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Background: A quarter of all patients presenting to emergency departments are children. Although there are several large, well-conducted studies on adults enabling accurate selection of patients with head injury at high risk for computed tomography scanning, no such study has derived a rule for children. Aim: To conduct a prospective multicentre diagnostic cohort study to provide a rule for selection of high-risk children with head injury for computed tomography scanning. Design: All children presenting to the emergency departments of 10 hospitals in the northwest of England with any severity of head injury were recruited. A tailor-made proforma was used to collect data on around 40 clinical variables for each child. These variables were defined from a literature review, and a pilot study was conducted before the children’s head injury algorithm for the prediction of important clinical events (CHALICE) study. All children who had a clinically significant head injury (death, need for neurosurgical intervention or abnormality on a computed tomography scan) were identified. Recursive partitioning was used to create a highly sensitive rule for the prediction of significant intracranial pathology. Results: 22 772 children were recruited over 2½ years. 65% of these were boys and 56% were <5 years old. 281 children showed an abnormality on the computed tomography scan, 137 had a neurosurgical operation and 15 died. The CHALICE rule was derived with a sensitivity of 98% (95% confidence interval (CI) 96% to 100%) and a specificity of 87% (95% CI 86% to 87%) for the prediction of clinically significant head injury, and requires a computed tomography scan rate of 14%. Conclusion: A highly sensitive clinical decision rule is derived for the identification of children who should undergo computed tomography scanning after head injury. This rule has the potential to improve and standardise the care of children presenting with head injuries. Validation of this rule in new cohorts of patients should now be undertaken.

In recent years, a strong effort has been dedicated to the development of tokamak plasma regimes alternative to the standard high confinement mode (H-mode) with type-I edge localized mode (ELM), i.e. ELM-free and small-ELM regimes, given the associated hardly sustainable energy and particle fluxes on plasma facing components. In this work, we will focus on new H-mode regimes with small-ELMs, the so-called baseline small-ELMs (BSE), characterized by high thermal confinement and low core impurity accumulation, which have been recently found at JET. In order to characterize the micro-turbulence at play at the top of the pedestal, an extensive local linear gyrokinetic analysis with the GKW code has been carried out. In particular, a comparison between a reference type-I ELM (#97395) and two BSE plasmas (#96994 and #94442) has been performed. The ion-scale (0.1 ≤ k θ ρ i ≤ 2) micro-turbulence is found to have different characteristics in the two regimes. Indeed, kinetic-ballooning modes (KBM) are destabilized in the type-I ELM regime at k θ ρ i ∼ 0.1, while they are stable in BSE regimes. In addition, negative (i.e. electron-diamagnetic-direction) frequency modes, identified as electron-temperature-gradient (ETG) modes, are destabilized at k θ ρ i ∼ 1.5 in the type-I ELM regime while BSE regimes are characterized by positive (i.e. ion-diamagnetic-direction) frequency modes. Meanwhile, at electron-scale (10 ≤ k θ ρ i ≤ 700) ETG modes are the dominant micro-instabilities in both regimes. Then, since BSE regimes are characterized by a higher impurity concentration at the pedestal, particular attention has been given to the role played by them. We found that impurities represent a critical player in the linear dynamics, strongly affecting the nature of micro-instabilities at ion-scale.

The installation of international thermonuclear experimental reactor-relevant materials for the plasma facing components (PFCs) in the Joint European Torus (JET) is expected to have a strong impact on the operation and protection of the experiment. In particular, the use of all-beryllium tiles, which deteriorate at a substantially lower temperature than the formerly installed carbon fiber composite tiles, imposes strict thermal restrictions on the PFCs during operation. Prompt and precise responses are therefore required whenever anomalous temperatures are detected. The new vessel thermal map real-time application collects the temperature measurements provided by dedicated pyrometers and infrared cameras, groups them according to spatial location and probable offending heat source, and raises alarms that will trigger appropriate protective responses. In the context of the JET global scheme for the protection of the new wall, the system is required to run on a 10 ms cycle communicating with other systems through the real-time data network. In order to meet these requirements a commercial off-the-shelf solution has been adopted based on standard x86 multicore technology. Linux and the multithreaded application real-time executor (MARTe) software framework were respectively the operating system of choice and the real-time framework used to build the application. This paper presents an overview of the system with particular technical focus on the configuration of its real-time capability and the benefits of the modular development approach and advanced tools provided by the MARTe framework.

The introduction of new regulations for Means of Access (MA) has led to an increase in the number and complexity of access openings, an increase in the size of the access openings in the ship’s structure, and a stricter maintenance regime which presents new challenges throughout the life of modern vessels. Several of the major issues at the design stage of Permanent Means of Access (PMA); the construction of ships; the application of protective coatings during new building, together with coating maintenance during the service lifetime; problems related to cleaning holds after cargoes have been removed; action by the Butterworth crude oil washing action and the challenges of maintenance in ballast tanks, are discussed in this paper.

