The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF): feasibility trial protocol

Background: Topical lidocaine patches, applied over rib fractures, have been suggested as a non-invasive method of local anaesthetic delivery to improve respiratory function, reduce opioid consumption and consequently reduce pulmonary complications. Older patients may gain most benefit from improved analgesic regimens yet lidocaine patches are untested as an early intervention in the Emergency Department (ED). The aim of this trial is to investigate uncertainties around trial design and conduct, to establish whether a definitive randomised trial of topical lidocaine patches in older patients with rib fractures is feasible. Methods: RELIEF is an open label, multicentre, parallel group, individually randomised, feasibility randomised controlled trial with economic scoping and nested qualitative study. Patients aged ≥ 65 years presenting to the ED with traumatic rib fracture(s) requiring admission will be randomised 1:1 to lidocaine patches (intervention), in addition to standard clinical management, or standard clinical management alone. Lidocaine patches will be applied immediately after diagnosis in ED and continued daily for 72 hours or until discharge. Feasibility outcomes will focus on recruitment, adherence and follow-up data with a total sample size of 100. Clinical outcomes, such as 30-day pulmonary complications, and resource use will be collected to understand feasibility of data collection. Qualitative interviews will explore details of the trial design, trial acceptability and recruitment processes. An evaluation of the feasibility of measuring health economics outcomes data will be completed. Discussion: Interventions to improve outcomes in elderly patients with rib fractures are urgently required. This feasibility trial will test a novel early intervention which has the potential of fulfilling this unmet need. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF) feasibility trial will determine whether a definitive trial is feasible. ISRCTN Registration: ISRCTN14813929 (22/04/2021)

Cloud feedbacks in extratopical cyclones: insight from long-term satellite data and high-resolution global simulations

A negative extratropical shortwave cloud feedback driven by changes in cloud optical depth is a feature of global climate models (GCMs). A robust positive trend in observed liquid water path (LWP) over the last two decades across the warming Southern Ocean supports the negative shortwave cloud feedback predicted by GCMs. This feature has been proposed to be due to transitions from ice to liquid with warming. To gain insight into the shortwave cloud feedback we examine extratropical cyclone variability and the response of extratropical cyclones to transient warming in GCM simulations. Multi-Sensor Advanced Climatology Liquid Water Path (MAC-LWP) microwave observations of cyclone properties from the period 1992–2015 are contrasted with GCM simulations, with horizontal resolutions ranging from 7 km to hundreds of kilometers. We find that inter-cyclone variability in LWP in both observations and models is strongly driven by the moisture flux along the cyclone's warm conveyor belt (WCB). Stronger WCB moisture flux enhances the LWP within cyclones. This relationship is replicated in GCMs, although its strength varies substantially across models. It is found that more than 80 % of the enhancement in Southern Hemisphere (SH) extratropical cyclone LWP in GCMs in response to a transient 4 K warming can be predicted based on the relationship between the WCB moisture flux and cyclone LWP in the historical climate and their change in moisture flux between the historical and warmed climates. Further, it is found that that the robust trend in cyclone LWP over the Southern Ocean in observations and GCMs is consistent with changes in the moisture flux. We propose two cloud feedbacks acting within extratropical cyclones: a negative feedback driven by Clausius–Clapeyron increasing water vapor path (WVP), which enhances the amount of water vapor available to be fluxed into the cyclone, and a feedback moderated by changes in the life cycle and vorticity of cyclones under warming, which changes the rate at which existing moisture is imported into the cyclone. Both terms contribute to increasing LWP within the cyclone. While changes in moisture flux predict cyclone LWP trends in the current climate and the majority of changes in LWP in transient warming simulations, a portion of the LWP increase in response to climate change that is unexplained by increasing moisture fluxes may be due to phase transitions. The variability in LWP within cyclone composites is examined to understand what cyclonic regimes the mixed-phase cloud feedback is relevant to. At a fixed WCB moisture flux cyclone LWP increases with increasing sea surface temperature (SST) in the half of the composite poleward of the low and decreases in the half equatorward of the low in both GCMs and observations. Cloud-top phase partitioning observed by the Atmospheric Infrared Sounder (AIRS) indicates that phase transitions may be driving increases in LWP in the poleward half of cyclones

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.</p

Comparison of the sliding wear behaviour of self-mated HIPed Stellite 3 and Stellite 6 in a simulated PWR water environment

Cobalt-based alloys such as Stellite 3 and Stellite 6 are widely used to protect stainless steel surfaces in primary circuit nuclear reactor applications where high resistance to wear and corrosion are required. In this study, selfmated sliding wear of Stellite 3 and Stellite 6 consolidated by hot isostatic pressing were compared. Tests were performed with a pin-on-disc apparatus enclosed in a water-submerged autoclave environment and wear was measured from room temperature up to 250 °C (a representative pressurized water reactor environment). Both alloys exhibit a microstructure of micron-sized carbides embedded in a cobalt-rich matrix. Stellite 3 (higher tungsten and carbon content) contains M7C3 and an eta (η) -carbide whereas Stellite 6 contains only M7C3. Furthermore, the former has a significantly higher carbide volume fraction and hardness than the latter. Both alloys show a significant increase in the wear rate as the temperature is increased but Stellite 3 has a higher wear resistance over the entire range; at 250 °C the wear rate of Stellite 6 is more than five times that of Stellite 3. There is only a minimal formation of a transfer layer on the sliding surfaces but electron backscatter diffraction on cross-sections through the wear scar revealed that wear causes partial transformation of the cobalt matrix from fcc to hcp in both alloys over the entire temperature range. It is proposed that the acceleration of wear with increasing temperature in the range studied is associated with a tribocorrosion mechanism and that the higher carbide fraction in Stellite 3 resulted in its reduced wear rate compared to Stellite 6

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma.

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma [version 1; peer review: 1 approved, 2 approved with reservations]

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH.  Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement.  Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework.  The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents.  Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi