Implementation of major trauma app: usability and data completeness.

BACKGROUND: The current UK standard for major trauma patients is to record notes in a paper trauma booklet. Through an innovative collaboration between a major trauma centre and a digital transformation industry partner, a TraumaApp was developed. Electronic notes have been shown to have fewer errors, granular data collection and enable time stamped contemporaneous record keeping. Implementation of digital clinical records presents a challenge within the context of trauma multidisciplinary trauma resuscitation. Data can be easily accessible and shared for quality improvement, audit and research purposes. This study compared paper and electronic notes for completeness and for acceptability data following the implementation of the TraumaApp. METHODS: Trauma team members who performed scribe function attended training for the newly launched TraumaApp. Two staff members acted as scribe, using either the paper trauma booklet or TraumaApp, and attended major trauma calls. A framework for comparison of paper and electronic notes was created and used for a retrospective review of major trauma patients' notes. Statistical analysis was performed using a two-tailed t-test. Staff using the TraumaApp completed a System Usability Score questionnaire. RESULTS: There was a total of 37 data points for collection per case. The mean numbers collected were paper notes 24.1 of 37 (65.1%) and electronic notes, 25.7 of 37 (69.5%). There was no statistical significance between the completeness of paper and electronic notes. The mean System Usability Score was 68.4. DISCUSSION: Recording accurate patient information during a major trauma call can be challenging and the role of the scribe to accurately record events is critical for immediate and future care. There was no statistically significant difference in completeness of paper and electronic notes, however the mean System Usability Score was 68.4, which is greater than the internationally validated standard of acceptable usability. CONCLUSION: It is feasible to introduce digital data collection tools enabling accurate record keeping during trauma resuscitation and improve information sharing between clinicians.

Usability of novel major TraumaApp for digital data collection.

BACKGROUND: Delivery of major trauma care is complex and often fast paced. Clear and comprehensive documentation is paramount to support effective communication during complex clinical care episodes, and to allow collection of data for audit, research and continuous improvement. Clinical events are typically recorded on paper-based records that are developed for individual centres or systems. As one of the priorities laid out by the Scottish Trauma Network project was to develop an electronic data collection system, the TraumaApp was created as a data collection tool for major trauma that could be adopted worldwide. METHODS: The study was performed as a service evaluation based at the Queen Elizabeth University Hospital Emergency Department. Fifty staff members were recruited in pairs and listened to five paired major trauma standby and handover recordings. Participants were randomised to input data to the TraumaApp and one into the existing paper proforma. The time taken to input data add into was measured, along with time for clarifications and any errors made. Those using the app completed a System Usability Score. RESULTS: No statistically significant difference was demonstrated between times taken for data entry for the digital and paper documentation, apart from the Case 5 Handover (p < 0.05). Case 1 showed a significantly higher time for clarifications and number of errors with digital data collection (p = 0.01 and p = 1.79E-05 respectively). There were no other differences between data for the app and the proforma. The mean System Usability score for this cohort was 75 out of 100, with a standard deviation of 17 (rounded to nearest integer). CONCLUSION: Digital real-time recording of clinical events using a tool such as the TraumaApp is comparable to completion of paper proforma. The System Usability Score for the TraumaApp was above the internationally validated standard of acceptable usability. There was no evidence of improvement in use over time or familiarity, most likely due to the brevity of the assessments and the refined user interface. This would benefit from further research, exploring data completeness and a potential mixed methods approach to explore training requirements for use of the TraumaApp.

Development of a Sub-ppb Resolution Methane Sensor Using a GaSb-Based DFB Diode Laser near 3270 nm for Fugitive Emission Measurement.

