Norwich University

Outbreaks of animal and zoonotic diseases in South Africa are costly and raise concerns about national biosecurity. The interconnectedness of humans, livestock, wildlife and their social and ecological environment necessitates a holistic approach to prevention, preparedness and response to zoonotic and animal diseases. One Health is an increasingly accepted approach in contemporary science and policy spheres, but with limited consideration for economic dimensions. To more fully estimate costs of animal and zoonotic diseases in the country and to explore further scope for applying a One Health economics lens, the Agricultural Research Council of South Africa, in collaboration with partners, held a One Health Economics mini-congress to provide a platform where multidisciplinary stakeholders discussed practical examples, primarily from the Southern African region. Discussions at the mini-congress centred around One Health economics and opportunities, economic insights on prevention and control of Rift Valley fever (RVF), avian influenza and other zoonotic diseases, return on investment for One Health approaches, and insights from the natural resources and animal and human health sectors. Regional and international perspectives on multi-sectoral economic analysis and financing were also shared. Key recommendations from the mini-congress included promoting coordination, co-creation and co-implemented efforts to minimize effects of One Health challenges, and including economic aspects of multi-sectoral engagement to identify and reduce trade-offs and maximize co-benefits of strategies and programmes. Integration of economics in One Health fora, research and collaboration, and promotion of communities of practice and applied training to enhance learning and knowledge exchange were also identified as important.

Introduction Most lumbar decompressive surgery patients experience symptom improvement to 3 months, after which about 13% experience a clinically relevant deterioration. Patient-reported outcome measures (PROMs) are accepted as indicators of clinical outcome, but the earliest timepoint when PROMs stabilise is unknown and few studies have assessed risk factors for symptom deterioration. This study aimed to identify risk factors for symptom deterioration and identify whether 3-month models or observed 3- or 6-month outcomes accurately predict 12-month disability and pain. Methods The development cohort included 1096 prospectively collected discectomy or laminectomy cases with or without single-level fusion from 01/01/2008–31/12/2020 at a single centre. Three-month models were developed using baseline clinical variables and 3-month PROM. The primary 12-month outcome was the Oswestry Disability Index (ODI), and secondary outcomes were back and leg pain. Validation was on 364 cases from 01/01/2021–31/12/2022. Predictive accuracy was evaluated by interclass correlation coefficient (ICC) and by area-under-the-curve (AUC) to classify to a minimal clinically important difference (MCID). MCID concordance rates for observed 3-month and 6-month with 12-month PROM were calculated. Results Three-month predictors of 12-month disability and pain were condition duration, smoking, diabetes, rheumatic disorder, lower limb arthroplasty, mobility aided, underweight (BMI < 18.5 kg/m²), and 3-month PROM. ODI model and observed 3-month ODI had equivalent ICC and AUC values. Observed 3-month ODI ICC was 0.71 [95% confidence intervals (CI) 0.68–0.74] and AUC was 0.83 [95%CI 0.80–0.86]. Observed 6-month ODI ICC was 0.82 [95%CI 0.79–0.85] and AUC was 0.92 [95%CI 0.89–0.95]. MCID concordance for 3-month ODI was 84% and 6-month ODI was 91%. Conclusion Symptom deterioration after 3 months is linked to baseline factors. This study demonstrates that 6-month PROM accurately predict individual patient 12-month disability and pain after 1–2 level discectomy or laminectomy. Fusion surgery requires a minimum 12-month PROM follow-up.

Framing the public health burden of firearm violence should include people with secondary exposure to firearm violence beyond acute bodily injury, yet such data are limited. Electronic health record clinical notes, when leveraged through natural language processing (NLP), are a potential source of data on firearm exposure. As part of NLP lexicon development, diverse stakeholders were engaged to identify keywords, and our findings demonstrated that engaging diverse stakeholders adds valuable input to NLP development.

Background Modern contemporary percutaneous coronary intervention (PCI) techniques with drug-eluting stents (DES) have high procedural success rates in chronic total occlusion (CTO) but with a high prevalence of repeat revascularization. The use of drug-coated balloons (DCBs) in CTO is an alternative treatment strategy. The evidence for DCBs in CTO is, therefore, of interest, and we provide a structured and comprehensive review of the evidence available in terms of the use of DCBs in CTO, including de novo and in-stent (IS) CTO lesions. Objectives We conducted a systematic review and meta-analysis on the use of DCBs in the management of coronary CTO. Methods Electronic databases (PubMed, Embase and Ovid) were systematically searched from inception to April 2024 for DCB CTO studies. A meta-analysis was undertaken using a random-effects inverse-variance method due to heterogeneity. The primary outcome is target lesion revascularization (TLR). Secondary outcomes are major adverse cardiac events (MACE) as a composite of target lesion revascularization (TLR), cardiac death (CD), and any myocardial infarction (MI) including procedural and non-procedural MI, target vessel revascularization (TVR), angiographic outcomes such as late lumen loss (LLL), binary restenosis, and reocclusion. Results A total of 10 studies consisting of 1,695 patients were systematically reviewed. This showed that late luminal changes in terms of lumen gain and minimal lumen loss were consistently seen in CTO cohorts 7–12 months after DCB treatment. Five studies were included for meta-analysis with 1,474 patients. There were no significant differences in TLR between treatment strategies such as DCB, DES, and hybrid (DES + DCB) in both de novo and IS-CTO populations as follows: DCB vs DES [OR, 0.71; 95% CI 0.49–1.02], DCB vs DES in IS-CTO [OR, 0.78; 95% CI 0.45–1.34], DCB vs Hybrid [OR, 0.96; 95% CI 0.39–1.43], and hybrid vs DES [OR, 0.76; 95% CI 0.15–3.84]. Similar findings were seen with the MACE outcome. A sensitivity analysis showed no difference between the above-mentioned groups in terms of MI, CD, and TVR. Conclusion The limited initial evidence on DCB in coronary CTO-PCI suggests a safe and effective alternative treatment strategy and suggests RCTs are, therefore, required. Graphical Abstract

Objectives To report the British Association of Urological Surgeons (BAUS) consensus document on the assessment and management of post‐prostatectomy incontinence‐stress urinary incontinence (PPI‐SUI). Methods We conducted a contemporary literature search to identify the current evidence base. A guideline development group was formed by the Female, Neurological and Urodynamic Urology (FNUU) Section of BAUS to formulate and review the recommendations. Where a lack of evidence was identified, expert opinion of the FNUU Executive Committee and a modified Delphi approach was utilised. Results This consensus addresses several knowledge gaps in the current literature on PPI‐SUI, in addition to tackling areas not addressed by the current international guidelines, e.g., prostate cancer survivorship. Of the initial draft, the modified Delphi consensus methodology was applied to 65 statements split into seven broad categories: terminology, assessment, conservative management, surgical treatment, perioperative care, complication management, and follow‐up after PPI‐SUI surgery. This is applicable to general and specialist Urologists worldwide. After three rounds, consensus was achieved with 63/65 statements. Conclusions We provide a modified Delphi consensus on the assessment and management of PPI‐SUI to help guide and standardise the assessment and management pathway of these patients.

Objective To determine characteristics and pregnancy outcomes in women with primary adrenal insufficiency (PAI). Design Retrospective multicentre cohort study. Setting Twenty‐three maternity units in the UK and Ireland. Sample Seventy‐nine women with PAI who had 101 pregnancies. Method Retrospective chart analysis. Main Outcome Measures Adrenal crisis, pregnancy outcomes. Results We obtained data on 101 pregnancies in 79 women with PAI. Most (51, 64.1%) had autoimmune disease, 8 (10.3%) had prior adrenal infarction/surgery/haemorrhage, 2 (2.6%) had congenital adrenal hyperplasia, and 18 (21.3%) were unclassified. 19 (24%) women experienced a crisis during pregnancy (18.8% of pregnancies). One woman died postpartum. Although all women had recorded endocrinology input during pregnancy, steroid emergency cards were only reportedly carried in 40 (39.6%) pregnancies and 9/19 (47.4%) of those with an adrenal crisis in pregnancy. Compared with the pre‐pregnancy dose, only 41% of women received an increased hydrocortisone dose in pregnancy. The caesarean section rate was higher than the UK average: 62/97 (63.9%). The preterm birth rate was 21.2% (21/99) and 12.8% (12/94) of neonates had a birthweight < 10th centile. Conclusion Whilst the obstetric outcome of pregnancy with PAI is generally favourable, there are high rates of caesarean birth and prematurity. A high number of women experienced adrenal crisis and further exploration is warranted. Recommendations regarding third trimester increases in hydrocortisone need consideration and potentially strengthening, in light of further evidence. Pregnant women with adrenal insufficiency should carry an NHS steroid warning card; this should be reinforced both by endocrine and obstetric teams because of the increased risk of life‐threatening adrenal crisis.

