke used in aluminum smelting and many studies have been undertaken on this parameter. These include previous work by BP that showed how particle shape could be modified by using different crushing technologies, and that changing shape parameters (i.e. sphericity and convexity) significantly influences coke bulk density. In this initial study, a single coke was used to keep coke porosity relatively constant. This study has now been extended to include the testing of a number of different petroleum cokes (calcined using diverse calcining technologies) and anode butt samples to vary porosity as well as shape. The results of the extended study confirmed the findings of the initial study and were used to populate a simple model of the factors that impact bulk density. This was then used to estimate the relative influence of particle shape and porosity on coke bulk density.

Crisis resolution teams (CRTs) provide treatment at home to people experiencing mental health crises, as an alternative to hospital admission. Previous UK research, based on self-report surveys, suggests that a loosely specified model has resulted in wide variations in CRTs' service delivery, organization and outcomes. A fidelity scale (developed through evidence review and stakeholder consensus) provided a means of objectively measuring adherence to a model of good practice for CRTs, via one-day fidelity reviews of UK crisis teams. Reviews included interviews with service users, carers, staff and managers, and examination of data, policies, protocols and anonymized case notes. Of the 75 teams reviewed, 49 (65%) were assessed as being moderate fidelity and the rest as low fidelity, with no team achieving high fidelity. The median score was 122 (range: 73-151; inter-quartile range: 111-132). Teams achieved higher scores on items about structure and organization, for example ease of referral, medication and safety systems, but scored poorly on items about the content of care and interventions. Despite a national mandate to implement the CRT model, there are wide variations in implementation in the UK and no teams in our sample achieved overall high fidelity. This suggests that a mandatory national policy is not in itself sufficient to achieve good quality implementation of a service model. The CRT Fidelity Scale provides a feasible and acceptable means to objectively assess model fidelity in CRTs. There is a need for development and testing of interventions to enhance model fidelity and facilitate improvements to these services.

BackgroundCrisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.AimsTo evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).MethodFifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.ResultsAll CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.ConclusionsThe CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.

Bulk density is a key property of anode grade petroleum coke used in aluminum smelting and many studies have been undertaken on this parameter. Although particle shape has been considered to influence coke bulk density (and hence baked anode density) in general terms, this relationship and its importance has not been detailed in studies to date. A correlation is presented showing that particle shape (i.e. sphericity and convexity) has a significant influence on coke bulk density. To gain additional insight into practical plant applicability of the testing, six different laboratory crushing methods were used to crush a single source coke and produce a range of particle shapes. This paper describes the study and results obtained, looks at the implications of the results, and outlines further studies being undertaken.

A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.

Empowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson

To assess the exposure of Blackfoot River mountain whitefish Prosopium williamsoni to the exotic parasite Myxobolus cerebralis, the cause of salmonid whirling disease, we investigated the spawning behavior of 49 adult mountain whitefish and their overlap with M. cerebralis within the Blackfoot River basin, Montana. A majority of the mountain whitefish radio-tagged in the Blackfoot River migrated upstream (range, 0.1–79.0 km) to spawning sites located primarily in the main stem of the Blackfoot River. Spawning ranged from 31 October in the lower river to 9 November in the upper river and occurred across a range of substrate and channel types. Despite later spawning in the upper river, eggs hatched earlier under the warming influence of groundwater inflows. Here, a majority of wild mountain whitefish fry (65%) tested positive for M. cerebralis infection during the immediate posthatch period of mid-April. Conversely, mountain whitefish fry from the lower river, downstream of the groundwater influenc...

The explosion of data types and volumes we are experiencing in the oil field, particularly in unconventional reservoir development, is stretching the capabilities of traditional manual workflows. The complex interactions between dynamic reservoir properties and the many-faceted well completions process are governed by complex physics that may be only partially understood. Furthermore, our best attempts to perform controlled experiments can often produce highly varied results, suggesting the stochastic nature of production from unconventionals and that we may benefit from adding new tools to our toolkit of deterministic, physics-based analysis.

The creation of future revenues is a formidable challenge and one to which organizational leaders are increasingly turning, now that they have been through years of reengineering and restructuring. Many of these leaders are finding that all the hard work, which may have been necessary for survival, hasn't proved enough for success.

