South Eastern Health and Social Care Trust

Acute Achilles tendon ruptures (AATRs), an extremely prevalent injury amongst adults who remain active, have been treated with surgical intervention for decades. This choice was made due to several decades-old studies demonstrating reduced re-rupture rates as opposed to nonsurgical interventions utilizing casts; however, numerous surgeons and researchers acknowledged potential complications such as wound problems and nerve damage. Functional braces and early weight-bearing now challenge this 'surgical by default' model. An evidence-based, focused review of randomized clinical trials, conventional and network meta-analysis, and large cohorts was conducted for the comparison of operative and nonoperative treatment for AATRs or the evaluation of various rehabilitation approaches. Operative management provides a lower rate of re-rupture in comparison to traditional cast-based nonoperative treatment; however, operative management also results in increased wound complications and sural nerve injuries. Nonoperative management employing functional bracing and early weight-bearing provides re-rupture rates approaching those of operative management, and the long-term functional outcome data are generally comparable. Differences in structural changes continue to exist between the two management groups, with longer tendon length and atrophy of the soleus muscle seen after conservative treatment, although for the majority of patients, the resultant strength and endurance deficits will be minimal. Both treatment options may provide optimal results if implemented through structured rehabilitation pathways. Treatment should be individualized based on the patient's specific factors, injury characteristics, and available resources. The use of current comparative effectiveness research to assist in making decisions regarding treatment with the patient is recommended.

OBJECTIVE:To collate and systematically review the evidence on the impact of substandard housing on early child development in high-income countries. DESIGN:Systematic review. METHODS:Five databases (Medline, Emcare, Web of Science, Scopus and PsycInfo) and relevant grey literature were searched between June and July 2024. Records were screened to include studies which explored the association between substandard housing and cognitive, language, motor, social, emotional and/or behavioural development in children aged 0-8 years living in high-income countries. Studies which only explored lead, radiation or secondhand smoking exposures were excluded. Data were extracted from relevant articles and reported via a narrative synthesis. Risk of bias was assessed using the Risk of Bias in Non-Randomised Studies of Exposures tool. Certainty of findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. All screening, data extraction and 20% of quality assessment were performed independently by a second assessor. RESULTS:6258 records were screened, from which 25 studies were included, representing >2 29 000 children from seven high-income countries. Studies mostly explored home air quality and overcrowding. Moderate certainty evidence was found for associations between mould, damp, condensation, overcrowding, hygiene and safety issues and unclean heating/cooking fuels and poorer early child development. Low certainty evidence was found for an inverse relationship with nitrogen dioxide, particulate matter and xylene levels. Very low certainty evidence was found for associations between limited home resources and poorer child development. ORs ranged from 1.28 to 3.53. All studies had a high or very high risk of bias. Meta-analysis was not possible due to heterogeneity. CONCLUSIONS:Policymakers and professionals working with children in healthcare, social and education settings should be aware that housing conditions may impact child development. Research is needed to further evaluate the impacts of substandard housing on childhood development, but notwithstanding this, our review supports the growing momentum for improving living situations for young children. FUNDING:No specific funding was received for this study. PROTOCOL REGISTRATION:PROSPERO: CRD42024564320.

BackgroundVitamin B12 deficiency can cause anaemia, fatigue, and neurological sequelae. Total B12 assays may not be reflective of tissue B12. Methylmalonic acid (MMA) can assess tissue B12 more accurately. NICE published clinical guidelines on Vitamin B12 deficiency in adults in 2024. They outlined MMA testing in two scenarios: in patients where nitrous oxide use is possible or who have an indeterminate total B12 result (180-350 ng/L) alongside symptoms or signs of B12 deficiency. MMA testing is costly, not readily available, and time consuming, so increased use will have implications.MethodsThis is a Case note review of patients who had MMA requested one year prior to and one year post-NICE NG239 publication. Audit standards followed were NG239 indications for MMA testing.ResultsIn the year after NG239, MMA testing increased by 96% (57 to 112). Whilst only 47% would have meet NG239 testing criteria in the prior group, this increased to 79% in the post group. More were diagnosed with B12 deficiency (16% prior and 21% post), and more commenced on B12 treatment (14% prior and 19% after). Comparing simultaneous total B12 and MMA results suggests an increase in the upper reference interval of the indeterminate range to 375 ng/L could be considered.ConclusionsDemand for MMA testing almost doubled after NG239 was published, though requests appeared much more appropriate. Whilst laboratory costs increased, there may have been savings elsewhere in the system. Further analysis would be required to review the extent of these healthcare savings in practice.

BACKGROUND:The STRENGTH (Self-management and Theory-based Rehabilitation Encouraging New Gateways to Healthy-Hearts) study evaluated a behaviour change intervention embedded within cardiac rehabilitation for individuals with coronary heart disease. This manuscript reports the process evaluation, which aimed to explore participants' experiences of physical activity, barriers and facilitators to maintaining physical activity, and contextual and process-related factors influencing engagement with the intervention. METHODS:A process evaluation was nested within a two-arm cluster randomised controlled trial. Semi-structured interviews were conducted with participants from both intervention and control groups, focus groups were conducted with intervention participants. Thematic analysis examined factors influencing physical activity maintenance, including context, implementation, mechanisms of impact and perceived outcomes. Quantitative procedures measured intervention fidelity through attendance records and participant diaries. RESULTS:Both groups highlighted environmental, social, and personal factors influencing participation in cardiac rehabilitation, such as social support, professional oversight, and structured programming. Trainers and peer interactions were valued for motivation and perceived safety. The intervention group reported additional facilitators, including tailored support, external accountability, and self-monitoring, which increased awareness and reinforced adherence. Mechanisms of impact included increased awareness of physical activity, greater exercise confidence, and a sense of accomplishment. A perceived lack of exercise confidence may have hindered independent physical activity engagement. CONCLUSIONS:While behaviour change strategies can enhance engagement in cardiac rehabilitation, their impact on measurable health outcomes remains unclear. Social support, professional oversight, and structured programming appear effective in maintaining physical activity levels, but future interventions should prioritise exercise confidence and education to promote sustained behaviour change. TRIAL REGISTRATION:Registered with ClinicalTrials.gov on 26-01-2023 (ID: NCT05705310).