Major Trauma Triage Tool Study (MATTS) expert consensus-derived injury assessment tool.

Introduction: Major trauma centre (MTC) care has been associated with improved outcomes for injured patients. English ambulance services and trauma networks currently use a range of triage tools to select patients for bypass to MTCs. A standardised national triage tool may improve triage accuracy, cost-effectiveness and the reproducibility of decision-making. Methods: We conducted an expert consensus process to derive and develop a major trauma triage tool for use in English trauma networks. A web-based Delphi survey was conducted to identify and confirm candidate triage tool predictors of major trauma. Facilitated roundtable consensus meetings were convened to confirm the proposed triage tool's purpose, target diagnostic threshold, scope, intended population and structure, as well as the individual triage tool predictors and cut points. Public and patient involvement (PPI) focus groups were held to ensure triage tool acceptability to service users. Results: The Delphi survey reached consensus on nine triage variables in two domains, from 109 candidate variables after three rounds. Following a review of the relevant evidence during the consensus meetings, iterative rounds of discussion achieved consensus on the following aspects of the triage tool: reference standard, scope, target diagnostic accuracy and intended population. A three-step tool comprising physiology, anatomical injury and clinical judgement domains, with triage variables assessed in parallel, was recommended. The triage tool was received favourably by PPI focus groups. Conclusions: This paper presents a new expert consensus derived major trauma triage tool with defined purpose, scope, intended population, structure, constituent variables, variable definitions and thresholds. Prospective evaluation is required to determine clinical and cost-effectiveness, acceptability and usability.

Individual risk factors predictive of major trauma in pre-hospital injured older patients: a systematic review.

Background: Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development. Methods: Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings. Results: Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations. Conclusions: Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.

Injured patients who would benefit from expedited major trauma centre care: a consensus-based definition for the United Kingdom.

INTRODUCTION: Despite the importance of treating the 'right patient in the right place at the right time', there is no gold standard for defining which patients should receive expedited major trauma centre (MTC) care. This study aimed to define a reference standard applicable to the United Kingdom (UK) National Health Service major trauma networks. METHODS: A one-day facilitated roundtable expert consensus meeting was conducted at the University of Sheffield, UK, in September 2019. An expert panel of 17 clinicians was purposively sampled, representing all specialities relevant to major trauma management. A consultation process was subsequently held using focus groups with Public and Patient Involvement (PPI) representatives to review and confirm the proposed reference standard. RESULTS: Four reference standard domains were identified, comprising: need for critical interventions; presence of significant individual anatomical injuries; burden of multiple minor injuries; and important patient attributes. Specific criteria were defined for each domain. PPI consultation confirmed all aspects of the reference standard. A coding algorithm to allow operationalisation in Trauma Audit and Research Network data was also formulated, allowing classification of any case submitted to their database for future research. CONCLUSIONS: This reference standard defines which patients would benefit from expedited MTC care. It could be used as the target for future pre-hospital injury triage tools, for setting best practice tariffs for trauma care reimbursement and to evaluate trauma network performance. Future research is recommended to compare patient characteristics, management and outcomes of the proposed definition with previously established reference standards.

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review.

BACKGROUND: Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care. METHODS: Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings. RESULTS: Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting. CONCLUSION: Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds. LEVEL OF EVIDENCE: Systematic review, level III.

Use of a closed-system drug transfer device reduces contamination with doxorubicin during bolus injection.

BACKGROUND: Administration of doxorubicin via bolus injection may result in environmental contamination and a risk of nurses becoming exposed. Small spills are frequently observed by nurses when syringes are connected to, and disconnected from, infusion lines. AIMS: The effect of a closed-system drug transfer device (CSTD) on the release of doxorubicin was studied during administration via bolus injections. METHODS: 10 administrations with the currently used technique and 10 administrations using the CSTD were compared by analysis of doxorubicin contamination on gauze pads, tissues and gloves. FINDINGS: Using the current technique, contamination was found during nine administrations, which was mainly on the gauze pads and, to a lesser extent, on the tissues and gloves, indicating release of doxorubicin during administration. With use of the CSTD, contamination was found only on one pair of gloves. CONCLUSION: Use of a CSTD significantly decreased the number of spills and level of contamination compared with the currently used technique and, consequently, the use of such devices offers a safer working environment for nurses.