A challenge for mobile measurement of fugitive methane emissions is the availability of portable sensors that feature high sensitivity and fast response times, simultaneously. A methane gas sensor to measure fugitive emissions was developed using a continuous-wave, thermoelectrically cooled, GaSb-based distributed feedback diode laser emitting at a wavelength of 3.27 µm to probe methane in its strong ν3 vibrational band. Direct absorption spectra (DAS) as well as wavelength-modulated spectra (WMS) of pressure-broadened R(3) manifold lines of methane were recorded through a custom-developed open-path multipass cell with an effective optical path length of 6.8 m. A novel metrological approach was taken to characterize the sensor response in terms of the linearity of different WMS metrics, namely, the peak-to-peak amplitude of the X2f component and the peak and/or the integrated area of the background-subtracted quadrature signal (i.e., Q(2f - 2f0)) and the background-subtracted 1f-normalized quadrature signal (i.e., Q(2f/1f - 2f0/1f0)). Comparison with calibration gas concentrations spanning 1.5 to 40 ppmv indicated that the latter WMS metric showed the most linear response, while fitting DAS provides a traceable reference. In the WMS mode, a sensitivity better than 1 ppbv was achieved at a 1 s integration time. The sensitivity and response time are well-suited to measure enhancements in ambient methane levels caused by fugitive emissions.

Ash-Decorated and Ash-Painted Soot from Residual and Distillate-Fuel Combustion in Four Marine Engines and One Aviation Engine.

Soot is typically the dominant component of the nonvolatile particles emitted from internal combustion engines. Although soot is primarily composed of carbon, its chemistry, toxicity, and oxidation rates may be strongly influenced by internally mixed inorganic metal compounds (ash). Here, we describe the detailed microstructure of ash internally mixed with soot from four marine engines and one aviation engine. The engines were operated on different fuels and lubrication oils; the fuels included four residual fuels and five distillate fuels such as diesel, natural gas, and Jet A-1. Using annular-dark-field scanning transmission electron microscopy (ADF-STEM), we observed that ash may occur either as distinct nodules on the soot particle (decorated) or as continuous streaks (painted). Both structures may exist within a single particle. Decorated soot was observed for both distillate and residual fuels and contained elements associated with either the fuel (V, Ni, Fe, S) or with the lubrication oil (Zn, Ca, P). Painted soot was observed only for residual-fuel soot, and only contained elements associated with the fuel. Additional composition measurements by inductively coupled plasma mass spectrometry (ICP-MS) of filter samples indicated that the internal mixing trends of ash with soot were consistent with the overall ash-to-carbon ratio of the sampled combustion aerosols. Painted soot may form when molten ash coagulates with or condenses onto soot within engines.

Assessment of a regulatory measurement system for the determination of the non-volatile particulate matter emissions from commercial aircraft engines.

The SAE International has published Aerospace Information Report (AIR) 6241 which outlined the design and operation of a standardized measurement system for measuring non-volatile particulate matter (nvPM) mass and number emissions from commercial aircraft engines. Prior to this research, evaluation of this system by various investigators revealed differences in nvPM mass emissions measurement on the order of 15-30% both within a single sampling system and between two systems operating in parallel and measuring nvPM mass emissions from the same source. To investigate this issue, the U. S. Environmental Protection Agency in collaboration with the U. S. Air Force's Arnold Engineering Development Complex initiated the VAriable Response In Aircraft nvPM Testing (VARIAnT) research program to compare nvPM measurements within and between AIR-compliant sampling systems used for measuring combustion aerosols generated both by a 5201 Mini-CAST soot generator and a J85-GE-5 turbojet engine burning multiple fuels. The VARIAnT research program has conducted four test campaigns to date. The first campaign (VARIAnT 1) compared two essentially identical commercial versions of the sampling system while the second campaign (VARIAnT 2) compared a commercial system to the custom-designed Missouri University of Science and Technology's North American Reference System (NARS) built to the same specifications. Comparisons of nvPM particle mass (i.e., black carbon), number, and size were conducted in both campaigns. Additionally, the sensitivity to variation in system operational parameters was evaluated in VARIAnT 1. Results from both campaigns revealed agreement of about 12% between the two sampling systems, irrespective of manufacturer, in all aspects except for black carbon determination. The major source of measurement differences (20-70%) was due to low BC mass measurements made by the Artium Technologies LII-300 as compared to the AVL 483 Micro-Soot Sensor, the Aerodyne Cavity Attenuated Phase Shift (CAPS PMSSA) monitor, and the thermal-optical reference method for elemental carbon (EC) determination, which was used as the BC reference.

