The Northern General Hospital is a large teaching hospital and Major Trauma Centre in Sheffield, England. Its departments include Accident and Emergency for adults, with children being treated at the Sheffield Children's Hospital on Western Bank. The hospital is managed by the Sheffield Teaching Hospitals NHS Foundation Trust.
With the global rise in diabetes prevalence, the burden of diabetic kidney disease (DKD) is projected to escalate substantially, contributing to increased morbidity, mortality, and healthcare costs. This narrative review aims to synthesize contemporary evidence on guideline-directed medical therapy (GDMT) for DKD, with a specific focus on primary prevention, secondary prevention, and real-world implementation of evidence-based pharmacologic and non-pharmacologic strategies to mitigate renal and cardiovascular risk. A comprehensive literature review (published 2012-2025) was conducted, integrating international clinical guidelines, landmark randomized controlled trials, meta-analyses, and implementation studies addressing the prevention and management of DKD. Recent advances in GDMT have reshaped the therapeutic landscape of DKD. Lifestyle interventions - including dietary optimization, regular physical activity, and smoking cessation - demonstrate meaningful renoprotective and cardiometabolic benefits. Pharmacologic therapies, such as renin-angiotensin system (RAS) blockade, sodium-glucose co-transporter 2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), have shown robust efficacy in reducing albuminuria, slowing estimated glomerular filtration rate (eGFR) decline, and lowering cardiovascular events. Landmark trials report relative risk reductions of approximately 30-40% in kidney disease progression with SGLT2 inhibitors and 18-23% reductions in renal and cardiovascular composite outcomes with finerenone and GLP-1 RAs. Despite strong guideline endorsement, real-world uptake of GDMT remains suboptimal, particularly in low-resource healthcare settings. Early detection through routine eGFR and urine albumin-to-creatinine ratio screening, combined with timely initiation and sustained implementation of GDMT, offers the most effective strategy to alter the natural history of DKD. Integrating lifestyle modification with optimized pharmacotherapy is essential to reducing long-term renal and cardiovascular complications.
One of the most common interventions in the ED and ICU to restore physiologic homeostasis is fluid administration. It is essential for the intensivists and ED physicians to be aware of the physiological characteristics of different fluids and the potential harm associated with their use. In this article, we explore the physiology and pathophysiology of fluid administration in humans, emphasizing how fluid administration can alter acid-base balance, perfusion, osmotic and oncotic pressures, immunologic and inflammatory responses, and hemodynamics. We also discuss fluid resuscitation strategies across common clinical scenarios, such as septic shock, diabetic ketoacidosis, rhabdomyolysis, acute pancreatitis, and acute brain injury. The most recent guidelines, clinical trials, and observational studies on fluid resuscitation were discussed and critically analyzed. We also discussed fluid management in high-risk populations, such as patients with end-stage renal disease or congestive heart failure, who are particularly susceptible to hypervolemia.
AIMS:After the relocation of paediatric spinal surgery services between specialist centres within the same region, monetary rebates for spinal procedures declined, despite consistent case volumes. A long-term quality improvement initiative was undertaken to enhance coding accuracy and ensure correct remuneration. METHOD:A five-year quality improvement project, consisting of three cycles, was undertaken to assess paediatric spinal procedures and related coding practices. Procedures were reviewed and given "optimal" codes by clinicians from the spinal deformity team, and mock rebates were generated. These were compared to actual codes and rebate values from the new site. Meetings were held with lead coders at the new site, and instruction was provided on how to more accurately code spinal procedures. A spinal coding operation manual with lay descriptions of spinal procedures and coding advice was developed. RESULTS:Rebate accuracy rose from 82.16% to 98.40% over the course of the project (p = 0.007). The mean difference between actual and optimal coding rebate fell from -£4,243.16 to -£264.42. The overall accuracy of clinical coding rose from 37.8% to 70.0% (p = 0.003). CONCLUSIONS:This long-term quality improvement project significantly increased the accuracy of clinical coding for paediatric spinal procedures and, when extrapolated to a mean of 150 cases per year, has generated an annual saving of approximately £596,811.00 for the site. This methodology can be easily replicated in institutions facing similar issues.
BACKGROUND:Total ankle arthroplasty (TAA) is increasingly used for end-stage ankle arthritis, with modern fixed-bearing designs demonstrating improved survivorship. The Canadian Orthopaedic Foot and Ankle Society (COFAS) classification stratifies patients by intra-articular and extra-articular deformity and adjacent joint arthritis. However, limited evidence exists on the impact of COFAS grade on mid-term TAA outcomes. This study reports the minimum 5-year outcomes of the Infinity fixed-bearing TAA and examines whether COFAS grade influences survivorship (defined as freedom from revision), complications, reoperations, revisions, radiographic findings, or patient-reported outcomes (PROMs). METHODS:A prospective, multi-center observational study included 502 ankles in 496 patients who underwent primary Infinity TAA across 11 UK centers. Patients were stratified by preoperative COFAS grade. Outcomes included implant survivorship, complications, reoperations, revisions, radiographic assessment of radiolucencies, and PROMs (the Manchester-Oxford Foot Questionnaire; the Ankle Osteoarthritis Scale [AOS]; and the EuroQol 5-dimension, 5-level index) collected preoperatively and at 2 and 5 years postoperatively. Patient-specific instrumentation (PSI) use was also recorded. RESULTS:Five-year implant survivorship was 98.2%, and reoperation without revision was 5.8%. There was no significant association between COFAS grade and revision or reoperation rates. Radiographic analysis demonstrated 5.7% linear radiolucencies >2 mm and 10.9% cystic radiolucencies >5 mm, with no correlation to COFAS grade. PROMs improved significantly across all domains from baseline to 5 years, with no differences between COFAS grades. PSI, used in 20.1% of cases, was associated with improved AOS scores at 5 years, though PSI and site effects could not be fully disentangled, and did not influence complication, revision, or radiographic outcomes. CONCLUSION:In this large multicenter cohort, higher COFAS grades were not associated with inferior outcomes in patients undergoing Infinity fixed-bearing TAA. Survivorship, complications, reoperations, radiographic outcomes, and PROMs were not statistically different across all grades. In this cohort, Infinity TAA was associated with favorable outcomes across all COFAS grades, including those with complex deformity or adjacent joint disease. LEVEL OF EVIDENCE:Level II, prospective cohort study.