The Effect of Physical Readiness Training on Reserve Officers' Training Corps Freshmen Cadets.

BACKGROUND: The U.S. Army Reserve Officers' Training Corps (ROTC) is the largest commissioning source among all branches. Physical Readiness Training (PRT) is fundamental to ROTC cadet training. However, although studies have evaluated the effectiveness of PRT in cadets with prior PRT experience, no study has examined the early phase adaptations in those cadets with no prior PRT experience. METHODS: To determine the effect of PRT over the course of an academic year (9 months) in freshmen ROTC cadets, thirteen (n = 13; 7 male [180.8 ± 4.7 cm, 77.4 ± 10.0 kg; 19.8 ± 6.5 % body fat], 6 female [159.5 ± 12.1 cm; 63.4 ± 8.4 kg; 29.6 ± 6.2% body fat]) cadets with no prior PRT performed laboratory (body composition, 1-repetition maximum [1RM] bench and squat, countermovement vertical jump, maximal aerobic capacity [VO2max]) and field-based ([Army Physical Fitness Test (APFT) (2 minutes maximum push-ups and sit-ups, 2-mile run)]) measures of performance before (PRE), mid-year (MID), and at the conclusion of the academic year (POST). PRT was performed 3 times per week in accordance with Army standards. FINDINGS: No changes occurred in body composition, VO2max, or countermovement vertical jump. 1RM bench improved at MID in men (PRE, 78.5 ± 8.4 kg; MID, 84.7 ± 8.0 kg) and women (PRE, 42.0 ± 10.2 kg; MID, 46.2 ± 10.9 kg) with no further improvement. Women improved 1RM back squat (PRE, 55.3 ± 13.5 kg; POST, 74.6 ± 14.6 kg) and APFT tests: push-ups (PRE, 27 ± 10; POST, 39 ± 12), sit-ups (PRE, 55 ± 19; POST, 74 ± 12), 2-mile run (PRE, 18.6 ± 2.9; POST, 17.2 ± 1.3 minutes); although men improved in push-ups (PRE, 54 ± 6; POST, 67 ± 8) and sit-ups (PRE, 63 ± 8; POST, 75 ± 9). DISCUSSION/IMPACT/RECOMMENDATIONS: Nine months of PRT improved APFT scores of freshmen cadets while minor effects were noted in laboratory-based performance. Given the lack of improvements in strength and power, it would be advisable to provide supplemental strength and power training. Being a large commissioning resource for the Army with greater access to equipment and resources, the time spent in ROTC may be a unique opportunity to improve and educate young commissioning officers on the benefits of proper strength and power training for the use in future commands while units are considerably smaller and equipment is more accessible on university grounds.

Amorphous Formulation and in Vitro Performance Testing of Instantly Disintegrating Buccal Tablets for the Emergency Delivery of Naloxone.

The aim of this study was to develop a freeze-dried buccal tablet for the rapid delivery of naloxone in opioid overdose. The tablet composition was optimized to produce an amorphous matrix, which was confirmed by the absence of peaks associated with crystallinity observed by differential scanning calorimetry and powder X-ray diffraction. Tablets with high gelatin content lacked adequate porosity. Mannitol was added to the formulation to bridge and intercalate gelatin's tight polymer aggregates, however sodium bicarbonate was also required to prevent crystallization within the tablets. A linear reduction in mannitol's recrystallization enthalpy was observed with increasing sodium bicarbonate concentration (ΔrecryH = -20.3[NaHCO3] + 220.9; r(2) = 0.9, n = 18). The minimum sodium bicarbonate concentration for full inhibition of mannitol crystallization was 10.9% w/w. Freeze-dried tablets with lower amounts of sodium bicarbonate possessed a crystalline fraction that PXRD identified as mannitol hemihydrate from the unique peak at 9.7° 2θ. Mannitol's greater affinity for both ions and residual water rather than its affinity for self-association was the mechanism for the inhibition of crystallization observed here. The optimized tablet (composition mannitol 24% w/w (4.26 mg), gelatin 65% w/w (11.7 mg), sodium bicarbonate 11% w/w (1.98 mg), and naloxone 800 µg) formed predominantly amorphous tablets that disintegrated in less than 10 s. Optimized tablets were chemically and physically stable over 9 months storage at 25 °C. As speed of drug liberation is the critical performance attribute for a solid dosage form designed to deliver drug in an emergency, a novel imaging based in vitro disintegration assay for buccal tablets was developed. The assay was optimized with regard to conditions in the buccal cavity: i.e., temperature 33-37 °C, volume of medium (0.1-0.7 mL), and use of mucin-containing biorelevant medium. The disintegration assay was sensitive to temperature, medium volume, and medium composition; naloxone tablet disintegration was extremely rapid, with full disintegration ranging from 5 to 20 s. In conclusion, rapidly disintegrating tablets have been developed which are suitable for proof-of-concept clinical trial in humans to determine the pharmacokinetics of naloxone delivered via the buccal route.