Antibacterial Properties of Mussel-Inspired Polydopamine Coatings Prepared by a Simple Two-Step Shaking-Assisted Method.

A simple two-step, shaking-assisted polydopamine (PDA) coating technique was used to impart polypropylene (PP) mesh with antimicrobial properties. In this modified method, a relatively large concentration of dopamine (20 mg ml-1) was first used to create a stable PDA primer layer, while the second step utilized a significantly lower concentration of dopamine (2 mg ml-1) to promote the formation and deposition of large aggregates of PDA nanoparticles. Gentle shaking (70 rpm) was employed to increase the deposition of PDA nanoparticle aggregates and the formation of a thicker PDA coating with nano-scaled surface roughness (RMS = 110 nm and Ra = 82 nm). Cyclic voltammetry experiment confirmed that the PDA coating remained redox active, despite extensive oxidative cross-linking. When the PDA-coated mesh was hydrated in phosphate saline buffer (pH 7.4), it was activated to generate 200 µM hydrogen peroxide (H2O2) for over 48 h. The sustained release of low doses of H2O2 was antibacterial against both gram-positive (Staphylococcus epidermidis) and gram-negative (Escherichia coli) bacteria. PDA coating achieved 100% reduction (LRV ~3.15) when incubated against E. coli and 98.9% reduction (LRV ~1.97) against S. epi in 24 h.

Kalman filter approach for uncertainty quantification in time-resolved laser-induced incandescence.

Time-resolved laser-induced incandescence (TiRe-LII) data can be used to infer spatially and temporally resolved volume fractions and primary particle size distributions of soot-laden aerosols, but these estimates are corrupted by measurement noise as well as uncertainties in the spectroscopic and heat transfer submodels used to interpret the data. Estimates of the temperature, concentration, and size distribution of soot primary particles within a sample aerosol are typically made by nonlinear regression of modeled spectral incandescence decay, or effective temperature decay, to experimental data. In this work, we employ nonstationary Bayesian estimation techniques to infer aerosol properties from simulated and experimental LII signals, specifically the extended Kalman filter and Schmidt-Kalman filter. These techniques exploit the time-varying nature of both the measurements and the models, and they reveal how uncertainty in the estimates computed from TiRe-LII data evolves over time. Both techniques perform better when compared with standard deterministic estimates; however, we demonstrate that the Schmidt-Kalman filter produces more realistic uncertainty estimates.

Sequential signal detection for high dynamic range time-resolved laser-induced incandescence.

A new method for collecting time-resolved laser-induced incandescence (TiRe-LII) signals with high dynamic range is presented. Gated photomultiplier tubes (PMT) are used to detect temporal sections of the LII signal. This helps to overcome the limitations of PMTs caused by restricted maximum signal current at the strong initial signal and poor signal-to-noise ratios when the signal intensity approaches the noise level. We present a simple method for increasing the accuracy of two-color pyrometry at later decay times and two advanced strategies for getting high accuracy over the complete temperature trace or even achieve single-shot capability with high dynamic range. Validation measurements in a standardized flame show that the method is sensitive enough to even resolve the local increase in gas temperature as a consequence of heating the soot particles with a laser pulse.

Effect of Drive Cycle and Gasoline Particulate Filter on the Size and Morphology of Soot Particles Emitted from a Gasoline-Direct-Injection Vehicle.

