A 17-month longitudinal surface sampling study carried out on public transport vehicles operating in England during the COVID-19 pandemic identified low levels of SARS-CoV-2 RNA contamination.

AIMS: To monitor severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA contamination in vehicles operating in England during the pandemic, to better understand transmission risk of SARS-CoV-2 on public transport. METHODS AND RESULTS: We collected 1314 surface samples between December 2020 and April 2022 on trains and buses managed by five different transport operators. The presence of SARS-CoV-2 RNA was investigated through reverse transcription polymerase chain reaction (RT-PCR). SARS-CoV-2 RNA was found on 197 (15%) of the 1314 surfaces sampled, including seat head rests, handholds, and air extract grilles, but the levels of RNA recovered on those samples (median value of 23.4, interquartile range: 14.3-35.4, N gene copies per extraction) made the presence of infectious virus at the time of sampling extremely unlikely. However, detection rates varied over time with peaks broadly coinciding with times of high community transmission, when it was more likely that people infected with SARS-CoV-2 were travelling on public transport. CONCLUSION: During the pandemic, and as in other public spaces, low levels of SARS-CoV-2 RNA were found on surfaces associated with public transport.

Technology for dementia care: what would good technology look like and do, from carers' perspectives?

BACKGROUND: The development of technology in dementia care has largely been without consultation with carers, and has primarily focused on safety, monitoring devices, and supporting activities of daily living. Further, while involving end-users in the design of technology has been recommended, this is yet to become common practice. METHOD: We conducted a mixed methods study with the aim of investigating carers' values and priorities for technology development, including prior experiences, barriers to use, and what they would like technology to do. Importantly, we asked carers for their design ideas and bespoke technology solutions for future development. RESULTS: Carers of people living with dementia (N = 127), including both unpaid (n = 102) and paid carers (n = 25) residing in Australia, completed an online survey. In addition, a subsample of carers (n = 23) participated in semi-structured interviews. Findings demonstrate that carers want technology to be person-centred, customisable, and to increase opportunities for meaningful social connection. Findings also demonstrate the ability of carers to generate creative design solutions for dementia care. CONCLUSIONS: These findings and implications will be discussed in relation to the importance of co-design with carers and engineers during the design phase of assistive technology. Also, the importance of technology to enhance, not replace, human-to-human social interactions is highlighted.

Quality of life after severe acute pancreatitis: systematic review.

BACKGROUND: Severe acute pancreatitis, the most severe form of acute pancreatitis, can alter pancreatic morphology, physiology, and function resulting in long-term morbidity, even after a single episode. This review assesses long-term outcomes and quality of life of severe acute pancreatitis. METHODS: A comprehensive literature review was conducted across MEDLINE, Embase, Scopus, and PubMed electronic databases on 18 January 2021 and updated on 26 April 2022 to ensure no new literature had been omitted. All studies were prospective or retrospective, included adult patients (>18 years) presenting with acute pancreatitis for whom data on long-term outcomes specifically after severe acute pancreatitis were reported. Quantitative and qualitative data extraction and synthesis were carried out and no meta-analysis was performed. Outcome measures included aetiology and mortality of severe acute pancreatitis, length of stay, endocrine and exocrine pancreatic insufficiency, chronic symptoms, and quality of life compared with healthy controls as assessed by validated questionnaires. RESULTS: Fourteen retrospective cohort studies were included, for a total of 779 patients, using quality of life questionnaires. The most common aetiology of severe acute pancreatitis was biliary (36 per cent) followed by alcoholic (29 per cent). Mortality rate ranged from 5 to 35 per cent and length of stay ranged from 2 to 367 days. Quality of life was somewhat lower in patients with exocrine insufficiency, but unaffected by endocrine insufficiency or chronic symptoms. Quality of life was more likely to be reduced in the first 4 years but normalize thereafter and was more likely to be negatively affected where alcohol was the aetiology. In four studies, the relationship between disease severity and lower quality of life was investigated, and a significant correlation was found. CONCLUSION: The review shows how a single episode of severe acute pancreatitis can have a variable effect on long-term quality of life, which is different to previous studies showing a strong reduction in quality of life. This could indicate that in current times treatment modalities are more effective.

Modeling the effect of temperature and relative humidity on exposure to SARS-CoV-2 in a mechanically ventilated room.

Computational fluid dynamics models have been developed to predict airborne exposure to the SARS-CoV-2 virus from a coughing person in a mechanically ventilated room. The models were run with three typical indoor air temperatures and relative humidities (RH). Quantile regression was used to indicate whether these have a statistically significant effect on the airborne exposure. Results suggest that evaporation is an important effect. Evaporation leads to respiratory particles, particularly those with initial diameters between 20 and 100 µm, remaining airborne for longer, traveling extended distances and carrying more viruses than expected from their final diameter. In a mechanically ventilated room, with all of the associated complex air movement and turbulence, increasing the RH may result in reduced airborne exposure. However, this effect may be so small that other factors, such as a small change in proximity to the infected person, could rapidly counter the effect. The effect of temperature on the exposure was more complex, with both positive and negative correlations. Therefore, within the range of conditions studied here, there is no clear guidance on how the temperature should be controlled to reduce exposure. The results highlight the importance of ventilation, face coverings and maintaining social distancing for reducing exposure.

Photocatalytic Reduction of CO2 to CO in Aqueous Solution under Red-Light Irradiation by a Zn-Porphyrin-Sensitized Mn(I) Catalyst.

This work demonstrates photocatalytic CO2 reduction by a noble-metal-free photosensitizer-catalyst system in aqueous solution under red-light irradiation. A water-soluble Mn(I) tricarbonyl diimine complex, [MnBr(4,4'-{Et2O3PCH2}2-2,2'-bipyridyl)(CO)3] (1), has been fully characterized, including single-crystal X-ray crystallography, and shown to reduce CO2 to CO following photosensitization by tetra(N-methyl-4-pyridyl)porphyrin Zn(II) tetrachloride [Zn(TMPyP)]Cl4 (2) under 625 nm irradiation. This is the first example of 2 employed as a photosensitizer for CO2 reduction. The incorporation of -P(O)(OEt)2 groups, decoupled from the core of the catalyst by a -CH2- spacer, afforded water solubility without compromising the electronic properties of the catalyst. The photostability of the active Mn(I) catalyst over prolonged periods of irradiation with red light was confirmed by 1H and 13C{1H} NMR spectroscopy. This first report on Mn(I) species as a homogeneous photocatalyst, working in water and under red light, illustrates further future prospects of intrinsically photounstable Mn(I) complexes as solar-driven catalysts in an aqueous environment.

Source terms for benchmarking models of SARS-CoV-2 transmission via aerosols and droplets.

There is ongoing and rapid advancement in approaches to modelling the fate of exhaled particles in different environments relevant to disease transmission. It is important that models are verified by comparison with each other using a common set of input parameters to ensure that model differences can be interpreted in terms of model physics rather than unspecified differences in model input parameters. In this paper, we define parameters necessary for such benchmarking of models of airborne particles exhaled by humans and transported in the environment during breathing and speaking.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial.

INTRODUCTION: Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention. METHODS AND ANALYSIS: A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19. ETHICS AND DISSEMINATION: The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER: SLCTR/2019/006, U1111-1220-8046.

Modeling the factors that influence exposure to SARS-CoV-2 on a subway train carriage.

We propose the Transmission of Virus in Carriages (TVC) model, a computational model which simulates the potential exposure to SARS-CoV-2 for passengers traveling in a subway rail system train. This model considers exposure through three different routes: fomites via contact with contaminated surfaces; close-range exposure, which accounts for aerosol and droplet transmission within 2 m of the infectious source; and airborne exposure via small aerosols which does not rely on being within 2 m distance from the infectious source. Simulations are based on typical subway parameters and the aim of the study is to consider the relative effect of environmental and behavioral factors including prevalence of the virus in the population, number of people traveling, ventilation rate, and mask wearing as well as the effect of model assumptions such as emission rates. Results simulate generally low exposures in most of the scenarios considered, especially under low virus prevalence. Social distancing through reduced loading and high mask-wearing adherence is predicted to have a noticeable effect on reducing exposure through all routes. The highest predicted doses happen through close-range exposure, while the fomite route cannot be neglected; exposure through both routes relies on infrequent events involving relatively few individuals. Simulated exposure through the airborne route is more homogeneous across passengers, but is generally lower due to the typically short duration of the trips, mask wearing, and the high ventilation rate within the carriage. The infection risk resulting from exposure is challenging to estimate as it will be influenced by factors such as virus variant and vaccination rates.

