Objectives & Background Traumatic brain injury (TBI) is a leading cause of death and disability in young adults. Reorganisation of trauma services with direct triage of suspected head injury patients to trauma centres may improve outcomes following TBI. This study aimed to determine the sensitivity of principal English triage tools for identifying significant TBI. Methods We performed a diagnostic cohort study using data prospectively collated from the Trauma Audit and Research Network database between 2005-2011. Adult head injury patients were retrospectively classified according to London Ambulance Service (LAS) and Head Injury Transportation Straight to Neurosurgery study (HITS-NS) triage criteria. Sensitivity and specificity were then calculated against a reference standard of significant TBI, comprising head region abbreviated injury score (AIS) ≥3 or neurosurgical operation. To investigate the determinants of triage rule sensitivity patient characteristics were compared between true positive and false negative groups using descriptive statistics and hypothesis testing. Additional analyses were conducted to explore the robustness of results to selection bias and examine the sensitivity of pre-hospital Glasgow Coma Score (GCS) for detecting significant TBI. Results 6,559 patients were included in complete case analyses. The LAS and HITS-NS triage tools demonstrated sensitivities of 44.5% (95% CI 43.2-45.9) and 32.6% (95% CI 31.4-33.9) respectively for identifying significant TBI patients. These results were not materially changed following multiple imputation of missing data under a missing at random assumption. False negative significant TBI cases were relatively older, more likely to be female, more frequently secondary to low-level falls, and were less likely to have very severe AIS 5 or 6 head injuries, p<0.01. Pre-hospital GCS did not appear to be a sensitive discriminator for identifying significant TBI, with 44.9% of patients classified as having significant TBI presenting with a PH GCS of ≥13. Conclusion considerable proportion of significant head injury patients may not to be triaged directly to trauma centres. Investment is therefore necessary to improve the accuracy of existing triage rules and maintain expertise in TBI diagnosis and management in non-specialist emergency departments. 876Emerg Med J 2013;30(10):866-880

Several digitalisation technologies have recently emerged, reshaping organisations across various industries and sectors. Such technologies, commonly placed under the industry 4.0 umbrella term, include Internet of Things (IoT), cloud computing, blockchain, and Artificial Intelligence (AI). They aim to enable the data collection, exchange, processing, and automation to enable a system to make decisions autonomously. This paper presents IN 4.0 project, aiming to ease the adaptation and adoption of industry 4.0 practices and technologies in maritime sector companies in order to improve their competitiveness. This will be achieved through a four-pronged approach aiming to: analyse the current state-of-art as applied to other industries; define a protocol for the redefinition of workers’ tasks; investigate cost-reduction methods for the implementation of 4.0 technologies; and counsel businesses for the transformation of maritime SMEs to the 4.0 era. Special focus will be given to the training required to get workers acquainted with new technologies and competitive in this changing labour market. Recent progress and advances of the IN 4.0 project along with future plans are presented and discussed, thus revealing the expected future transformation of the maritime industry.

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Objectives & BackgroundExhaled Volatile Organic Compounds (eVOCs) have been used to identify patients with many diseases including pseudomonas infection and lung cancer. Breath for eVOC analysis is conventionally collected from one or more deep exhalations. The long controlled exhalation of the American Thoracic Association nitric oxide protocol has been the commonest method used in breath research. However, some patients may be unable or unwilling to perform deep exhalations. Movement of breath analysis from the laboratory to the bedside requires a patient-friendly method for collecting breath samples, especially if breath analysis is to be tested in the relatively uncontrolled environment of an Emergency Department. Continuous monitoring of VOC spectra throughout the breath cycle during tidal breathing has the potential to provide an easier method of sample collection in the clinical situation. This study was designed to compare single controlled exhalation with tidal breathing.MethodsExhaled breath volatile organic compounds were measured to compare two methods of breath collection in emergency care; the standard single prolonged exhalation (incentive test) and relaxed breathing (tidal test). 125 patients with minor conditions were recruited from the Emergency Department and samples were collected in real-time using an on-line PTR-ToF-MS coupled to Loccioni breath collection apparatus. A Matlab program was used to extract the spectra of the alveolar portion of breath and measure the abundance of each eVOC.ResultsThe total amount of eVOCs detected by the two methods was highly correlated (R2=0.91), with the incentive method giving slightly higher overall eVOC levels than the tidal breath method (mean of differences=98,749 NCPS, P<0.0001). Although the total VOCs were highly correlated, there was a large amount of unexplained variation in the spectra. The tidal breath test had a much higher completion (99% compared with 75% for the incentive test), which was due to the greater reliability (less complex sampling equipment) and greater ease of use by patients.ConclusionFollowing this study we recommend the use of a tidal breath sampling method in future studies of emergency care patients to prevent selection bias.