bluuebunny/crossref_metadata_2025 huggingface dataset:
Predation by grey wolf on wild ungulates and livestock in centralIran
Authors: Hosseini‐Zavarei F. , Farhadinia M. S. , Beheshti‐Zavareh M. , Abdoli A.
Published: March 2013

The grey wolfCanis lupushas the largest geographical range of large mammalian carnivores in westAsia. However, it is one of the least studied species, particularly inIran. Feeding ecology is a critical aspect of predator ecology and has important implications when formulating species and ecosystem management strategies. Also, predation on livestock is a crucial cause of wolf–human conflicts throughout the wolf's global range. Accordingly, we investigated the diet of the grey wolf inGhamishlou, an area with high population densities of wild and domestic ungulates in centralIran, betweenJuly 2007 andApril 2009. Scat analysis indicated that livestock was the single most important prey species for wolves with 47.1% of total biomass consumed, whereas Persian gazelle comprised 27.0% and wild sheep 15.9%. Wild kills were significantly skewed towards males relative to their proportion in the population, and were mainly preyed on during post‐rutting months. Based on interview surveys, less than 1% of mean herd size was lost to wolf depredation; however, almost six times more died from non‐depredation causes during each winter. We concluded that the high occurrence of livestock in the wolves' diet is mainly because of scavenging rather than depredation; however, owing to high pressure of wolves on local herds during non‐winter seasons in other areas with depleted prey populations, local people dislike wolves and try to eradicate them. Finally, management implications are discussed and solutions are recommended.
Optimization of transit strategies while diving in foraging king penguins
Authors: Hanuise N. , Bost C.‐A. , Handrich Y.
Published: March 2013

Optimal foraging theories predict that air‐breathing, diving foragers should maximize time spent at feeding depths, and minimize time spent travelling between surface and depth (transits). The second part of this hypothesis was tested in free‐ranging king penguins Aptenodytes patagonicus using measurements of vertical speed, swimming speed, body angle and flipper stroke frequency during transits in relation to an index of foraging success (number of wiggles), during the bottom and the ascent phases of the dive. We found that, except for flipper stroke frequency, all measured variables increased with diving depth and foraging activity. The change in vertical speed was driven mainly by a change in body angle and a slight change in swimming speed. These results suggest a shortening of transit duration in response to increased foraging activity. Whereas the time spent commuting between the surface and foraging depths was reduced when foraging activity was high, vertical speed was only at its maximum over a small part of both ascent and descent phases of the dive. Within the first 10 m of descent, vertical speed increased with maximum dive depth and an index of foraging activity, suggesting that penguins anticipated their diving depth and foraging activity. Our results show that foraging king penguins adjust their diving behaviour in response to both diving depth and foraging activity. Further studies should consider ecological, physiological or mechanical constraints as factors that may limit foraging optimization.
Context‐dependent social behaviour: testing the interplay between season and kinship with raccoons
Authors: Robert K. , Garant D. , Vander Wal E. , Pelletier F.
Published: March 2013

Animals are organized in a wide range of social structures. Variability in sociality is found both within and among species and is influenced by extrinsic and intrinsic factors. Here we examine the interplay between social behaviour, social thermoregulation and kinship in shaping sociality. We do so for raccoonProcyon lotor, a species suggested to exhibit flexible sociality – from solitary to highly gregarious. We hypothesize that this variation in sociality is driven by environmental conditions, relatedness and their interaction. We used proximity‐logging telemetry collars to quantify intraspecific encounters and infer social behaviour among female raccoons. We tested the effect of extrinsic (season and temperature) and intrinsic (pairwise relatedness) variables on proximity. We monitored 15 female raccoons fromApril 2010 toAugust 2011, which composed 120 dyads. Daily proximal encounter rate was eight times higher in winter (mean ± standard error: 24.1 ± 4.2) than in summer (3.0 ± 2.6) and daily encounter duration was 12 times longer in winter (558.8 ± 130.3 s) than in summer (43.4 ± 33.1 s). We also found a negative relationship between ambient temperature and proximal encounter rate, which suggested that female raccoons use social thermoregulation as a mechanism to reduce energetic costs in cold environments. Finally, we found that relatedness was positively correlated with encounter rate during summer and winter. Our results suggest that ecological factors, such as seasonality, may affect the evolution of sociality in temperate species, and that the evolution of social thermoregulation in raccoons is likely driven by kin selection.
Lipids and addiction: how sex steroids, prostaglandins, and cannabinoids interact with drugs of abuse
Authors: Leishman Emma , Kokesh Kevin J. , Bradshaw Heather B.
Published: March 2013

Lipidomics aims to identify and characterize all endogenous species of lipids and understand their roles in cellular signaling and, ultimately, the functioning of the organism. We are on the cusp of fully understanding the functions of many of the lipid signaling systems that have been identified for decades (e.g., steroids, prostaglandins), whereas our understanding of newer lipid signaling systems (e.g., endocannabinoids,N‐acyl amides) still lags considerably behind. With an emphasis on their roles in the neurophysiology of addiction, we will examine three classes of lipids—sex steroids, prostaglandins, and cannabinoids—and how they work synergistically in the neurocircuitry of motivation. We will first give a brief overview of the biosynthesis for each class of lipid and its receptors, and then summarize what is known about the collective roles of the lipids in cocaine and alcohol abuse. This approach provides a novel view of lipid signaling as a class of molecules and their synergistic roles in addiction.
Predictors of Advanced Lead Extraction Based on a Systematic Stepwise Approach: Results from a High Volume Center
Authors: MAZZONE PATRIZIO , TSIACHRIS DIMITRIS , MARZI ALESSANDRA , CICONTE GIUSEPPE , PAGLINO GABRIELE , SORA NICOLETA , SALA SIMONE , VERGARA PASQUALE , GULLETTA SIMONE , BELLA PAOLO DELLA
Published: March 2013

Background

Lead extraction (LE) techniques have evolved from simple traction to extraction with dilators and powered sheaths with very high success rates. On the basis of the systematic implementation of a stepwise approach, we aimed to identify those characteristics that can predict the need for advanced LE techniques.

Methods

Between April 2005 and March 2012, 208 consecutive LE procedures were performed and 456 leads were extracted using an initial superior approach. Advanced techniques for LE (step 4 according to our stepwise approach) were used in 122 patients (58.7%).

Results

Younger patient age (odds ratio [OR] = 0.963, P = 0.002), longer duration of the initial implantation (OR = 1.013, P = 0.002), the number of extracted leads (OR = 2.184, P < 0.001), and the presence of right ventricular defibrillator leads (OR = 2.144, P = 0.049) independently predicted the necessity of using step 4 in multivariate analysis. A prediction tool was created taking into account four categorical variables derived even from Receiver Operating Curve analysis of quantitative characteristics (age < 70.7 years, implant duration > 37 months, extraction of at least two leads, one of them being a defibrillator lead). The absence of all the four characteristics was accompanied by 0% positive predictive value for the requirement of step 4 for LE, whereas the coexistence of all four risk factors is characterized by 87% requirement of advanced LE.

Conclusion

In most of the patients with indication for LE, use of a powered sheath extraction is necessary in order to obtain clinical success. We have identified four patient and lead characteristics that may help the operator plan the means of extraction.
Reducing Patient Radiation Dosage during Pediatric SVT Ablations Using an “ALARA” Radiation Reduction Protocol in the Modern Fluoroscopic Era
Authors: GELLIS LAURA A. , CERESNAK SCOTT R. , GATES GREGORY J. , NAPPO LYNN , PASS ROBERT H.
Published: March 2013

Background

Ablation for supraventricular tachycardia (SVT) relies upon fluoroscopy (fluoro), which exposes the patient and staff to ionizing radiation. The objective of this work was to present a new “ALARA—As Low As Reasonably Achievable” protocol with alterations to fluoroscopic x‐ray parameters to reduce dose without an electroanatomical (EAM) approach.

Methods

All patients <21 years of age undergoing ablation of SVT at our institution from June 2011 to April 2012 were included. EAM was not utilized in any case. An ALARA protocol of low frame rates (2 or 3 fps), low fluoro dose/frame (10–18 nGy/frame), and other techniques aimed at reducing use of fluoroscopy were employed. Demographics, procedural, and radiation data were analyzed.

Results

Forty‐two patients underwent ablation and were studied. Median age was 14.1 years (range 4.8–21.1 years), weight was 51 kg (range 18.2–75 kg), and body surface area was 1.51 m2 (range 0.72– 1.94 m2). Seventeen (41%) had Wolff‐Parkinson‐White syndrome, 14 (33%) atrioventricular nodal reentrant tachycardia, and 11 (26%) concealed pathways. Median procedural time was 114 minutes (57–246 minutes). Median dose area product (DAP) for posterioanterior and lateral fluoroscopy was 343.2 uGym2 (range 38.2–3,172 uGym2); the median air Kerma product (K) was 45.4 mGy (range 6.7–567.5 mGy). DAP and K are lower than prior data from EAM and fluoroscopy techniques. The acute success rate was 95%; no procedural complications.

Conclusions

An ALARA protocol for ablation of SVT reduced radiation to below levels previously reported for combined EAM/fluoro approaches. Success rates were excellent with no complications and without the costs of EAM.
Stimulating whole saliva affects the response of antimicrobial proteins to exercise
Authors: Allgrove J. E. , Oliveira M. , Gleeson M.
Published: March 2013

This study investigated the salivary secretion rates of antimicrobial proteins in response to prolonged, exhaustive exercise in both stimulated (STIM) and unstimulated (UNSTIM) saliva flow sample methods. Twenty‐four trained men cycled for 2.5 h at 60% and then to exhaustion at 75% . Timed collections of whole saliva were made before exercise, mid‐exercise, at the end of the moderate exercise bout and post‐exhaustive exercise. After each UNSTIM collection, a STIM sample was collected following chewing flavored gum for 1 min. Saliva was analysed for lysozyme, α‐amylase and salivary immunoglobulin A (s‐IgA), and secretion rates were calculated. Saliva flow was 156% higher in STIM compared with UNSTIM (P < 0.001) and decreased with exercise in STIM only (P < 0.001). Exercise increased lysozyme and α‐amylase levels and secretion rates were 144% higher and 152% higher in STIM compared with UNSTIM for lysozyme and α‐amylase, respectively (all P < 0.001). S‐IgA concentration (P < 0.05) and secretion rate (P < 0.001) increased with exercise but were both lower in STIM compared with UNSTIM (P < 0.001). In conclusion, a STIM saliva flow collection during exercise by chewing flavored gum increased the quantity of saliva and the secretion of lysozyme and α‐amylase, but had a limited impact on the secretion of s‐IgA.
The South American ancestry of the North Patagonian Massif: geochronological evidence for an autochthonous origin?
Authors: Rapalini Augusto E. , de Luchi Mónica López , Tohver Eric , Cawood Peter A.
Published: March 2013

New U‐Pb and 40Ar/39Ar age data from deformed and undeformed granitoids of the North Patagonian Massif establish the presence of Early Cambrian and widespread Ordovician magmatism in northern Patagonia. These data suggest that the Pampean (Cambrian) and Famatinian (Ordovician) magmatic belts of the Sierras Pampeanas are continuous into Patagonia. SHRIMP U‐Pb age spectra from detrital zircons of Cambro‐Ordovician metasedimentary rocks show patterns very similar to those from equivalent units of the Pampia block, over 500 km farther north. These results suggest that the North Patagonian Massif was likely part of the South American margin of Gondwana in the early Palaeozoic and strongly argue in favour of an authochtonous or para‐autochthonous origin for this block.
Spatial Effects in Industrial Location Choices: Industry Characteristics and Urban Accessibility
Authors: Artal‐Tur Andrés , Navarro-Azorín José Miguel , Alamá‐Sabater María Luisa , Briones‐Peñalver Antonio Juan
Published: March 2013