Hybrid device employing three-dimensional arrays of MnO in carbon nanosheets bridges battery-supercapacitor divide.

It is a challenge to meld the energy of secondary batteries with the power of supercapacitors. Herein, we created electrodes finely tuned for this purpose, consisting of a monolayer of MnO nanocrystallites mechanically anchored by pore-surface terminations of 3D arrays of graphene-like carbon nanosheets ("3D-MnO/CNS"). The biomass-derived carbon nanosheets should offer a synthesis cost advantage over comparably performing designer nanocarbons, such as graphene or carbon nanotubes. High Li storage capacity is achieved by bulk conversion and intercalation reactions, while high rates are maintained through stable ∼20 nm scale diffusion distances. For example, 1332 mAh g(-1) is reached at 0.1 A g(-1), 567 mAh g(-1) at 5 A g(-1), and 285 mAh g(-1) at 20 A g(-1) with negligible degradation at 500 cycles. We employed 3D-MnO/CNS (anode) and carbon nanosheets (cathode) to create a hybrid capacitor displaying among the most promising performances reported: based on the active materials, it delivers 184 Wh kg(-1) at 83 W kg(-1) and 90 Wh kg(-1) at 15 000 W kg(-1) with 76% capacity retention after 5000 cycles.

Interconnected carbon nanosheets derived from hemp for ultrafast supercapacitors with high energy.

We created unique interconnected partially graphitic carbon nanosheets (10-30 nm in thickness) with high specific surface area (up to 2287 m(2) g(-1)), significant volume fraction of mesoporosity (up to 58%), and good electrical conductivity (211-226 S m(-1)) from hemp bast fiber. The nanosheets are ideally suited for low (down to 0 °C) through high (100 °C) temperature ionic-liquid-based supercapacitor applications: At 0 °C and a current density of 10 A g(-1), the electrode maintains a remarkable capacitance of 106 F g(-1). At 20, 60, and 100 °C and an extreme current density of 100 A g(-1), there is excellent capacitance retention (72-92%) with the specific capacitances being 113, 144, and 142 F g(-1), respectively. These characteristics favorably place the materials on a Ragone chart providing among the best power-energy characteristics (on an active mass normalized basis) ever reported for an electrochemical capacitor: At a very high power density of 20 kW kg(-1) and 20, 60, and 100 °C, the energy densities are 19, 34, and 40 Wh kg(-1), respectively. Moreover the assembled supercapacitor device yields a maximum energy density of 12 Wh kg(-1), which is higher than that of commercially available supercapacitors. By taking advantage of the complex multilayered structure of a hemp bast fiber precursor, such exquisite carbons were able to be achieved by simple hydrothermal carbonization combined with activation. This novel precursor-synthesis route presents a great potential for facile large-scale production of high-performance carbons for a variety of diverse applications including energy storage.

Body centered cubic magnesium niobium hydride with facile room temperature absorption and four weight percent reversible capacity.

