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This project aimed to increase same-day emergency care (SDEC)-suitable activity within an existing ambulatory medical unit, in line with the recommendations set out in the NHS Long Term Plan. Prior to the project, much of the unit's activity was non-urgent and focused on supporting early discharges. Scoping exercises were undertaken to better understand current activity and identify interventions to increasing same-day referrals from within the urgent and emergency care system. Quality improvement methodology was then used to implement and study a variety of interventions, including but not limited to the development of new condition-based referral pathways. Retrospective review of SDEC activity demonstrated a threefold increase.

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BACKGROUND: Point-of-care (POC) lung ultrasound (LUS) is widely used in the emergency setting and there is an established evidence base across a range of respiratory diseases, including previous viral epidemics. The necessity for rapid testing combined with the limitations of other diagnostic tests has led to the proposal of various potential roles for LUS during the COVID-19 pandemic. This systematic review and meta-analysis focused specifically on the diagnostic accuracy of LUS in adult patients presenting with suspected COVID-19 infection. METHODS: Traditional and grey-literature searches were performed on 1 June 2021. Two authors independently carried out the searches, selected studies and completed the Quality Assessment Tool for Diagnostic Test Accuracy Studies (QUADAS-2). Meta-analysis was carried out using established open-source packages in R. We report overall sensitivity, specificity, positive and negative predictive values, and the hierarchical summary receiver operating characteristic curve for LUS. Heterogeneity was determined using the I2 statistic. RESULTS: Twenty studies were included, published between October 2020 and April 2021, providing data from a total of 4314 patients. The prevalence and admission rates were generally high across all studies. Overall, LUS was found to be 87.2% sensitive (95% CI 83.6 to 90.2) and 69.5% specific (95% CI 62.2 to 72.5) and demonstrated overall positive and negative likelihood ratios of 3.0 (95% CI 2.3 to 4.1) and 0.16 (95% CI 0.12 to 0.22), respectively. Separate analyses for each reference standard revealed similar sensitivities and specificities for LUS. Heterogeneity was found to be high across the studies. Overall, the quality of studies was low with a high risk of selection bias due to convenience sampling. There were also applicability concerns because all studies were undertaken during a period of high prevalence. CONCLUSION: During a period of high prevalence, LUS had a sensitivity of 87% for the diagnosis of COVID-19 infection. However, more research is required to confirm these results in more generalisable populations, including those less likely to be admitted to hospital. PROSPERO REGISTRATION NUMBER: CRD42021250464.

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Introduction: Lung ultrasound (LUS) has an established evidence base and has proven useful in previous viral epidemics. An understanding of the utility of LUS in COVID-19 is crucial to determine its most suitable role based on local circumstances. Method: Online databases, specialist websites and social media platforms were searched to identify studies that explore the utility of LUS in COVID-19. Case reports and recommendations were excluded. Findings: In total, 33 studies were identified which represent a rapidly expanding evidence base for LUS in COVID-19. The quality of the included studies was relatively low; however, LUS certainly appears to be a highly sensitive and fairly specific test for COVID-19 in all ages and in pregnancy. Discussion: There may be LUS findings and patterns that are relatively specific to COVID-19; however, specificity may also be influenced by factors such as disease severity, pre-existing lung disease, operator experience, disease prevalence and the reference standard. Conclusion: LUS is almost certainly more sensitive than chest radiograph for COVID-19 and has several advantages over computed tomography and real-time polymerase chain reaction. High-quality research is needed into various aspects of LUS including: diagnostic accuracy in undifferentiated patients; triage and prognostication; monitoring progression and guiding interventions; the persistence of residual LUS findings; inter-observer agreement and the role of contrast-enhanced LUS.