In this paper we study how neighbourhood‐related spillovers affect location choices of manufacturing firms at a local level. A spatial Dirichlet‐multinomial regression model is applied to 90,000 new establishments of the Spanish Mediterranean Axis. Empirical findings show that spatial spillovers play an important role, together with traditional explanatory factors, in driving decisions of companies. Their size and scope depends on two main issues, the specific characteristics of the manufacturing industry the firm belongs to, and the accessibility of the urban environment where the firm is located.
Mixed Neighbourhoods: Effects of Urban Restructuring and New Housing Development
Authors: Boschman Sanne , Bolt Gideon , Van Kempen Ronald , Van Dam Frank
Published: March 2013

Many European countries use mixed housing policies to decrease the spatial concentration of low‐income households. Also in the Netherlands, social housing in deprived neighbourhoods is demolished and replaced by more expensive dwellings. The idea is that these new dwellings attract higher‐income groups to urban restructuring neighbourhoods. At the same time, however large numbers of relatively expensive dwellings have been built on greenfield locations. This leads to a dilemma: will higher‐income households choose housing in deprived neighbourhoods, while attractive new housing on greenfield locations is available? This study shows that urban restructuring attracts higher‐income households to mixed tenure developments in deprived neighbourhoods, even when competing with greenfield development. Nevertheless, another process is also taking place: especially in urban regions with extensive greenfield development; there is a significant outflow of higher‐income households from deprived neighbourhoods. The net result is an increasing concentration of low‐income households in deprived neighbourhoods.
Ursodeoxycholic acid attenuates colonic epithelial secretory function
Authors: Kelly Orlaith B. , Mroz Magdalena S. , Ward Joseph B. J. , Colliva Carolina , Scharl Michael , Pellicciari Roberto , Gilmer John F. , Fallon Padraic G. , Hofmann Alan F. , Roda Aldo , Murray Frank E. , Keely Stephen J.
Published: March 2013

Key points

Although diarrhoeal diseases represent a significant health and economic burden to society, therapeutic options remain limited.

While several bile acids are known to stimulate epithelial Cl− secretion, the major driving force for fluid secretion in the intestine, the effects of ursodeoxycholic acid (UDCA) on epithelial transport function are not well described.

We report that in contrast to other bile acids, UDCA exerts anti‐secretory actions on colonic epithelial cells in vitro.

In contrast, in vivo administration of UDCA enhances epithelial secretory function, an affect we ascribe to being due to its bacterial metabolism to lithocholic acid. In keeping with this hypothesis, in vivo administration of a metabolically stable analogue of UDCA, 6α‐methyl‐UDCA, was anti‐secretory.

Our findings reveal novel anti‐secretory actions of UDCA and suggest that metabolically stable analogues of bile acid may be useful for development as a new class of anti‐diarrhoeal drug.