The genetically encoded fluorescent proteins (FP), used in combination with Forster resonance energy transfer (FRET) microscopy, provide the tools necessary for the direct visualization of protein interactions inside living cells. Currently, the FPs most commonly used for live-cell FRET studies are the Cerulean and Venus variants of the cyan and yellow FPs. However, there are problems associated with this donor-acceptor pair, and these might be overcome by exploiting the characteristics of some of the newer FPs. For example, earlier we showed that the monomeric teal FP (mTFP) has advantages over Cerulean as a FRET donor for Venus. Here, using mTFP as the common donor fluorophore, we characterize a variety of different yellow, orange and red FPs as potential acceptors of FRET. We employed a "FRET standard" genetic construct to minimize variability in the separation distance and positioning of the fused donor and acceptor FPs. Using spectral FRET imaging and fluorescence lifetime measurements from living cells expressing the fused proteins, we characterized both sensitized acceptor emission and the shortening of the donor lifetime resulting from quenching for each of the fused FP pairs. Surprisingly, we found disagreements between the spectral FRET and lifetime measurements for some of the different FP pairs. Our results appear to indicate that some of the orange and red FPs can quench the mTFP donor while yielding little sensitized emission. We are characterizing the basis for this observation.

The new President spent some time digesting what he’d learned; looking at each of the pieces, relating each to each other and reflecting on how they all worked together as a whole. He was pretty sure he was going to be able to apply it. Obviously he was going to make mistakes, maybe even some big ones, but that was OK. As he’d learned, it went with the territory. It was part of the learning and growing process.

The new President found that reflecting on Values and Purposes was a lonely job. So he brought some close colleagues together into a group to explore them with him. They found that, by tracing the reasons for their company’s success back to the special beliefs that had guided founders, they could quite easily agree on the core values that they felt distinguished it.

Within a day his desk looked just like it had before. Within week it ten times worse. Haft of his people weren’t implementing his plan at all. And the other haft were implementing it in ways contradictory to each other!

Since the introduction of the new consultant contract in 2003, annual formal job planning has become increasingly important. It is likely that those subject to a new staff and associate specialist contract will have to complete a similar process. I may be 'teaching my grandmother to suck eggs' but colleagues, particularly the newly appointed or those with clinical lead responsibilities, find themselves unsure how to plan their jobs. Ideally, job planning should enable employer and employee to deliver an efficient, transparent service for patients. The implementation and interpretation of job plans and the contract vary between Trusts. Areas of particular difficulty surround supporting activities (structured professional activities (SPAs)) and external duties.

Continental Group's brief epic bout of restructuring did not deter a takeover. Diverse views of the complex story are presented: First, the analysis of the corporation's planning consultant, Mike Davidson; the CEO makes his case to a forum of security analysts; and analysts and the financial press render their judgment.

During the Seventies, strategic planning was tried and found wanting. Or was it? Corporate leadership's response to the tremendous increase in competitive intensity in the Seventies was, appropriately, to elevate strategy to its number one priority. For a number of companies, strategic planning failed to deliver. I don't think it was the concepts of strategy that failed, but the way we tackled the planning.

International audience; The actin cytoskeleton of dendritic spines plays a key role in morphological aspects of synaptic plasticity. The detailed analysis of the spine structure and dynamics in live neurons, however, has been hampered by the diffraction-limited resolution of conventional fluorescence microscopy. The advent of nanoscopic imaging techniques thus holds great promise for the study of these processes. We implemented a strategy for the visualization of morphological changes of dendritic spines over tens of minutes at a lateral resolution of 25 to 65 nm. We have generated a low-affinity photoconvertible probe, capable of reversibly binding to actin and thus allowing long-term photoactivated localization microscopy of the spine cytoskeleton. Using this approach, we resolve structural parameters of spines and record their long-term dynamics at a temporal resolution below one minute. Furthermore, we have determined changes in the spine morphology in response to pharmacologically induced synaptic activity and quantified the actin redistribution underlying these changes. By combining PALM imaging with quantum dot tracking, we could also simultaneously visualize the cytoskeleton and the spine membrane, allowing us to record complementary information on the morphological changes of the spines at super-resolution.