We have synthesized a new metastable metal hydride with promising hydrogen storage properties. Body centered cubic (bcc) magnesium niobium hydride (Mg(0.75)Nb(0.25))H(2) possesses 4.5 wt% hydrogen gravimetric density, with 4 wt% being reversible. Volumetric hydrogen absorption measurements yield an enthalpy of hydride formation of -53 kJ mol(-1) H(2), which indicates a significant thermodynamic destabilization relative to the baseline -77 kJ mol(-1) H(2) for rutile MgH(2). The hydrogenation cycling kinetics are remarkable. At room temperature and 1 bar hydrogen it takes 30 minutes to absorb a 1.5 µm thick film at sorption cycle 1, and 1 minute at cycle 5. Reversible desorption is achieved in about 60 minutes at 175 °C. Using ab initio calculations we have examined the thermodynamic stability of metallic alloys with hexagonal close packed (hcp) versus bcc crystal structure. Moreover we have analyzed the formation energies of the alloy hydrides that are bcc, rutile or fluorite.

Electrochemical Supercapacitor Electrodes from Sponge-like Graphene Nanoarchitectures with Ultrahigh Power Density.

We employed a microwave synthesis process of cobalt phthalocyanine molecules templated by acid-functionalized multiwalled carbon nanotubes to create three-dimensional sponge-like graphene nanoarchitectures suited for ionic liquid-based electrochemical capacitor electrodes that operate at very high scan rates. The sequential "bottom-up" molecular synthesis and subsequent carbonization process took less than 20 min to complete. The 3D nanoarchitectures are able to deliver an energy density of 7.1 W·h kg(-1) even at an extra high power density of 48 000 W kg(-1). In addition, the ionic liquid supercapacitor based on this material works very well at room temperature due to its fully opened structures, which is ideal for the high-power energy application requiring more tolerance to temperature variation. Moreover, the structures are stable in both ionic liquids and 1 M H2SO4, retaining 90 and 98% capacitance after 10 000 cycles, respectively.

Feeding on poplar leaves by caterpillars potentiates foliar peroxidase action in their guts and increases plant resistance.

Peroxidases (PODs) are believed to act as induced and constitutive defenses in plants against leaf-feeding insects. However, little work has examined the mode of action of PODs against insects. Putative mechanisms include the production of potentially antinutritive and/or toxic semiquinone free radicals and quinones (from the oxidation of phenolics), as well as increased leaf toughness. In this study, transgenic hybrid poplar saplings (Populus tremula × Populus alba) overexpressing horseradish peroxidase (HRP) were produced to examine the impact of elevated HRP levels on the performance and gut biochemistry of Lymantria dispar caterpillars. HRP-overexpressing poplars were more resistant to L. dispar than wild-type (WT) poplars when the level of a phenolic substrate of HRP (chlorogenic acid) was increased, but only when leaves had prior feeding damage. Damaged (induced) leaves produced increased amounts of hydrogen peroxide, which was used by HRP to increase the production of semiquinone radicals in the midguts of larvae. The decreased growth rates of larvae that fed on induced HRP-overexpressing poplars resulted from post-ingestive mechanisms, consistent with the action of HRP in their midguts. The toughness of HRP-overexpressing leaves was not significantly greater than that of WT leaves, whether or not they were induced. When leaves were coated with ellagitannins, induced HRP leaves also produced elevated levels of semiquinone radicals in the midgut. Decreased larval performance on induced HRP leaves in this case was due to post-ingestive mechanisms as well as decreased consumption. The results of this study provide the first demonstration that a POD is able to oxidize phenolics within an insect herbivore's gut, and further clarifies the chemical conditions that must be present for PODs to function as antiherbivore defenses.

In vitro uses of biological cryoprotectants.

Ice can be anything from a highly destructive agent in agriculture to a useful building material. Established industries are based on the known rules of physics and chemistry which allow some control of amounts of ice or ice crystal geometry. However, organisms have much more subtle requirements to maintain their delicate internal structure if they are to survive freezing. As a result they have selected specific molecules for freezing-point depression, osmotic regulation, ice nucleation and crystal growth inhibition. All these active species may have potential commercial use once they are identified, understood and produced at economic scales. We examine the progress made so far in extending biological subtlety into commercial processes, and look for prospects for further innovation.