The size and morphology of particulate matter emitted from a light-duty gasoline-direct-injection (GDI) vehicle, over the FTP-75 and US06 transient drive cycles, have been characterized by transmission-electron-microscope (TEM) image analysis. To investigate the impact of gasoline particulate filters on particulate-matter emission, the results for the stock-GDI vehicle, that is, the vehicle in its original configuration, have been compared to the results for the same vehicle equipped with a catalyzed gasoline particulate filter (GPF). The stock-GDI vehicle emits graphitized fractal-like aggregates over all driving conditions. The mean projected area-equivalent diameter of these aggregates is in the 78.4-88.4 nm range and the mean diameter of primary particles varies between 24.6 and 26.6 nm. Post-GPF particles emitted over the US06 cycle appear to have an amorphous structure, and a large number of nucleation-mode particles, depicted as low-contrast ultrafine droplets, are observed in TEM images. This indicates the emission of a substantial amount of semivolatile material during the US06 cycle, most likely generated by the incomplete combustion of accumulated soot in the GPF during regeneration. The size of primary particles and soot aggregates does not vary significantly by implementing the GPF over the FTP-75 cycle; however, particles emitted by the GPF-equipped vehicle over the US06 cycle are about 20% larger than those emitted by the stock-GDI vehicle. This may be attributed to condensation of large amounts of organic material on soot aggregates. High-contrast spots, most likely solid nonvolatile cores, are observed within many of the nucleation-mode particles emitted over the US06 cycle by the GPF-equipped vehicle. These cores are either generated inside the engine or depict incipient soot particles which are partially carbonized in the exhaust line. The effect of drive cycle and the GPF on the fractal parameters of particles, such as fractal dimension and fractal prefactor, is insignificant.

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Emergency physician performed 2-point bedside compression ultrasound for deep venous thrombosis.

A short cut review was carried out to establish the diagnostic utility of Emergency Physician performed ultrasound in confirming or refuting the diagnosis of deep vein thrombosis compared with a radiology scan. A systematic review incorporating 16 studies and two studies published subsequently were found to be relevant to the question. The clinical bottom line was that some studies demonstrated high sensitivity and specificity compared with the reference standard but this finding was not universal.

Application of the Hough transform for the automatic determination of soot aggregate morphology.

We report a new method for automated identification and measurement of primary particles within soot aggregates as well as the sizes of the aggregates and discuss its application to high-resolution transmission electron microscope (TEM) images of the aggregates. The image processing algorithm is based on an optimized Hough transform, applied to the external border of the aggregate. This achieves a significant data reduction by decomposing the particle border into fragments, which are assumed to be spheres in the present application, consistent with the known morphology of soot aggregates. Unlike traditional techniques, which are ultimately reliant on manual (human) measurement of a small sample of primary particles from a subset of aggregates, this method gives a direct measurement of the sizes of the aggregates and the size distributions of the primary particles of which they are composed. The current version of the algorithm allows processing of high-resolution TEM images by a conventional laptop computer at a rate of 1-2 ms per aggregate. The results were validated by comparison with manual image processing, and excellent agreement was found.

Quantitative field measurement of soot emission from a large gas flare using sky-LOSA.

Particulate matter emissions from unconfined sources such as gas flares are extremely difficult to quantify, yet there is a significant need for this measurement capability due to the prevalence and magnitude of gas flaring worldwide. Current estimates for soot emissions from flares are rarely, if ever, based on any form of direct data. A newly developed method to quantify the mass emission rate of soot from flares is demonstrated on a large-scale flare at a gas plant in Uzbekistan, in what is believed to be the first in situ quantitative measurement of soot emission rate from a gas flare under field conditions. The technique, named sky-LOSA, is based on line-of-sight attenuation of skylight through a flare plume coupled with image correlation velocimetry. Monochromatic plume transmissivities were measured using a thermoelectrically cooled scientific-grade CCD camera. Plume velocities were separately calculated using image correlation velocimetry on high-speed movie data. For the flare considered, the mean soot emission rate was determined to be 2.0 g/s at a calculated uncertainty of 33%. This emission rate is approximately equivalent to that of 500 buses driving continuously and equates to approximately 275 trillion particles per second. The environmental impact of large, visibly sooting flares can be quite significant.

Sky-scattered solar radiation based plume transmissivity measurement to quantify soot emissions from flares.