Introduction Attention‐deficit‐hyperactivity disorder (ADHD) is highly heritable and increases the likelihood of nicotine dependence (ND). The self‐medication hypothesis of nicotine use in ADHD proposes that ADHD patients seek nicotine for its ability to improve their symptoms, and they have less success quitting, possibly due to the worsening of ADHD symptoms in withdrawal. Methods The present analysis compared transcriptomic data from the brains of rodent models of ADHD and those of ND, with a focus on striatal gene expression. Differential expression analysis, pathway enrichment analysis, and gene‐network mapping identified signaling networks and candidate genes that may contribute to the high co‐occurrence between ADHD and ND. Results We identified novel differentially expressed genes (PRKAG2, MAPK1), and genes with known associations to either ADHD or ND (ANK3, CALD1, CHRNA4, CHRNA7, CMTM8, DLG4, DUSP6, GNG3, GNG11, GRIK5, GRINA2, GRM5, ICAM2, KCNJ6, PRKAB1, SNAP25, SYNPO, SYT1, VAMP2). In addition, synaptic transmission (hsa04728, R‐HAS‐112315, R‐HSA‐442755) and MAPK signaling pathways (hsa04010, hsa04014, hsa04015, R‐HSA‐5673001, R‐HSA‐5684996) were enriched in both ADHD and ND. Conclusion The signaling pathways implicated by this analysis mediate neurological mechanisms known to contribute to ND. The association of analogous differently expressed genes and common signaling pathways suggests an important causal relationship between ND and ADHD that may be clinically important.

Purpose There is much variation in minimally invasive surgery (MIS) uptake throughout the UK and Ireland and therefore a gap in understanding of current MIS practice. We surveyed paediatric surgery specialist centres in the UK and Ireland for perspectives on the uptake and future of laparoscopic and robotic paediatric surgery. Methods A questionnaire was created using Google Forms. This was circulated to an index member of the British Association of Paediatric Endoscopic Surgeons (BAPES) in each centre providing specialist paediatric surgery services in the UK and Ireland. Results Responses were received from all 25 paediatric surgery centres in UK and Ireland (257 consultants). In all 25 centres, laparoscopic surgery is well-established. However, only 5% of consultants have an active robotic surgery practice. Most centres feel that laparoscopic surgery offers enhanced vision, reduced post-operative pain, smaller scars and faster recovery. Respondents feel that the advantages of robotic surgery compared to laparoscopic surgery are better precision and control (76%) and enhanced vision (60%). Cost is the biggest perceived barrier to robotic surgery. Conclusion The majority of centres have a well-established laparoscopic practice, but there is still room for improvement. Although only a small number of paediatric surgeons have adopted robotic surgery, 40% of centres report plans to start a robotic programme in the near future, with cost being perceived as the principle barrier to further uptake. With increasing robotic surgery there may be an overall increase in MIS procedures being performed for children in the UK and Ireland in the coming years.

Aim In recent years, the incidence of nephrolithiasis in the paediatric population appears to be increasing. Aim of this study was to evaluate the effectiveness of the twin-surgeon model on the paediatric stone patients of our centre. Methods A retrospective study with data retrieval from our electronic patient system was conducted; it included a total of 41 patients up to 18 years of age diagnosed with renal calculus. Results From 2004 to 2024 29 male and 12 female were retrieved. The average age for females was slightly higher than males; 9.92 vs. 7.78. Pain was the main symptom for most patients. Of them 36.6% were treated conservatively as stone spontaneous passage occurred. Twenty nine underwent surgical treatment using the twin-surgeon model. The surgically treated patients were had stones with average size 10.1 mm; they underwent either a percutaneous nephrolithotomy or flexible ureteroscopy and lasertripsy and in 2 cases with pelvic ureteric obstruction an open stone retrieval was performed. Preoperative stent placement was needed in 7% of patients, whereas 41.5% had a stent implanted postoperatively for 7–19 days. 53.8% of the surgical treated patients were stone free and 96.4% symptom free at follow-up. Conclusions Endoscopic stone removal using the twin surgeons model is safe and effective for stone size 2-3 cm. This treatment management enables a local treatment of children from a multidisciplinary urology team addressing effectively the special characteristics of stones during the paediatric age.