Modeling and experimental study of dispersion and deposition of respiratory emissions with implications for disease transmission.

The ability to model the dispersion of pathogens in exhaled breath is important for characterizing transmission of the SARS-CoV-2 virus and other respiratory pathogens. A Computational Fluid Dynamics (CFD) model of droplet and aerosol emission during exhalations has been developed and for the first time compared directly with experimental data for the dispersion of respiratory and oral bacteria from ten subjects coughing, speaking, and singing in a small unventilated room. The modeled exhalations consist of a warm, humid, gaseous carrier flow and droplets represented by a discrete Lagrangian particle phase which incorporates saliva composition. The simulations and experiments both showed greater deposition of bacteria within 1 m of the subject, and the potential for a substantial number of bacteria to remain airborne, with no clear difference in airborne concentration of small bioaerosols (<10 µm diameter) between 1 and 2 m. The agreement between the model and the experimental data for bacterial deposition directly in front of the subjects was encouraging given the uncertainties in model input parameters and the inherent variability within and between subjects. The ability to predict airborne microbial dispersion and deposition gives confidence in the ability to model the consequences of an exhalation and hence the airborne transmission of respiratory pathogens such as SARS-CoV-2.

Expert elicitation on the relative importance of possible SARS-CoV-2 transmission routes and the effectiveness of mitigations.

OBJECTIVES: To help people make decisions about the most effective mitigation measures against SARS-CoV-2 transmission in different scenarios, the likelihoods of transmission by different routes need to be quantified to some degree (however uncertain). These likelihoods need to be communicated in an appropriate way to illustrate the relative importance of different routes in different scenarios, the likely effectiveness of different mitigation measures along those routes, and the level of uncertainty in those estimates. In this study, a pragmatic expert elicitation was undertaken to supply the underlying quantitative values to produce such a communication tool. PARTICIPANTS: Twenty-seven individual experts from five countries and many scientific disciplines provided estimates. OUTCOME MEASURES: Estimates of transmission parameters, assessments of the quality of the evidence, references to relevant literature, rationales for their estimates and sources of uncertainty. RESULTS AND CONCLUSION: The participants' responses showed that there is still considerable disagreement among experts about the relative importance of different transmission pathways and the effectiveness of different mitigation measures due to a lack of empirical evidence. Despite these disagreements, when pooled, the majority views on each parameter formed an internally consistent set of estimates (for example, that transmission was more likely indoors than outdoors, and at closer range), which formed the basis of a visualisation to help individuals and organisations understand the factors that influence transmission and the potential benefits of different mitigation measures.

International transfers of personal data for health research following Schrems II: a problem in need of a solution.

On 16 July 2020, the Court of Justice of the European Union issued their decision in the Schrems II case concerning Facebook's transfers of personal data from the EU to the US. The decision may have significant effects on the legitimate transfer of personal data for health research purposes from the EU. This article aims: (i) to outline the consequences of the Schrems II decision for the sharing of personal data for health research between the EU and third countries, particularly in the context of the COVID-19 pandemic; and, (ii) to consider certain options available to address the consequences of the decision and to facilitate international data exchange for health research moving forward.

Radical collaboration during a global health emergency: development of the RDA COVID-19 data sharing recommendations and guidelines.

