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New surgical procedures can expose patients to harm and should be carefully evaluated before widespread use. The InSpace balloon (Stryker, USA) is an innovative surgical device used to treat people with rotator cuff tears that cannot be repaired. We aimed to determine the effectiveness of the InSpace balloon for people with irreparable rotator cuff tears.We conducted a double-blind, group-sequential, adaptive randomised controlled trial in 24 hospitals in the UK, comparing arthroscopic debridement of the subacromial space with biceps tenotomy (debridement only group) with the same procedure but including insertion of the InSpace balloon (debridement with device group). Participants had an irreparable rotator cuff tear, which had not resolved with conservative treatment, and they had symptoms warranting surgery. Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Participants and assessors were masked to group assignment. Masking was achieved by using identical incisions for both procedures, blinding the operation note, and a consistent rehabilitation programme was offered regardless of group allocation. The primary outcome was the Oxford Shoulder Score at 12 months. Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The primary analysis was on a modified intention-to-treat basis, adjusted for the planned interim analysis. The trial was registered with ISRCTN, ISRCTN17825590.Between June 1, 2018, and July 30, 2020, we assessed 385 people for eligibility, of which 317 were eligible. 249 (79%) people consented for inclusion in the study. 117 participants were randomly allocated to a treatment group, 61 participants to the debridement only group and 56 to the debridement with device group. A predefined stopping boundary was met at the first interim analysis and recruitment stopped with 117 participants randomised. 43% of participants were female, 57% were male. We obtained primary outcome data for 114 (97%) participants. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design -4·2 [95% CI -8·2 to -0·26];p=0·037) favouring control. There was no difference in adverse events between the two groups.In an efficient, adaptive trial design, our results favoured the debridement only group. We do not recommend the InSpace balloon for the treatment of irreparable rotator cuff tears.Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health and Care Research partnership.

Efficient adsorbents were fabricated by modifying the orchard waste biochar (BC) to produce zero-valent iron composited BC (BC/Fe0) and phosphorus embedded BC (BC/P). The efficacy of these adsorbents for copper [Cu(II)] removal from aqueous media was investigated via pH, kinetics, and adsorption batch trials. The solution pH 7 was found optimum for the highest Cu(II) removal. Elovich model was fitted well to the Cu(II) kinetics adsorption and higher initial sorption rate 79.44, 75.71, 72.28, 61.60 mg g−1 min−1 for BC/Fe0, BC, AC, and BC/P, respectively, was observed than other kinetic models. Langmuir, Freundlich, and Redlich–Peterson isotherm models were applied to the experimental data and Langmuir model fitted well predicting the adsorption capacity of 427.11 mg g−1. The BC became more selective in copper removal after the introduction of Fe0, and a higher removal rate of Cu(II) was observed in a short time compared to the other tested adsorbents. Therefore, zero-valent iron composited orchard waste-derived biochar as a green and cost-effective adsorbent can open new ways for the efficient removal of Cu(II) from aqueous solutions.

Background Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability. Methods This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care; ‘Personalised Knee Therapy’ (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of follow-up (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use. Results We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months. Conclusion This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability. Trial registration The trial was prospectively registered on the International Standard Randomised Controlled Trial Number registry on the 22/12/2016 (reference number: ISRCTN14950321). http://www.isrctn.com/ISRCTN14950321

Introduction: Traumatic brain injuries (TBIs) are 1 of the most common reasons for young adult death and disability. This study sought to provide novel data for TBIs in Southern Punjab, as well as to identify any areas of service improvement to reduce the acute and long-term burden of this condition. Methods: A survey in English was created, which was then circulated to members of the emergency and neurosurgical department for a 3-wk period. Results: A total of 450 patients (379 male [84.2%] and 71 female [15.2%]) were included as TBI admissions or attendances with a mean age of 28.9 y. Of the total, 420 people (93.2%) had experienced a TBI following a road traffic incident (RTI), with 78.7% (n = 354) of TBIs involving motorbike users who were not wearing helmets. A total of 226 (50.1%) patients arrived by car to the hospital, and 201 (44.7%) arrived by means of provincial government-funded emergency ambulance services. Conclusions: TBIs in Southern Punjab mostly affect younger males involved in RTIs while riding motorbikes. Recommendations to reduce the acute and long-term burden of TBIs in this region include formal training of all hospital and prehospital staff in the management of acute trauma cases according to international guidelines and operating provincial government emergency ambulance services in a wider geographic area.

High penetration of renewable energy generation is an important trend in the development of power systems. However, the problem of wind and solar energy curtailment due to their inherent randomness and fluctuation remains to be solved. Multienergy complementary operation based on the complementarity between different renewable energy units is an important means to improve the consumption. In this paper, a complementarity evaluation index is proposed to describe the matching ability of the total output of renewable power generation to the load. The interaction between the proposed index and an optimal allocation model of wind and photovoltaic capacity is analyzed in detail. Based on the analysis of the interaction, we can get a satisfying allocation result simply but effectively by maximizing the index. Compared with the existing complementarity indices, the proposed index can describe the complementarity between renewable energy sources in different capacity allocation results.

