SummaryBackgroundFemoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery, including reshaping the hip, or with physiotherapist-led conservative care. We aimed to compare the clinical effectiveness of hip arthroscopy with best conservative care.MethodsUK FASHIoN is a pragmatic, multicentre, assessor-blinded randomised controlled trial, done at 23 National Health Service hospitals in the UK. We enrolled patients with femoroacetabular impingement syndrome who presented at these hospitals. Eligible patients were at least 16 years old, had hip pain with radiographic features of cam or pincer morphology but no osteoarthritis, and were believed to be likely to benefit from hip arthroscopy. Patients with bilateral femoroacetabular impingement syndrome were eligible; only the most symptomatic hip was randomly assigned to treatment and followed-up. Participants were randomly allocated (1:1) to receive hip arthroscopy or personalised hip therapy (an individualised, supervised, and progressive physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre and was done by research staff at each hospital, using a central telephone randomisation service. Patients and treating clinicians were not masked to treatment allocation, but researchers who collected the outcome assessments and analysed the results were masked. The primary outcome was hip-related quality of life, as measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed in all eligible participants who were allocated to treatment (the intention-to-treat population). This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN64081839, and is closed to recruitment.FindingsBetween July 20, 2012, and July 15, 2016, we identified 648 eligible patients and recruited 348 participants: 171 participants were allocated to receive hip arthroscopy and 177 to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (319 of 348 participants). At 12 months after randomisation, mean iHOT-33 scores had improved from 39·2 (SD 20·9) to 58·8 (27·2) for participants in the hip arthroscopy group, and from 35·6 (18·2) to 49·7 (25·5) in the personalised hip therapy group. In the primary analysis, the mean difference in iHOT-33 scores, adjusted for impingement type, sex, baseline iHOT-33 score, and centre, was 6·8 (95% CI 1·7–12·0) in favour of hip arthroscopy (p=0·0093). This estimate of treatment effect exceeded the minimum clinically important difference (6·1 points). There were 147 patient-reported adverse events (in 100 [72%] of 138 patients) in the hip arthroscopy group) versus 102 events (in 88 [60%] of 146 patients) in the personalised hip therapy group, with muscle soreness being the most common of the...

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A total of 21 rumen-cannulated wether sheep and six rumen-cannulated Ayrshire cows were used in a series of experiments to investigate fermentation in the rumen in animals given silage diets and the nominal metabolism of silage lactic acid. Dietary experiments with sheep (three experiments) and cows (two experiments) given diets consisting of formic acid-preserved perennial ryegrass (Lolium perenne) silages, in some cases with supplements of rolled barley, were conducted to investigate the ruminal concentrations of lactic acid and of volatile fatty acids (VFA) after feeding. Ingestion of silage was followed by a short-lived peak in lactic acid concentration in the rumen and by a subsequent increase in the concentration of propionate or propionate and butyrate. Butyrate production was more evident in cattle than in sheep. Taken as an average over a 6 h period of sampling the proportions (m-mol/mol total VFA) of acetate, propionate and butyrate in the rumen in animals given silage alone were typically 590-600, 210-250 and 70-150 respectively. When silage was supplemented with barley, in both sheep and cattle, the proportion of propionate was reduced and the proportion of butyrate was increased. In one experiment with sheep these changes in fermentation pattern were shown to be accompanied by an increase in the number of rumen protozoa from 2-78xl0 B /ml to 18-66 x 10 5 /ml (P<001). However, in a subsequent experiment it was shown that defaunation led to an increase in the proportion of butyrate in the rumen.Twelve estimates were also made with sheep of the metabolism of lactic acid infused into the rumen in a single dose of 20-50 g. These experiments showed that both (L + ) and DL-lactio acid were metabolized equally rapidly with a half-life of approximately 25 min. In faunated animals the major products of fermentation were propionate with a small amount of butyrate. In defaunated animals lactate metabolism was slowed and the major product of fermentation was butyrate.In vitro studies of lactate fermentation were carried out using strained liquor and isolated bacterial and protozoal fractions from the rumen of sheep receiving silage diets. The rates of lactate disappearance (/Jg/mg protein/h) were 50 and 22-2 for the rumen liquor and bacterial fraction, respectively, which were significantly (P<0-05, n = 5) less than the rate of 294-7 for the protozoal fraction. Rumen liquor, bacterial and protozoal fractions yielded a similar mixture of fermentation end-products, propionate accounting for approximately 60 % of the VFA produced.The results are discussed in relation to the metabolism of silage lactic acid in the rumen, the production of VFA and the yield of ATP for microbial cell synthesis. It is concluded that the pathways of lactate fermentation are regulated by the rumen microbial population and that protozoa may have an important role in the regulation of lactate fermentation.