Technology-based online support services are emerging as a resource for people recovering from substance abuse. This study presents findings on how individuals seeking help for a substance use disorder through 12-step fellowship meetings (Alcoholics Anonymous, Narcotics Anonymous) adjusted to virtual rather than in-person meetings during the COVID-19 pandemic. Fifty individuals (50) were interviewed, recruited primarily from 12-step meetings in 3 locations in a rural New England state in the United States. Subjects were asked about whether they had attended virtual meetings during the pandemic, how online meetings compare to in-person meetings, and if they encountered any obstacles when attending virtual meetings (eg, Internet connectivity). More individuals preferred in-person meetings for a variety of reasons, although many participants were willing to give virtual meetings a try. Some participants continued to attend virtual meetings, even after in-person meetings returned. Positives of virtual recovery meetings included convenience and the fact that they could be accessed from anywhere. Internet connectivity and technical difficulties presented a challenge for some. Some individuals were unable to focus in virtual meetings and got easily distracted. Digital recovery support services should continue to be offered as some recovering individuals find them helpful. Virtual meetings are a resource, particularly for those individuals living in rural areas without many in-person resources readily available, or access to adequate transportation. Treatment providers working in rural states may consider advocating to policymakers for quality Internet services (eg, high-speed broadband access), to sufficiently meet residents’ treatment and other healthcare needs.

Purpose Posterior urethral valves (PUVs) are the most common cause of bladder outlet obstruction in male infants and are associated with significant renal and bladder morbidity and long-term outcomes. This study evaluates the long-term renal and vesical outcomes and the impact of time of diagnosis in patients with PUV managed at a single tertiary centre. Methods A retrospective analysis was conducted on 29 patients diagnosed with posterior urethral valves (PUVs). Patients were categorised based on the timing of initial resection of PUVs: those diagnosed or treated within the first year of life were classified as early, while those diagnosed or treated after 1 year were classified as late. Long-term outcomes were assessed to evaluate differences between early and late diagnosis groups. Results In this study, 12 out of 29 patients (41.38%) had late diagnosis while the remaining 17 patients were diagnosed early (58.62%). There were no statistically significant differences between the early and late diagnosis groups in terms of upper urinary tract dilatation, urinary continence, bladder function, or the presence of residual valves. At follow-up, structural renal and bladder anomalies persisted in 50% and 13.8% had compromised renal function. Urinary continence improved with 36.7% being incontinent at 1-year post-surgery to 27% at 5 years post-surgery. Conclusion Structural bladder and renal abnormalities persist despite surgical interventions, indicating the need for long-term follow-up. Time of detection did not have a bearing on long-term outcomes. Multidisciplinary care focusing on both functional and anatomical outcomes is crucial to optimise quality of life.

Background and Aims In 2019, we conducted a cross‐sectional study, collecting information on 50 patients with CMT4B, an ultrarare CMT subtype, to better define the clinical phenotype. We now aimed at investigating disease progression in 26 patients with CMT4B1/CMT4B2, recruited from the previous study and among the Inherited Neuropathy Consortium. Materials and Methods We retrospectively analysed disease progression in patients with CMT4B1/CMT4B2, collecting MRC scores from nine muscle pairs, Charcot‐Marie‐Tooth Examination Score (CMTES), and a minimal dataset of clinical information (walking difficulties, aids dependency, upper limb impairment, cranial nerves involvement) at baseline and follow‐up visits. Thirteen centres from four continents were involved. Results Thirteen CMT4B1 and 13 CMT4B2 patients were followed up for 7.1 ± 4.9 and 7.9 ± 4.5 years, respectively. During follow‐up, walking aid dependency increased: two CMT4B1 patients adopted AFOs (overall 11/12 at follow‐up), and one started using wheelchair (6/12 at follow‐up) at the age of 19; among CMT4B2 patients, two more required unilateral support in walking (4/11 at follow‐up) by the age of 33 and 49 years, respectively. We found that disease progression, as measured by CMTES, was faster in CMT4B1 as compared to CMT4B2 patients (ΔCMTES/year 0.7 vs. 0.3, p = 0.037) but tended to slow down over time as burden of disease increased. At the end of follow‐up, CMT4B1 was associated to higher disability. Conclusions This international collective effort enabled collection of relevant data for characterizing natural history and estimating disease progression of CMT4B1/CMT4B2 ultrarare diseases, aiming at improving their management and paving the way for designing future clinical trials.

