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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. 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. 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. 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. The UK National Institute for Health Research Health Technology Assessment Programme.

The dissolved organic carbon (DOC) export from land to ocean via rivers is a significant term in the global C cycle, and has been modified in many areas by human activity. DOC exports from large global rivers are fairly well quantified, but those from smaller river systems, including those draining oceanic regions, are generally under-represented in global syntheses. Given that these regions typically have high runoff and high peat cover, they may exert a disproportionate influence on the global land–ocean DOC export. Here we describe a comprehensive new assessment of the annual riverine DOC export to estuaries across the island of Great Britain (GB), which spans the latitude range 50–60° N with strong spatial gradients of topography, soils, rainfall, land use and population density. DOC yields (export per unit area) were positively related to and best predicted by rainfall, peat extent and forest cover, but relatively insensitive to population density or agricultural development. Based on an empirical relationship with land use and rainfall we estimate that the DOC export from the GB land area to the freshwater-seawater interface was 1.15 Tg C year−1 in 2017. The average yield for GB rivers is 5.04 g C m−2 year−1, higher than most of the world’s major rivers, including those of the humid tropics and Arctic, supporting the conclusion that under-representation of smaller river systems draining peat-rich areas could lead to under-estimation of the global land–ocean DOC export. The main anthropogenic factor influencing the spatial distribution of GB DOC exports appears to be upland conifer plantation forestry, which is estimated to have raised the overall DOC export by 0.168 Tg C year−1. This is equivalent to 15% of the estimated current rate of net CO2 uptake by British forests. With the UK and many other countries seeking to expand plantation forest cover for climate change mitigation, this ‘leak in the ecosystem’ should be incorporated in future assessments of the CO2 sequestration potential of forest planting strategies.

Purpose Studies on healthy lifestyle interventions in survivors of colorectal cancer have been disappointing, demonstrating only modest changes. This study aims to quantify people’s preferences for different aspects of dietary intervention. Method A best-worst discrete choice experiment was designed and incorporated into a questionnaire including participants’ characteristics and a self-assessment of lifestyle. Results The response rate was 68% and 179 questionnaires were analysed. When analysing aggregate preferences, the modes of information provision selected as the most preferred were “face-to-face” (willingness to pay (WTP) £63.97, p  ≤ 0.001) and “telephone” (WTP £62.36, p  < 0.001) discussions whereas group discussions were preferred least (WTP −£118.96, p  ≤ 0.001). Scenarios that included hospitals were most preferred (WTP £17.94, p  = 0.031), and the favoured provider was bowel cancer nurses (WTP £75.11, p  ≤ 0.001). When investigating preference heterogeneity, three sub-groups were identified: Firstly, “technophiles” preferring email (WTP £239.60, p  ≤ 0.001) were male, were younger and had fewer risk factors. Secondly, a “one-to-one” group had strong preference for interventions over the telephone or at their local doctors and were older (WTP £642.13, p  ≤ 0.001). Finally, a “person-centred” group preferred face-to-face individual or group sessions (WTP £358.79, p  < 0.001) and had a high risk lifestyle. Conclusion For survivors of colorectal cancer, there is not one approach that suits all when it comes to providing dietary advice. Implications for Cancer Survivors This is important information to consider when planning healthy lifestyle interventions which include dietary advice for survivors of colorectal cancer. Aligning services to individuals’ preferences has the potential to improve patient experience and outcomes by increasing uptake of healthy lifestyle advice services and promoting a more tailored approach to dietary modifications, acknowledging sub-groups of people within the total population of colorectal cancer survivors.

ObjectiveTo implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care.DesignBefore and after study, investigating the effects of the intervention during two 11-month periods before and after implementation.SettingFour local neonatal units (LNUs) in South West England.ParticipantsInfants without major anomalies born at 27–33 weeks’ gestation admitted to participating units, and their parents.Train-to-Home interventionA family-centred discharge package to increase parents’ involvement and understanding of their baby's needs, comprising a train graphic and supporting care pathways to facilitate parents’ understanding of their baby's progress and physiological maturation, combined with improved estimation of the likely discharge date.Main outcome measuresPerceived Maternal Parenting Self-Efficacy (PMP S-E) scores, infant length of stay (LOS) and healthcare utilisation for 8 weeks following discharge.ResultsParents reported that the Train-to-Home improved understanding of their baby's progress and their preparedness for discharge. Despite a lack of change in PMP S-E scores with the intervention, the number of post-discharge visits to emergency departments (EDs) fell from 31 to 20 (p<0.05), with a significant reduction in associated healthcare costs (£3400 to £2200; p<0.05) after discharge. In both study phases, over 50% of infants went home more than 3 weeks before their estimated date of delivery (EDD), though no reduction in LOS occurred.ConclusionsDespite the lack of measurable effect on the parental self-efficacy scores, the reduction in ED attendances and associated costs supports the potential value of this approach.