Chamberlain, D. G., Thomas, P. C., Wilson, W., Newbold, J., Macdonald, J. C. (1985). The effects of carbohydrate supplements on ruminal concentrations of ammonia in animals given diets of grass silage. Journal of Agricultural Science, 104 (2), 331-340.A total of 15 rumen-cannulated sheep and four rumen-cannulated goats (Expt 3) were used in five latin square experiments designed to investigate the effects of carbohydrate supplements on ruminal ammonia concentration in animals given grass silage diets. In Expt 1 barley supplements were given at the same time, 1 h before or 2 h before a meal of silage. The treatments were designed to alter the synchronization between energy release from fermentation of barley and ammonia release from the degradation of silage N compounds. As compared with the unsupplemented control diet, barley supplements reduced (P < 0?05) rumen ammonia concentration and increased (P < 0?01) the number of total protozoa, but the time at which barley was given was without effect. In Expt 2 animals receiving silage or silage-barley diets were defaunated chemically. This treatment led to a 20?25 % reduction in rumen ammonia concentration. In Expt 3 supplements of maize starch, glucose and sucrose were compared. Mean ammonia concentrations were 231 mg/1 for the control unsupplemented diet and 205, 155 and 160 mg/1 (S.E. 21) for the starch, glucose and sucrose treatments. Corresponding numbers of protozoa were 7?7, 15?1, 6?1 and 6?3 x 10s/ml (S.E. 1?8). In Expt 4 the diets were unsupplemented silage or the same diet plus supplements of sucrose or xylose. Xylose reduced ammonia concentration more than sucrose, the values (mg/1) being 236 (control), 206 (sucrose) and 125 (xylose) (S.E. 19). There was no difference between the supplements in numbers of protozoa. Xylose induced a smaller reduction in pH, a higher (P < 0?05) proportion of acetate and a lower (P < 0?05) proportion of butyrate in rumen fluid than did sucrose. Effects of rumen pH were examined in Expt 5 where supplements of sucrose were given alone or together with NaHCO3. Rumen pH values were 6?38 for the control unsupplemented diet and 5?99, 6?28 and 6?55 (S.E. 0?06) for the diets supplemented with sucrose, sucrose plus 50 g NaHC03 and sucrose plus 100 g NaHCO3. Corresponding values for ruminal ammonia were 193, 151, 93 and 41 mg/1 (S.E. 10). Differences in VFA proportions between sucrose treatments were small and significant (P < 0?05) only for butyrate. It is concluded that there are important differences between carbohydrate sources in their effects on nitrogen metabolism in the rumen. Differences between starch and sugars appear to relate to the influence of the carbohydrates on the microbial population of the rumen, as was indicated by the differential effects of the carbohydrate sources on the number of total protozoa; differences between sugars appear to depend in part on the rates of sugar fermentation and the associated reduction in rumen pH.Peer reviewe

We characterise Gel Point derived markers of clot microstructure in patients admitted with emergency arterial thrombosis. This point of care test can potentially be used to assess the efficacy of therapeutic interventions by measuring changes in clot microstructure.