We aimed to investigate the safety of drug-coated balloon (DCB)-only percutaneous coronary intervention compared to drug-eluting stent (DES) for de novo lesions in large vessels. To pursue this goal, we conducted a systematic review and meta-analysis following the PRISMA guidelines. The analysis included studies that utilized DCB-only or hybrid angioplasty for de novo lesions in large coronary vessel (> 2.75 mm). The primary outcome was to assess the target lesion revascularization (TLR) rate, while secondary outcomes included cardiac death, myocardial infarction (MI), and the composite of these. A total of 15 studies, comprising 3975 patients (of whom 2114 treated with DCB) were included. Median age was 62 ± 1.5 years, with 77.4% being male. Overall, 26.9% had diabetes, and 67.6% were diagnosed with acute coronary syndrome. Over a pooled follow-up of 20.6 ± 1.9 months, the incidence of TLR was 4% in the pooled DBC group. Additionally, over a pooled follow-up of 25.8 ± 2.7 months, no significant differences were observed in incidence of TLR between the DCB group and the DES group (4.3% vs. 6.9%, odds ratio 0.71, 95% confidence interval 0.50–1.01, p = 0.059). Furthermore, there were no differences in incidence of cardiac death and MI. DCB angioplasty treatment of de novo lesions in large coronary vessels could be a safe and effective strategy in both acute and chronic coronary settings. The incidence of target lesion revascularization appears to be similar to that of contemporary DES.

Background Biallelic variants in polyribonucleotide‐nucleotidyltransferase‐1 (PNPT1) have been associated with a range of phenotypes from syndromic hearing loss to Leigh's syndrome. More recently, heterozygous variants in PNPT1, have been reported in three families with cerebellar ataxia and prominent sensory neuropathy. Methods Whole genome sequencing was performed in two families with autosomal dominant sensory ataxic neuropathy (SAN). Results Segregating heterozygous splice site (c.2014‐3C>G) and nonsense (p.Arg715Ter) variants were detected in both families. All patients initially presented with an isolated SAN clinically and neurophysiologically with subsequent variable cerebellar involvement. Conclusion We report two heterozygous PNPT1 variants in two families with a predominant SAN, including the novel p.Arg715Ter. This strengthens the argument of PNPT1 causing dominant disease and highlights a new cause for dominantly inherited SAN.

Background There are scarce data available on upadacitinib in children with Crohn's disease (CD). Aim To evaluate the effectiveness and safety of upadacitinib as an induction therapy in paediatric CD. Methods This was a multicentre retrospective study between 2022 and 2024 of children treated with upadacitinib for induction of remission of active CD conducted in 30 centres worldwide affiliated with the IBD Interest and Porto group of the ESPGHAN. We recorded demographic, clinical and laboratory data and adverse events (AEs) at week 8 post‐induction. The analysis of the primary outcome was based upon the intention‐to‐treat (ITT) principle. Results We included 100 children (median age 15.8 [interquartile range 14.3–17.2]). All were previously treated with biologic therapies including 89 with ≥ 2 biologics. At the end of the 8‐week induction period, we observed clinical response, clinical remission and corticosteroid‐ and exclusive enteral nutrition‐free clinical remission (CFR) in 75%, 56% and 52%, respectively. By the end of induction, 68% had achieved normalisation of C‐reactive protein, and 58% had faecal calprotectin (FC) < 150 mcg/g. There was combined CFR and FC remission in 13/31 children with available data at 8 weeks (13% of the ITT population). AEs were recorded in 24 children; the most frequent was acne in 12. Two AEs (severe acne and hypertriglyceridemia) led to discontinuation of therapy. Conclusion Upadacitinib is an effective induction therapy for refractory paediatric CD. Efficacy should be weighed against the potential risks of AEs.

Background: There are no data regarding the outcomes of patients with stent thrombosis (ST) being treated with drug-coated balloon (DCB) angioplasty. Our aim was to compare the outcomes of patients with ST treated with DCB vs. a drug eluting stent (DES). Methods: In this registry analysis, we identified all patients treated for ST in our institution from June 2011 until November 2019. We excluded patients who died in the cath lab, patients with uncrossable lesions, and patients treated with thrombectomy only. Patient outcomes were obtained from Hospital Episodes Statistics from NHS England. The primary endpoint of this study was the composite of cardiovascular mortality, acute coronary syndrome, or target lesion revascularisation. The data were analysed with Cox regression and Kaplan–Meier estimator plots. Results: A total of 173 patients were identified; 92 treated with DCB-only, 36 with balloon angioplasty (BA), 26 with DES, and 19 with a combination of DES and DCB. We compared the outcomes of 92 patients with DCB versus 20 patients with DES, all of which had presented with late or very late ST. There was no difference between DCB and DES in terms of the primary endpoint (p = 0.06). Multivariate analysis identified diabetes (adverse) and the use of GPIIbIIIa inhibitor (favourable) as the only independent predictors of the primary endpoint. Implantation of a DES was independently associated with worse cardiovascular mortality. Conclusions: This is the first study assessing the outcomes of patients with ST treated with DCB only. It has demonstrated that DCBs are an attractive therapeutic option with a tendency towards favourable outcomes when compared to DESs.