Objectives: Meniscal allograft transplantation (MAT) is indicated for active patients with symptomatic meniscal deficiency. Various graft fixation techniques have been described, including bone plugs, bone bridge-and-slot, and transosseous fixation. More recently, with the advent of all-inside meniscal repair devices, suture-only graft fixation methods have also gained popularity, although the comparative outcomes of this technique remain uncertain. This study aims to investigate the relationship between various meniscal allograft fixation techniques and reoperation rates following MAT. Methods: A retrospective chart review was conducted to identify patients who underwent MAT at a single academic institution. Patient demographics, including age at surgery, sex, and BMI were collected. Meniscal allograft fixation technique was recorded, as well as subsequent ipsilateral knee surgeries that occurred following the index MAT procedure. The fixation methods analyzed were bone plug, bone bridge-and-slot, and suture-only. Fisher’s exact test was used to evaluate the association between fixation technique and reoperation rate. Statistical significance was set at p < 0.05. Results: A total of 155 patients were included in the study cohort, with 86 (55.48%) being male. The average time to follow-up was 5.89 years with a mean age at the time of surgery of 29.4 ± 9.83 years and mean BMI of 27.5 ± 5.58. Lateral MAT was performed in 81 (52.26%) of cases whereas the remaining 74 (47.74%) underwent medial MAT. Patients who underwent MAT with suture-only fixation had a significantly higher reoperation rate (19/53, 35.8%) than those who underwent either bone bridge-and-slot (8/50, 16.0%) or bone plug (8/52, 15.4%) fixation (p = 0.023) (Table 1). The most common reoperation procedures were partial meniscectomy (14/35, 40%) and meniscal root repair (6/35, 17.14%), which together accounted for over half of all reoperations within the cohort. Conclusions: Suture-only meniscal allograft fixation was associated with a significantly higher reoperation rate than either bone bridge-and-slot or bone plug fixation, with the majority of reoperations being either partial meniscectomy or meniscal root repair. Although previous meta-analyses have reported similar graft survivorship between bony and suture-based fixation, our findings suggest that there may be a greater likelihood of reoperation (including revision meniscal procedures) with suture-only graft fixation. Surgeons may consider this information when selecting their preferred MAT technique and counseling patients preoperatively regarding the expected risks and benefits of the procedure.

Objectives: The use of bioinductive implants in surgical management of rotator cuff (RC) pathology is thought to be beneficial by providing collagenous and vascular support during the critical early postoperative phases of healing. Preliminary clinical studies have reported favorable outcomes with these implants in partial and full-thickness RC tears. Other studies have raised concerns about increased risk of postoperative stiffness when these implants are used, which can significantly affect patient outcomes and delay recovery. This study aims to evaluate clinical and patient-reported outcomes (PROs) following arthroscopic rotator cuff repair done with or augmented with a bioinductive collagen patch, with a minimum follow-up of two years. Specific objectives include assessing the incidence of postoperative complications, stiffness, the rate of rotator cuff re-tear, and the proportion of patients achieving a patient-acceptable symptom state (PASS) for select PROs. Methods: A single-institution retrospective review was conducted on consecutive patients who underwent arthroscopic rotator cuff repair between January 2011 and June 2024 with a minimum of 2-year follow-up. Patients were included if a bioinductive collagen patch was used as part of the surgical repair. A retrospective chart review was utilized to collect data on tear thickness, concomitant procedures, shoulder range of motion (ROM) measurements, occurrence of post-operative stiffness, treatment of stiffness with oral or injected corticosteroids, return to the OR for management of post-operative stiffness, occurrences of rotator cuff re-tear, and need for revision surgery for a re-tear. Post-operative stiffness was defined as decreased ROM or diagnosis of adhesive capsulitis persisting for 6 months or longer after surgery and stiffness requiring treatment. PROs were assessed at a minimum 2-year follow-up using the Tegner activity scale, American Shoulder and Elbow Surgeons Score (ASES), and Single Assessment Numeric Evaluation (SANE). The proportion of patients achieving PASS for ASES and SANE scores was calculated based on previously defined thresholds for arthroscopic rotator cuff repair. Results: 93 patients, with an average age of 55.03 ± 10.74 years (51.6% male, BMI 28.76 ± 5.27), underwent arthroscopic rotator cuff repair with the use of a bioinductive collagen patch, and were evaluated at an average follow-up of 47.9 ± 16.9 months. Of the 93 rotator cuff tears, 85 (91.4%) were partial-thickness and 8 (8.6%) were full-thickness. Among the partial-thickness tears, 76 (89.4%) were treated with a bioinductive patch alone, while 9 (10.6%) underwent rotator cuff repair augmented with a bioinductive patch. All 8 full-thickness tears (100%) were treated with rotator cuff repair augmented with a bioinductive patch. Concomitant procedures included biceps tenodesis in 38 patients (40.9%) and subacromial decompression in 29 patients (31.2%). 19 patients (20.4%) experienced postoperative stiffness that necessitated treatment or persisted past 6 months. 5 patients (5.4%) required MUA (manipulation under anesthesia) and arthroscopic LOA (lysis of adhesios). 8 patients (8.6%) had stiffness treated with steroid injections within 3 months of initial surgery and 5 patients (5.4%) were prescribed oral steroids. 4 patients (4.3%) experienced re-tear of the initial rotator cuff repair, and 2 patients (2.2%) required a revision repair. Subgroup analyses were conducted for patients who completed PROs (42 patients, 45.2% follow-up). The average ASES score was 89.3 ± 14.0 with 30 (71.4%) achieving PASS. The average SANE score for the injured and contralateral arms were 75.2 ± 24.3 and 75.8 ± 28.2 respectively, with 19 (45%) achieving PASS. Conclusions: Arthroscopic rotator cuff repair of full and partial tears, utilizing a bioinductive collagen patch yielded favorable outcomes, with a notably low incidence of re-tear and postoperative complications.  Almost three-quarters of analzyed patients achieved PASS for ASES scores and almost a half achieved PASS for SANE, underscoring the potential of bioinductive collagen augmentation to enhance the durability and clinical success of rotator cuff repairs. However, the use of bioinductive patches is not without complications, as 1 in 5 patients experienced persistent post-operative stiffness that required further intervention. These findings mirror previous literature, which suggests increased rates of post-operative stiffness in cuff repair with addition of a bioinductive patch to the rotator cuff repair construct. Further prospective studies are essential to validate the long-term efficacy and broader applicability of this technique in diverse patient populations.

