BackgroundThere were at least 31,171 metal-on-metal (MoM) hip implants in the UK between 2003 and 2011. Some of these were subject to failure and widescale recalls and revisions followed.MethodThis is a presentation of ten cases (mean age 60 years) where we evaluated neuropsychiatric morbidity following metal-on-metal hip implant failure and revision. Implants were ASR total hip replacement (acetabular implant, taper sleeve adaptor and unipolar femoral implants) performed between 2005 and 2009. This case series describes, for the first time, neuropsychiatric complications after revision where there has been cobalt and chromium toxicity.ResultsPre-revision surgery, nine patients had toxic levels of chromium and cobalt (mean level chromium 338 nmol/l, mean cobalt 669.4 nmol/l). Depression assessment showed 9 of 9 respondents fulfilled the BDI criteria for depression and 3 of these were being treated. 7 of 9 patients showing short term memory deficit with mean mini mental state examination score of 24.2. The normal population mean MMSE for this group would be expected to be 28 with <25 indicating possible dementia.ConclusionsWe found neurocognitive and depressive deficits after cobalt and chromium metallosis following MoM implant failure. Larger studies of neurocognitive effects are indicated in this group. There may be implications for public health.

-General hospitals have commonly involved a wide range of medical specialists in the care of unselected medical emergency admissions. In 1999, the Royal Liverpool University Hospital, a 915-bed hospital with a busy emergency service, changed its system of care for medical emergencies to allow early placement of admitted patients under the care of the most appropriate specialist team, with interim care provided by specialist acute physicians on an acute medicine unit -a system we have termed 'specialty triage'. Here we describe a retrospective study in which all 133,509 emergency medical admissions from February 1995 to January 2003 were analysed by time-series analysis with correction for the underlying downward trend from 1995 to 2003. This showed that the implementation of specialty triage in May 1999 was associated with a subsequent additional reduction in the mortality of the under-65 age group by 0.64% (95% CI 0.11 to 1.17%; P=0.021) from the 2.4% mortality rate prior to specialty triage, equivalent to approximately 51 fewer deaths per year. No significant effect was seen for those over 65 or all age groups together when corrected for the underlying trend. Length of stay and readmission rates showed a consistent downward trend that was not significantly affected by specialty triage. The data suggest that appropriate specialist management improves outcomes for medical emergencies, particularly amongst younger patients. KEY WORDS: acute medicine, mortality, outcome, specialism IntroductionThere is good evidence that patients with acute medical conditions may fare better in respect of a range of clinical outcomes if they are cared for by a medical team whose specialty interest is relevant to their complaint. This has been shown for myocardial infarction, 1 unstable angina, 2 asthma, 3-8 pneumothorax, 9 pleural effusion, 10-11 acute upper gastrointestinal haemorrhage, 12-14 diabetes 15 and stroke. 16 Indeed, it would be a strong indictment of the emphasis on specialty training over the past 20 years if there were no benefit in being looked after by a specialist. Nevertheless, it is common practice in the United Kingdom for patients who are ill enough to warrant emergency admission to be looked after by a specialty team that has been randomly selected according to the day of the week or week of the year, a system that might be termed 'calendar triage' , even though less ill patients, referred to the same hospital for an outpatient opinion, are likely to be seen by the relevant specialists. This widely accepted anomaly has arisen partly as a result of perceived necessity driven by staffing constraints and partly by the need to provide training in general internal medicine. An alternative model, 'specialty triage' , can be developed for the larger general hospital to allow patients admitted as medical emergencies to be placed under the care of the relevant specialty team with initial care directed by specialists in acute medicine. 17 We introduced this system at the Royal Liverpool University Hospital in ...

This study has demonstrated that the introduction of a simple low-cost LP pack into a busy acute medical setting can improve the diagnosis of CNS infections and, thus, guide treatment. Further work is needed to see if these results are more widely reproducible, and to examine the clinical, health and economic impact on overall management of patients with suspected CNS infections.

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The differential diagnosis of episodes of transient loss of consciousness can be straightforward but can also present some of the greatest diagnostic difficulties. In most circumstances, when there is uncertainty, usually when there have been only one or a few poorly observed events, it may be reasonable to admit to that uncertainty and await any further events to clarify the diagnosis. We have reason to know from bitter experience that this is not always the case and that more rigorous consideration of investigation may be justified rather than allowing the passage of time to clarify the diagnosis.

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