Background: The coronavirus disease 2019 (COVID-19) global pandemic required a rapid and effective response. This included ethical and legally appropriate sharing of data. The European Commission (EC) called upon the Research Data Alliance (RDA) to recruit experts worldwide to quickly develop recommendations and guidelines for COVID-related data sharing. Purpose: The purpose of the present work was to explore how the RDA succeeded in engaging the participation of its community of scientists in a rapid response to the EC request. Methods: A survey questionnaire was developed and distributed among RDA COVID-19 work group members. A mixed-methods approach was used for analysis of the survey data. Results: The three constructs of radical collaboration (inclusiveness, distributed digital practices, productive and sustainable collaboration) were found to be well supported in both the quantitative and qualitative analyses of the survey data. Other social factors, such as motivation and group identity were also found to be important to the success of this extreme collaborative effort. Conclusions: Recommendations and suggestions for future work were formulated for consideration by the RDA to strengthen effective expert collaboration and interdisciplinary efforts.

Entrepreneurial homeworkers.

Nearly 40% of British self-employees are homeworkers. Using a large representative sample of the UK longitudinal survey data, we explore the determinants of self-employed homeworking, distinguishing between genders. We reject the notion that homeworking is a transitional entrepreneurial state that the self-employed "grow out of", while establishing that both employer status and business structure play an important role in predicting which self-employed become homeworkers. Our findings also shed light on two outstanding puzzles in entrepreneurship scholarship: why so few of the self-employed create jobs for others, and why on average the self-employed suffer an earnings penalty compared with employees.

Management of osteoarthritis at the base of the thumb.

AIMS: Base of thumb osteoarthritis (BTOA) is a common age-related disease which has a significant negative impact upon quality of life. Our aim was to assess current UK practice in secondary care with regard to the nature of non-surgical treatments, the surgical procedures most commonly performed, and factors influencing the surgical decision-making process. METHODS: Ten consecutive patients undergoing surgery for BTOA between March 2017 and May 2019 were prospectively identified in 15 UK centres. Demographic details, duration of symptoms, radiological grade, non-surgical management strategies, and surgery conducted were recorded. A supplementary consultant questionnaire consisting of four multiple-choice-questions (MCQ) based on hypothetical clinical scenarios was distributed. RESULTS: A total of 150 patients were identified with a mean age of 64 years (SD 9), comprising 119 females and 31 males. Median duration of symptoms prior to surgery was 24 months (Interquartile range (IQR) 12 to 40). Hand therapy was used in 67 patients (45%), splints in 80 (53%), and 121 patients (81%) received one or more intra-articular injections, of which 81 (67%) were image-guided (14 (12%) ultrasound and 67 (55%) fluoroscopic). Only 48 patients (32%) received all three non-surgical treatments. Simple trapeziectomy (79 patients) and trapeziectomy with ligament reconstruction and/or tendon interposition (69 patients) were the most commonly performed operations. One patient was treated with arthrodesis, and one with arthroplasty. The supplementary questionnaire revealed that no specific patient or disease characteristics significantly influenced the type of surgery undertaken. CONCLUSION: We found considerable variation in practice of both non-surgical and surgical management of BTOA. The proportion of patients exhausting non-surgical strategies before being offered surgery is low. Surgeons tend to favour a single type of surgery irrespective of patient or disease characteristics. Cite this article: Bone Joint J 2020;102-B(5):600-605.

Sterically hindered Re- and Mn-CO2 reduction catalysts for solar energy conversion.

Novel molecular Re and Mn tricarbonyl complexes bearing a bipyridyl ligand functionalised with sterically hindering substituents in the 6,6'-position, [M(HPEAB)(CO)3(X)] (M/X = Re/Cl, Mn/Br; HPEAB = 6,6'-{N-(4-hexylphenyl)-N(ethyl)-amido}-2,2'-bipyridine) have been synthesised, fully characterised including by single crystal X-ray crystallography, and their propensity to act as catalysts for the electrochemical and photochemical reduction of CO2 has been established. Controlled potential electrolysis showed that the catalysts are effective for electrochemical CO2-reduction, yielding CO as the product (in MeCN for the Re-complex, in 95 : 5 (v/v) MeCN : H2O mixture for the Mn-complex). The recyclability of the catalysts was demonstrated through replenishment of CO2 within solution. The novel catalysts had similar reduction potentials to previously reported complexes of similar structure, and results of the foot-of-the-wave analysis showed comparable maximum turnover rates, too. The tentative mechanisms for activation of the pre-catalysts were proposed on the basis of IR-spectroelectrochemical data aided by DFT calculations. It is shown that the typical dimerisation of the Mn-catalyst was prevented by incorporation of sterically hindering groups, whilst the Re-catalyst undergoes the usual mechanism following chloride ion loss. No photochemical CO2 reduction was observed for the rhenium complex in the presence of a sacrificial donor (triethylamine), which was attributed to the short triplet excited state lifetime (3.6 ns), insufficient for diffusion-controlled electron transfer. Importantly, [Mn(HPEAB)(CO)3Br] can act as a CO2 reduction catalyst when photosensitised by a zinc porphyrin under red light irradiation (λ > 600 nm) in MeCN : H2O (95 : 5); there has been only one reported example of photoactivating Mn-catalysts with porphyrins in this manner. Thus, this work demonstrates the wide utility of sterically protected Re- and Mn-diimine carbonyl catalysts, where the rate and yield of CO-production can be adjusted based on the metal centre and catalytic conditions, with the advantage of suppressing unwanted side-reactions through steric protection of the vacant coordination site.