Abstract  Dihydroxy bile acids, such as chenodeoxycholic acid (CDCA), are well known to promote colonic fluid and electrolyte secretion, thereby causing diarrhoea associated with bile acid malabsorption. However, CDCA is rapidly metabolised by colonic bacteria to ursodeoxycholic acid (UDCA), the effects of which on epithelial transport are poorly characterised. Here, we investigated the role of UDCA in the regulation of colonic epithelial secretion. Cl− secretion was measured across voltage‐clamped monolayers of T84 cells and muscle‐stripped sections of mouse or human colon. Cell surface biotinylation was used to assess abundance/surface expression of transport proteins. Acute (15 min) treatment of T84 cells with bilateral UDCA attenuated Cl− secretory responses to the Ca2+ and cAMP‐dependent secretagogues carbachol (CCh) and forskolin (FSK) to 14.0 ± 3.8 and 40.2 ± 7.4% of controls, respectively (n= 18, P < 0.001). Investigation of the molecular targets involved revealed that UDCA acts by inhibiting Na+/K+‐ATPase activity and basolateral K+ channel currents, without altering their cell surface expression. In contrast, intraperitoneal administration of UDCA (25 mg kg−1) to mice enhanced agonist‐induced colonic secretory responses, an effect we hypothesised to be due to bacterial metabolism of UDCA to lithocholic acid (LCA). Accordingly, LCA (50–200 μm) enhanced agonist‐induced secretory responses in vitro and a metabolically stable UDCA analogue, 6α‐methyl‐UDCA, exerted anti‐secretory actions in vitro and in vivo. In conclusion, UDCA exerts direct anti‐secretory actions on colonic epithelial cells and metabolically stable derivatives of the bile acid may offer a new approach for treating intestinal diseases associated with diarrhoea.
Polarity control and transport properties of Mg-doped (0001) InN by plasma-assisted molecular beam epitaxy
Authors: Choi Soojeong , Wu Feng , Bierwagen Oliver , Speck James S.
Published: March 2013

The authors report on the plasma-assisted molecular beam epitaxy growth and carrier transport of Mg-doped In-face (0001) InN. The 1.2 μm thick InN films were grown on GaN:Fe templates under metal rich conditions with Mg concentration from 1 × 1017/cm3 to 3 × 1020/cm3. A morphological transition, associated with the formation of V-shape polarity inversion domains, was observed at Mg concentration over 7 × 1019/cm3 by atomic force microscopy and transmission electron microscopy. Seebeck measurements indicated p-type conductivity for Mg-concentrations from 9 × 1017/cm3 to 7 × 1019/cm3, i.e., as it exceeded the compensating (unintentional) donor concentration.
Susceptibility Testing of Extensively Drug-Resistant and Pre-Extensively Drug-Resistant Mycobacterium tuberculosis against Levofloxacin, Linezolid, and Amoxicillin-Clavulanate
Authors: Ahmed Imran , Jabeen Kauser , Inayat Raunaq , Hasan Rumina
Published: March 2013

Pakistan is a high-burden country for tuberculosis (TB). The emergence and increasing incidence of extensively drug-resistant (XDR) TB has been reported in Pakistan. Similarly, the prevalence of multidrug-resistant TB infections with fluoroquinolone resistance (pre-XDR) is also increasing. To treat these infections, local drug susceptibility patterns of alternate antituberculosis agents, including levofloxacin (LVX), linezolid (LZD), and amoxicillin-clavulanate (AMC), is urgently needed. The aim of this study was to determine the susceptibility frequencies of drug-resistant (DR)
Mycobacterium tuberculosis
against LVX, LZD, and AMC. All susceptibilities were determined on Middlebrook 7H10 agar. A critical concentration was used for LVX (1 μg/ml), whereas MICs were determined for LZD and AMC.
M. tuberculosis
H37Rv was used as a control strain. A total of 102
M. tuberculosis
isolates (XDR,
n
= 59; pre-XDR,
n
= 43) were tested. Resistance to LVX was observed in 91.2% (93/102). Using an MIC value of 0.5 μg/ml as a cutoff, resistance to LZD (MIC ≥ 1 μg/ml) was noted in 5.9% (6/102). Although the sensitivity breakpoints are not established for AMC, the MIC values were high (>16 μg/ml) in 97.1% (99/102). Our results demonstrate that LZD may be effective for the treatment of XDR and pre-XDR cases from Pakistan. High resistance rates against LVX in our study suggest the use of this drug with caution for DR-TB cases from this area. Drug susceptibility testing against LVX and AMC may be helpful in complicated and difficult-to-manage cases.
Azathioprine hypersensitivity presenting as septic shock with encephalopathy
Authors: James Antonia , Blagojevic Jelena , Benham Stuart W , Cornall Richard , Frater John
Published: March 2013