For gas flares typical of the upstream energy industry and similar point sources, most current methods for characterizing soot emissions are based on plume opacity rather than a quantitative measure of mass flux. The absence of more quantitative approaches is indicative of the inherent complexity of soot and the difficulties in characterizing emissions in an unbounded plume. A new experimental approach has been developed for the investigation of soot emissions in industrial plumes. Referred to as sky-LOSA, the diagnostic permits evaluation of 2D spatially resolved monochromatic sky-light transmissivity data over the width of a plume, where sky-light intensities behind the plume are obtained via an interpolation algorithm. By using Rayleigh-Debye-Gans Fractal Aggregate theory to relate transmissivity data to soot concentrations, and with knowledge of the velocity of the plume, it is possible to quantify mass flow rates of soot in a plume. Experiments on an unconfined lab-scale soot plume were used to support a detailed uncertainty analysis under a wide range of conditions and to estimate sensitivity limits of the technique. Results suggest field measurements of soot emission from flare plumes should be possible with overall uncertainties of less than 32%. This represents a significant advancement over existing techniques based on opacity measurements.

Diffuse-light two-dimensional line-of-sight attenuation for soot concentration measurements.

A technique of diffuse-light two-dimensional line-of-sight attenuation (diffuse 2D-LOSA) is described and demonstrated that achieves very high levels of sensitivity in transmissivity measurements (optical thicknesses down to 0.001) while effectively mitigating interferences due to beam steering. An optical system is described in which an arc lamp coupled with an integrating sphere is used as a source of diffuse light that is imaged to the center of the particulate laden medium. The center of the medium is then imaged onto a CCD detector with 1:1 magnification. Comparative measurements with collimated 2D-LOSA in nonpremixed flames demonstrate the accuracy and improved optical noise rejection of the technique. Tests in weakly sooting, nonpremixed methane-air flames, and in high pressure methane-air flames, reveal the excellent sensitivity of diffuse 2D-LOSA, which is primarily limited by the shot noise of the lamp and CCD detector.

Clinical outcomes of magnetic resonance imaging in blunt cervical trauma.

OBJECTIVES: To determine whether MRI of the cervical spine resulted in a change in management of patients with blunt trauma and normal plain X-ray (XR)/CT of the cervical spine. METHODS: An explicit chart review was conducted of patients seen at a Level 1 trauma centre over a 1 year period. Clinical details were extracted from the charts of patients with blunt trauma who had a normal plain XR and CT scan of the cervical spine and who underwent cervical spine MRI. A comparison of clinical details was made between those with a normal/abnormal MRI secondary to the acute injury. RESULTS: One hundred and thirty-four patients met entry criteria. Discharge non-operative management of the cervical spine was associated with a change in management by the MRI result (P < 0.0001) where MRI of the cervical spine occurred a median of 3 days (interquartile range 0-4.5, range 0-137) after the injury. The MRI occurred before discharge 90% of the time in both groups. Operative management occurred in three patients and was delayed until after first outpatient review in two patients. CONCLUSIONS: An abnormal MRI after normal plain XR and CT cervical spine studies resulted in a change in non-operative management at discharge. Early MRI resulted in one patient receiving surgery before discharge. No unstable injuries were detected by MRI that were not evident on plain XR or CT cervical spine.

Deconvolution of axisymmetric flame properties using Tikhonov regularization.

We present a method based on Tikhonov regularization for solving one-dimensional inverse tomography problems that arise in combustion applications. In this technique, Tikhonov regularization transforms the ill-conditioned set of equations generated by onion-peeling deconvolution into a well-conditioned set that is less susceptible to measurement errors that arise in experimental settings. The performance of this method is compared to that of onion-peeling and Abel three-point deconvolution by solving for a known field variable distribution from projected data contaminated with an artificially generated error. The results show that Tikhonov deconvolution provides a more accurate field distribution than onion-peeling and Abel three-point deconvolution and is more stable than the other two methods as the distance between projected data points decreases.

Spinning-induced rhabdomyolysis: a case report.

Exercise induced rhabdomyolysis has previously been described as occurring in unfit adults or those attempting exhaustive exercise, but is rarely seen in previously fit adults undertaking moderate exercise. This case report describes what we believe to be the first reported case of exercise induced rhabdomyolysis due to the patient completing a 'spinning class' at her local gymnasium. The report also covers diagnosis and management of this condition.