Fostering global data sharing: highlighting the recommendations of the Research Data Alliance COVID-19 working group.

The systemic challenges of the COVID-19 pandemic require cross-disciplinary collaboration in a global and timely fashion. Such collaboration needs open research practices and the sharing of research outputs, such as data and code, thereby facilitating research and research reproducibility and timely collaboration beyond borders. The Research Data Alliance COVID-19 Working Group recently published a set of recommendations and guidelines on data sharing and related best practices for COVID-19 research. These guidelines include recommendations for clinicians, researchers, policy- and decision-makers, funders, publishers, public health experts, disaster preparedness and response experts, infrastructure providers from the perspective of different domains (Clinical Medicine, Omics, Epidemiology, Social Sciences, Community Participation, Indigenous Peoples, Research Software, Legal and Ethical Considerations), and other potential users. These guidelines include recommendations for researchers, policymakers, funders, publishers and infrastructure providers from the perspective of different domains (Clinical Medicine, Omics, Epidemiology, Social Sciences, Community Participation, Indigenous Peoples, Research Software, Legal and Ethical Considerations). Several overarching themes have emerged from this document such as the need to balance the creation of data adherent to FAIR principles (findable, accessible, interoperable and reusable), with the need for quick data release; the use of trustworthy research data repositories; the use of well-annotated data with meaningful metadata; and practices of documenting methods and software. The resulting document marks an unprecedented cross-disciplinary, cross-sectoral, and cross-jurisdictional effort authored by over 160 experts from around the globe. This letter summarises key points of the Recommendations and Guidelines, highlights the relevant findings, shines a spotlight on the process, and suggests how these developments can be leveraged by the wider scientific community.

Does lumbar arthrodesis compromise outcome of total hip arthroplasty?

INTRODUCTION: This matched cohort study aims to determine whether the presence of a spinal arthrodesis (SA) compromises outcome of total hip arthroplasty (THA) and whether the outcome is better if THA is performed before- (THA-1st) or after- SA (THA-2nd). METHODS: This is a single centre, multi-surgeon, review of prospective data. Thirty-seven patients (47 hips) that had SA and 1° THA(s), formed the cases (26 THA-1st; 21 THA-2nd). Most cases had 1-level SA (n = 24). Controls were patients without SA that had THA, over the same period matched for age, gender and prosthesis type. Outcome measures included complication-, revision- rates, Oxford-Hip- and Harris-Hip-Scores (OHS/HHS) (Δ: difference between pre- and post-operative scores). This is a single-centre, multi-surgeon, review of prospective data. RESULTS: At a mean follow-up of 6 years, more complications were seen in cases of THA and SA compared with controls without SA (7 vs. 2) (p = 0.03). Consequently, more cases were revised (n = 4) compared with controls (n = 0) (p = 0.02). There were no differences in functional outcome between cases and controls (p = 0.1-0.6). No differences in complications- (4/26 vs. 3/21; p = 1.00) or revision- rates (2/26 vs. 2/21; p = 1.00) were seen between THA-1st and THA-2nd Groups. The THA-1st Group had higher pre- and post-operative OHS/HHS, compared to the THA-2nd Group. However, no significant difference in ΔOHS (24 vs. 17) and ΔHHS (39 vs. 26) were seen between the THA-1st and THA-2nd Groups (p = 0.1). CONCLUSIONS: Patients with THA and SA, had increased rates of revision; but no differences in patient-reported outcome measures (PROMs) were detected. Addressing the hip pathology first may be associated with improved functional outcome.