Studies of underground miners occupationally exposed to radon have consistently demonstrated an increased risk of lung cancer in both smokers and non-smokers. Radon exposure also occurs elsewhere, especially in houses, and estimates based on the findings for miners suggest that residential radon is responsible for about one in 20 lung cancers in the UK, most being caused in combination with smoking. These calculations depend, however, on several assumptions and more direct evidence on the magnitude of the risk is needed. To obtain such evidence, a case-control study was carried out in south-west England in which 982 subjects with lung cancer and 3185 control subjects were interviewed. In addition, radon concentrations were measured at the addresses at which subjects had lived during the 30-year period ending 5 years before the interview. Lung cancer risk was examined in relation to residential radon concentration after taking into account the length of time that subjects had lived at each address and adjusting for age, sex, smoking status, county of residence and social class. The relative risk of lung cancer increased by 0.08 (95% CI -0.03, 0.20) per 100 Bq m(-3) increase in the observed time-weighted residential radon concentration. When the analysis was restricted to the 484 subjects with lung cancer and the 1637 control subjects with radon measurements available for the entire 30-year period of interest, the corresponding increase was somewhat higher at 0.14 per 100 Bq m(-3) (95% CI 0.01, 0.29), although the difference between this group and the remaining subjects was not statistically significant. When the analysis was repeated taking into account uncertainties in the assessment of radon exposure, the estimated increases in relative risk per 100 Bq m(-3) were larger, at 0.12 (95% CI -0.05, 0.33) when all subjects were included and 0.24 (95% CI -0.01, 0.56) when limited to subjects with radon measurements available for all 30 years. These results are consistent with those from studies of residential radon carried out in other countries in which data on individual subjects have been collected. The combined evidence suggests that the risk of lung cancer associated with residential radon exposure is about the size that has been postulated on the basis of the studies of miners exposed to radon.

Background: NICE guidelines for the management of head injury were published in June 2003. Their recommendations differ markedly from previous guidelines published by the Royal College of Surgeons (RCS). In place of skull radiography and admission, computed tomography (CT) is advocated. The impact of these guidelines on service provision in the UK is unknown. Methods: Data on all clinical correlates of children presenting with any severity of head injury was collected in three hospitals in the northwest of England. The current skull radiograph (SXR), CT scan, and admission rates were determined. The rates of SXR, CT scan, and admission that should have occurred when following either the RCS or NICE guidelines were then determined. Results: Data from 10 965 patients who attended three hospitals between February 2000 and August 2002 was studied. Twenty five per cent of patients received a SXR, 0.9% a CT scan, and 3.7% were admitted. Strict adherence to the RCS guidelines would have resulted in a 50% SXR rate, a 1.6% CT scan rate, and a 7.1% admission rate. Adherence to NICE guidelines would result in a 0.3% SXR rate, an 8.7% CT scan rate, and a 1.4% admission rate, although the CT rate would drop to 6.3% if vomiting three or more times in the under 12s was used instead of more than one vomit. Conclusions: The new NICE guidelines do not increase the workload caused by patients attending with head injury but they move their management from the observation ward to the radiology department.

In his recent article ‘The State as Person in International Theory’, Alexander Wendt advocates explicitly ‘personifying the state’. In his philosophical argument, he opposes a ‘physicalism’ which would reduce states to their individual members with his own ‘thin version of personhood’ derived from social theory. But this approach, neglecting normative criteria, sets up an opposition between false extremes, as well as being false to the full nature of human beings. It is doubtful whether the state is ever, in practice, the perfect corporate agent of Wendt's prescription, and it would be suspect if it were.

A short cut review was carried out to establish whether levels of S-100b were predictive of long-term disability after head injury. 200 papers were found using the reported searches, of which 12 presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that a raised level of S-100b is a marker of poorer long-term outcome after both major and minor head injury.