Objective This study presents findings about vaccination willingness or resistance and mask-wearing among individuals recovering from a substance use disorder during the COVID-19 pandemic period. Study design Content analysis. Method Fifty individuals were interviewed. Interviews were transcribed verbatim, and then coded using Atlas Ti qualitative analysis software. A content analysis was conducted, eliciting recurring themes and overarching COVID-19 health behavior dimensions for getting (or not) vaccinated and wearing a mask. Results While most subjects were willing to get vaccinated and wear mask, a small minority were not. Both formal (mandates) and informal (pressure from others) mechanisms played a role in getting participants to mask-up and get vaccinated, even when they did not want to. Concern for others motivated some individuals to both get vaccinated and wear a mask. Fear and ambivalence emerged as emotional themes, as did suspicion particularly among vaccine-refusing subjects. Reasons for not getting vaccinated included lack of trust in the government, as well as the vaccine-development process. Conclusions The results suggest that many COVID-19 prevention initiatives have gone right in terms of reaching individuals recovering from substance addiction. Public health officials may consider alternative ways of reaching individuals whose frame of reference regarding vaccines, public health, and government outreach is one of suspicion and distrust of facts. Future research should examine sources of health and medical information, and how these contribute to individuals’ vaccination hesitancy.

Introduction: The management of complex limb injuries can be very challenging, and it demands a multidisciplinary approach to treatment. Amputation and limb reconstruction are the two options that clinicians must choose. This study aims to comprehensively synthesize existing tools and resources from the literature that can assist clinicians in the decision-making process. Evaluation: The initial resuscitation and the prehospital care are the first important steps in the management of these injuries, while the immediate transfer to trauma centers is recommended for complex cases. After the stabilization of the patient, a thorough clinical examination of the limb is necessary with emphasis on the degree of soft tissue damage. Blunt trauma in the lower limb is associated with a higher risk of early amputation. Polytrauma patients with complex limb injuries require a holistic approach, with Damage Control Orthopedics (DCO) principles. Traumatic bleeding significantly increases mortality rates, necessitating prompt control using pressure bandages or tourniquets. Computed tomography angiography (CTA) is necessary in order to assess the viability of the limb. Management: Scoring systems can be used as a tool in the management of complex lower and upper limb injuries. Mangled Extremity Severity Score (MESS) calculates ischemia, shock, bone and soft tissue damage, and patient characteristics. The Narakawa Index (NISSSA score) constitutes an alteration of MESS with the implementation of a nerve injury element. The Musculoskeletal Score for Severity of Injury (MESI score) estimates the risk of limb amputation by evaluating injury, neurovascular damage, type of fracture, patient characteristics, and the period from the occurrence of trauma to the definitive treatment. Further interventions and patient preferences should be incorporated into the decision-making process. Outcome: The outcomes of limb salvage versus amputation for complex limb injuries encompass various factors, including patient’s preinjury health status, psychological well-being, functional outcomes, and economic impact. While some studies suggest better psychological outcomes with limb reconstruction and others find similar functional outcomes between the two approaches, economic considerations play a significant role in decision-making. Conclusion: Managing complex limb injuries effectively necessitates a comprehensive approach involving thorough assessment, multidisciplinary collaboration, and patient-centered care. Given the diverse factors influencing management and long-term outcomes, it is crucial to integrate medical expertise with patient preferences and expectations.

Purpose of Review This review aims to summarise recent evidence on the effects of dietary patterns on the risk of bone fractures and sarcopenia. Recent Findings Several dietary patterns have been investigated in relation to musculoskeletal health, including Mediterranean Dietary Patterns (MDP), Dietary Inflammatory Indices, vegetarian and vegan diets. Adherence to ‘healthier’ dietary patterns appears to be protective against fractures and sarcopenia, with the strongest protective associations found between the MDP and fractures. Individuals following vegan or vegetarian eating patterns need to be aware of calcium and vitamin D requirements to maintain musculoskeletal health. Summary Although more healthy dietary patterns may be protective for musculoskeletal health the current evidence base is limited by variation in the construction of dietary pattern scores and reported outcome measures. Future research should fully report scoring methods, intakes of dietary components across scoring groups or categories, and consider outcome measures that allow for better comparison between studies.