Outcomes of Hip Arthroplasty After Failed Hip Arthroscopy: A Case-Control Study.

BACKGROUND: Hip arthroscopy is increasingly being used in joint preservation surgery with clear benefits in the treatment of prearthritic conditions. A number of patients, however, will still go on to require subsequent hip arthroplasty, and at present, little evidence exists determining the impact that prior hip arthroscopy may have on the outcomes of a subsequent arthroplasty. METHODS: Using prospectively collated data, we identified 35 patients who had a hip arthroplasty (22 total hip arthroplasties and 13 hip resurfacing arthroplasties) after prior ipsilateral hip arthroscopy (cases). Cases were matched for age, gender, and prosthesis type with 70 controls (patients who received a primary arthroplasty over the same period, without prior arthroscopy). Outcome measures included range of movement, implant survival, complications, and functional outcome (Oxford Hip Score and Harris Hip Score). RESULTS: There was no demonstrable difference in improved range of motion after hip arthroplasty between the 2 groups, across any axis of movement (flexion, extension, internal/external rotation, abduction, and adduction; P = .07-.78). There was no significant difference in complication rate (P = .72). Overall 7-year implant survival was 85.9% (95% confidence interval [CI], 75-95.8). There was no difference in survival between cases (87.6%; 95% CI, 73.5-100) and controls (86.3%; 95% CI, 74.6%-98.0%; P = .2). Ten of the 11 revision arthroplasties performed were due to adverse reactions to metal debris in metal-on-metal hip resurfacing arthroplasty cases (P = .01). There was no difference in improvement of functional outcome postarthroplasty between groups (P = .48-.76). CONCLUSION: This study demonstrates that hip arthroscopy does not adversely influence outcome of a subsequent hip arthroplasty.

Knee dislocation and vascular injury: 4 year experience at a UK Major Trauma Centre and vascular hub.

INTRODUCTION: Knee dislocation is a rare but potentially devastating injury. Quoted rates of associated vascular compromise vary dramatically between 3.3% and 64%, and the best approach to investigate and diagnose such an injury remains controversial. We aim to evaluate our own 4-year experience of knee dislocation and vascular injury as a UK Major Trauma Centre and vascular hub. METHODS: Knee dislocation was defined as disruption of at least two major stabilising ligaments of the knee and gross instability requiring an operation. Patients were identified from the Department of Trauma and Orthopaedics patient database across a 4 year period from 2010 to 2014. Electronic patient records, imaging and hard notes were retrieved and reviewed retrospectively and relevant information recorded. RESULTS: Twenty-five cases of knee dislocation were identified. Male to female ratio was 11.5:1 with a mean age of 33 years (range 17-71). One patient had a vascular injury which ultimately required a femoro-popliteal bypass graft. Twenty-four patients had documented examination findings pertaining to the vascular status of the limb. Seventeen patients had specific reference to the presence or absence of pedal pulses. The remaining seven cases were documented as either "warm well perfused" or "neurovascularly in-tact". Nine patients were discharged directly from the emergency department with outpatient follow up. All admitted cases had documented vascular examination findings the following day. Two patients had additional adjunctive non-invasive investigations. No patients were examined with duplex ultrasound, although two patients had pulses confirmed with hand-held doppler ultrasound. Three patients had an angiogram. Four cases have a documented discussion with or review from a vascular surgeon. DISCUSSION AND CONCLUSIONS: Our rates of vascular injury are in line with the most recent and largest study to date. Non-invasive investigation and selective angiography has been safe in identifying significant vascular compromise, however, there is inconsistency in management pathways, and too much reassurance attributed to the presence of pedal pulses on initial examination. Safety and consistency could be improved with the introduction of a formalised evidence-based protocol for the initial evaluation of knee dislocation and vascular injury.