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BACKGROUND: Early transfusion of packed red blood cells (PRBC) has been associated with improved survival in patients with haemorrhagic shock. This study aims to describe the characteristics of patients receiving pre-hospital blood transfusion and evaluate their subsequent need for in-hospital transfusion and surgery. METHODS: The decision to administer a pre-hospital PRBC transfusion was based on clinical judgment. All patients transfused pre-hospital PRBC between February 2013 and December 2014 were included. Pre-hospital and in-hospital records were retrospectively reviewed. RESULTS: One hundred forty-seven patients were included. 142 patients had traumatic injuries and 5 patients had haemorrhagic shock from a medical origin. Median Injury Severity Score was 30. 90% of patients receiving PRBC had an ISS of >15. Patients received a mean of 2.4(±1.1) units of PRBC in the pre-hospital phase. Median time from initial emergency call to hospital arrival was 114 min (IQR 103-140). There was significant improvement in systolic (p < 0.001), diastolic (p < 0.001) and mean arterial pressures (p < 0.001) with PRBC transfusion but there was no difference in HR (p = 0.961). Patients received PRBC significantly faster in the field than waiting until hospital arrival. At the receiving hospital 57% required an urgent surgical or interventional radiology procedure. At hospital arrival, patients had a mean lactate of 5.4(±4.4) mmol/L, pH of 6.9(±1.3) and base deficit of -8.1(±6.7). Mean initial serum adjusted calcium was 2.26(±0.29) mmol/L. 89% received further blood products in hospital. No transfusion complications or significant incidents occurred and 100% traceability was achieved. DISCUSSION: Pre-hospital transfusion of packed red cells has the potential to improvde outcome for trauma patients with major haemorrhage. The pre-hospital time for trauma patients can be several hours, suggesting transfusion needs to start in the pre-hospital phase. Hospital transfusion research suggests a 1:1 ratio of packed red blood cells to plasma improves outcome and further research into pre-hospital adoption of this strategy is needed. CONCLUSION: Pre-hospital PRBC transfusion significantly reduces the time to transfusion for major trauma patients with suspected major haemorrhage. The majority of patients receiving pre-hospital PRBC were severely injured and required further transfusion in hospital. Further research is warranted to determine which patients are most likely to have outcome benefit from pre-hospital blood products and what triggers should be used for pre-hospital transfusion.

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It has been suggested that corrosion and fretting at the tapered, modular junctions of hip arthroplasties may contribute to implant failure. In this study the reliability of a commonly used peer-reviewed scoring system for visual assessment of corrosion and fretting at these junctions was evaluated. Volumetric material loss at the tapered head surface was measured and associations with the visual scores were investigated. We found that the inter-observer reproducibility and single-observer repeatability of the corrosion scores were substantial using Cohen's weighted Kappa statistic (k = 0.64-0.71). The reproducibility and repeatability of the fretting scores however were slight to fair (k = 0.18-0.31). Taper corrosion scores were significantly and moderately correlated with the volume of material loss measured (Spearman's r = 0.59; P < 0.001). We recommend the continued use of this scoring system but it should not be a substitute for measurement of material loss.

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Suboptimal component position and design are thought to lead to edge wear and raised blood metal ion levels in metal-on-metal hip resurfacing (MOM-HR). These factors are thought to influence the "contact patch to rim distance" (CPRD), and calculation of this distance may improve prediction of wear and blood metal ion levels. We measured blood cobalt and chromium ion levels and the wear rates of the bearing surfaces in 165 MOM-HR retrieval cases. We then determined the contribution and effect sizes of cup inclination and version angles, component size and design, and CPRD (calculated from case-specific data) on blood metal ion levels and component wear rates. Acetabular orientation explained between 16.3% and 28.5% of the variation in wear rates and metal ion levels, whereas component size and design explained between 7.3% and 21.8% of the variability. In comparison, CPRD explained up to 67.7% of the variability, significantly greater than any other variable (all p < 0.0001). CPRD is a good predictor of wear and improves our understanding of wear performance and the mechanisms leading to edge loading.

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It has been speculated that material loss, either as corrosion or wear, at the head-stem taper junction is implicated in the high revision rates reported for metal-on-metal total hip replacements. We measured the volume of material loss from the taper and bearing surfaces of retrieved devices, and investigated the associations with blood metal ion levels and the diagnosis of a cystic or solid pseudotumor. The median volumes of material lost from the female and male taper surfaces were 2.0 and 0.29 mm(3) , respectively, while the median volumes of wear from the cup and head bearing surfaces were 1.94 and 3.44 mm(3) , respectively. Material loss from the female taper was similar to that from the acetabular bearing surface (p = 0.55), but significantly less than that from the femoral bearing surface (p < 0.001). Material loss from the male taper was less than that from both bearing surfaces (p < 0.001). Multivariable analysis demonstrated no significant correlations between the volume of material lost from the taper surfaces and either blood cobalt or chromium ions, or the presence of pseudotumor. While a substantial volume of material is lost at the taper junction, the clinical significance of this debris remains unclear.

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BACKGROUND: A large proportion of metal-on-metal hip arthroplasty failures are due to unexplained pain. The mechanism of failure has been thought to be associated with factors that increase material loss, including specific design features and surgical positioning of components. However, recent evidence suggests that there is not a simple dose-response relationship. An analysis of failed metal-on-metal hip arthroplasties involving a single design was performed in an attempt to help resolve this issue. Our aim was to identify the clinical and component variables associated with failure of metal-on-metal hip arthroplasties, particularly in patients undergoing revision arthroplasty because of unexplained hip pain, and to clarify the role of material loss. METHODS: We prospectively recruited fifty-five patients who were undergoing revision of a metal-on-metal Birmingham Hip Resurfacing System (BHR) arthroplasty (Smith & Nephew). We collected clinical data preoperatively, intraoperatively, and following the revision arthroplasty. Data included chromium and cobalt levels in whole blood, which were measured with use of inductively coupled plasma mass spectrometry (ICPMS), and component orientation, which was typically measured with use of computed tomography (CT) scans. The wear of the retrieved components was also quantified postoperatively. All parameters were compared with those in a comparable group of patients with a well-functioning BHR arthroplasty. RESULTS: Sixty-nine percent of the patients who underwent revision arthroplasty did so following a diagnosis of unexplained hip pain. When compared with patients with a well-functioning arthroplasty, patients who underwent revision arthroplasty had a significantly higher acetabular cup inclination angle (p < 0.01), a significantly smaller femoral head diameter (p < 0.01), and significantly higher blood cobalt and chromium ion levels (p < 0.01). However, almost 50% of the patients who underwent revision arthroplasty had blood metal ion levels below the clinical threshold of 7 ppb and low component wear rates of <5 µm/year. CONCLUSIONS: In a large number of patients with unexplained hip pain leading to revision of a metal-on-metal hip arthroplasty, the acetabular cup orientation was satisfactory and the material loss rate was low. We suspect that patient-specific factors may have been responsible for the failure in a large proportion of these patients.

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BACKGROUND: Pseudotumors are sterile inflammatory lesions found in the soft tissues surrounding metal-on-metal (MOM) and metal-on-polyethylene hip arthroplasties. In patients with MOM hip arthroplasties, pseudotumors are thought to represent an adverse reaction to metal wear debris. However, the pathogenesis of these lesions remains unclear. Currently, there is inconsistent evidence regarding the influence of adverse cup position and increased wear in the formation of pseudotumors. QUESTIONS/PURPOSES: We therefore determined whether pseudotumor formation was associated with (1) adverse cup position, (2) raised metal ion levels, and (3) increased wear rates of the retrieved components. METHODS: We retrospectively reviewed all 352 patients for whom we had retrieved specimens from revisions of a current-generation MOM hip prosthesis between February 2008 and September 2010; of these, 105 met our inclusion criteria. We used multivariate logistic regression analysis to compare acetabular orientation, metal ion levels before revision, and component wear rates between patients with (n = 72) and without (n = 33) pseudotumors, according to findings on metal artifact reduction sequence MRI. RESULTS: The proportion of patients demonstrating evidence of a pseudotumor in well-positioned hips was similar to those with adverse cup positions (67% and 66%, respectively). Patients revised with pseudotumors had similar whole-blood metal ion levels and component wear rates to those who were not revised. CONCLUSIONS: Pseudotumors were not associated with increased wear or metal ion levels, suggesting patient susceptibility is likely to be more important.

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Given the recent reports of high failure rates, an improved understanding of the mechanism of failure of large diameter metal-on-metal hip arthroplasties is essential. We present clinical data and tribological analysis of a consecutive series of 74 failed large diameter metal-on-metal hips, comparing the Durom (Zimmer) with the Birmingham hip resurfacing (BHR) (Smith and Nephew). We retrospectively analysed pre-, intra-, and post-operative clinical data and measured the linear wear and component form of the explanted components using a roundness measuring machine. A significantly higher proportion of hips in the Durom group failed as a result of acetabular loosening (p=0.001) and this was supported by evidence of reduced bone in-growth on the backside of the cup. Comparison of roundness measurement revealed that the Durom hip was significantly lower wearing than the BHR (p<0.05) but the Durom femoral components were subject to significantly greater form errors (p<0.001), the pole of the head being flattened by up to 31 microns. Although the Durom hip is low wearing, reduced sphericity of the femoral component may have resulted in equatorial bearing, leading to an increased frictional torque at the cup-bone interface, preventing bone in-growth, and culminating in acetabular loosening. This supports recent clinical findings of high revision rates as a result of acetabular loosening for the Durom metal-on-metal hip system.

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