Introduction Orthopaedic training has undergone considerable changes in the last few decades. Although structured training pathways exist in most countries, the requirements for completion of training are remarkably different. This review aims to assess key differences among orthopaedic curricula in selected high-income countries with well-established orthopaedic training programmes, focusing on their criteria for assessing technical competence prior to completion of training. Methods Current orthopaedic training curricula published by the relevant accrediting bodies in the UK, USA, Canada, Australia, Germany and the European Union were reviewed. Data extracted included specified training duration, minimum or desirable operative experience requirements, methods and timing of in-training assessments. Results The overall training duration ranged between 9 and 10 years in the UK and Australia, compared to 5–6 years in all other countries. While operative logbook was an essential component of formative and end-of-training reviews in all countries, minimum indicative numbers in index operations were a requirement only in the UK (minimum total required; 1800, index operations; 365) and USA (minimum total required; 1000, index operations; 455). On average, USA residents performed 1700 procedures compared to German residents performing 730 procedures before completion of training. Conclusion There is a lack of robust data describing the operative experiences of orthopaedic trainees outside of the UK and USA. UK training is the longest among countries compared in this review and also sets the highest standards in minimum operative experience requirements. Based on the evidence available, surgeons exiting training and entering independent practice in the above countries are not trained to the same minimum standard.

The advancement in electrical load forecasting techniques with new algorithms offers reliable solutions to operators for operational cost reduction, optimum use of available resources, effective power management, and a reliable planning process. The focus is to develop a comprehensive understanding regarding the forecast accuracy generated by employing a state of the art optimal autoregressive neural network (NARX) for multiple, nonlinear, dynamic, and exogenous time varying input vectors. Other classical computational methods such as a bagged regression tree (BRT), an autoregressive and moving average with external inputs (ARMAX), and a conventional feedforward artificial neural network are implemented for comparative error assessment. The training of the applied method is realized in a closed loop by feeding back the predicted results obtained from the open loop model, which made the implemented model more robust when compared with conventional forecasting approaches. The recurrent nature of the applied model reduces its dependency on the external data and a produced mean absolute percentage error (MAPE) below 1%. Subsequently, more precision in handling daily grid operations with an average improvement of 16%&ndash, 20% in comparison with existing computational techniques is achieved. The network is further improved by proposing a lightning search algorithm (LSA) for optimized NARX network parameters and an exponential weight decay (EWD) technique to control the input error weights.

Resilience against major disasters is the most essential characteristic of future electrical distribution systems (EDS). A multi-agent-based rolling optimization method for EDS restoration scheduling is proposed in this paper. When a blackout occurs, considering the risk of losing the centralized authority due to the failure of the common core communication network, the agents available after disasters or cyber-attacks identify the communication-connected parts (CCPs) in the EDS with distributed communication. A multi-time interval optimization model is formulated and solved by the agents for the restoration scheduling of a CCP. A rolling optimization process for the entire EDS restoration is proposed. During the scheduling/rescheduling in the rolling process, the CCPs in the EDS are reidentified and the restoration schedules for the CCPs are updated. Through decentralized decision-making and rolling optimization, EDS restoration scheduling can automatically start and periodically update itself, providing effective solutions for EDS restoration scheduling in a blackout event. A modified IEEE 123-bus EDS is utilized to demonstrate the effectiveness of the proposed method., Comment: This version is accepted by Journal of Modern Power Systems and Clean Energy (MPCE). The final version will be published in MPCE

IntroductionDespite multiple scandals in the medical implant sector, premarket testing has been the attention of little published research. Complications related to new devices, such as the DePuy Articular Surface Replacement (ASR, DePuy Synthes, USA), have raised the issue of how designs are tested and whether engineering standards remain up to date with our understanding of implant biomechanics. Despite much work setting up national joint registries to improve implant monitoring, there have been few academic studies examining the premarket engineering standards new implants must meet. Emerging global economies mean that the markets have changed, and it is unknown to what degree engineering standards vary around the world. Governments, industry and independent regulatory bodies all produce engineering standards; therefore, the comparison of surgical implants across different manufacturers and jurisdictions is difficult. In this review, we will systematically collate and compare engineering standards for trauma and orthopaedic implants around the world. This will help inform patient, hospital and surgeon choice and provide an evidence base for future research in this area.Methods and analysisThis protocol is based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will conduct a systematic review of trauma and orthopaedic engineering standards from four main sources of information as identified in our preliminary scoping searches: governments, industry, independent regulatory bodies and engineering and medical publications. Any current standard relevant to trauma and orthopaedic implants will be included. We will use a predefined search strategy and follow the recommendations of the Cochrane handbook where applicable. We will undertake a narrative synthesis with qualitative evaluation of homogeneity between engineering standards.Ethics and disseminationNo ethics approval is required as no primary data are being collected. The results will be made available by peer-reviewed publication and reported according to PRISMA-P guidelines.