We present a case of azathioprine hypersensitivity presenting as septic shock with associated encephalopathy. The patient was presented with rapid onset of fever, hypotension, confusion and a rapidly declining conscious level. He was admitted to the intensive care unit where he received numerous invasive investigations and treatments with broad-spectrum antibiotics, antivirals and antifungals. All microbial cultures were negative. The patient—consistent with azathioprine hypersensitivity—made a spontaneous recovery after 7 days. The case shows that a time line of drug initiation is a key part of the medical history and consideration of azathioprine hypersensitivity could avoid unnecessary interventions and excessive antimicrobial use.
Kosovo 1999 - A Surgical Template for Modern Conflict
Authors: Parker Paul J
Published: March 2013

246 surgical operations were performed in a UK Field Hospital over an eight month period during Op AGRICOLA in 1999. Whilst there were many injuries caused by military weaponry, nonconflict related injuries were also common. Sixteen laparotomies were performed, nine for mine and gunshot injuries, seven were for ‘peacetime’ causes. Four extremity external fixators were applied - three after high energy transfer fragment wounds to bone and one after a road traffic accident. One pelvic external fixator was applied. Six limbs were amputated, three in one child. Eight split-skin grafts and three local flaps were performed. Wound debridements (including delayed primary suture), of which half were due to fragment and bullet wounds to non-vital structures, were the most common operation performed. Of the 246 consecutive operations analysed, 91 were performed solely by the orthopaedic surgeon. There were 29 combined cases where one surgeon actively assisted the other. 146 operations were performed on local civilians. A consultant orthopaedic surgeon and a consultant general surgeon along with experienced anaesthetic and operating theatre staff remains the combination best suited to provide medical support to future military operations of this kind.
Unfit for Further Service:Trends in Medical Discharge from the British Army 1861-1998
Authors: Bergman BP , Miller SAStJ
Published: March 2013

Military service requires individuals who are free from ill-health and who are physically and mentally robust, and throughout history those who have become unfit for service have been discharged on medical grounds. This paper uses published historical records to examine trends in the rate of discharge for six key conditions for the period 1861-1998 and to draw conclusions. In the late 19th and early 20th centuries, communicable diseases such as tuberculosis and syphilis were a major problem together with illdefined conditions such as “disordered action of the heart”. By the mid-20th century, psychiatric and gastrointestinal disorders had become the principal causes of medical discharge, whereas in the late 20th century, the majority of discharges resulted from injuries and musculoskeletal disorders. The pattern of conditions leading to medical discharge from the Army tends to mirror conditions which are prevalent at that time in the civilian population.
Small Fragment Wounds: Biophysics, Pathophysiology and Principles of Management
Authors: Hill PF , Edwards DP , Bowyer GW
Published: March 2013

Military surgical doctrine has traditionally taught that all ballistic wounds should be formally managed by surgical intervention. There is now, however, both experimental and clinical evidence supporting the nonoperative treatment of selected small fragment wounds. Low energytransfer wounds affecting the soft tissues, without neuro-vascular compromise and with stable fracture patterns, may be suitable for early antibiotic treatment. The management of ballistic wounds to the gastrointestinal tract requires surgical intervention but, advances in the treatment of these wounds, especially those involving the colon, may allow more effective treatment with a reduced morbidity.
Organisation and design of regular field hospitals
Authors: Bricknell MCM
Published: March 2013

The organisation and design of field hospitals within the British Army has been under review since the Gulf War. This paper discusses principles for the organisation and design of field hospitals and makes suggestions for further development. The paper describes the deployment of field hospitals from a 25 bed hospital troop up to a 200 bed field hospital.
Occupational Health Development in the Army
Authors: Owen JP
Published: March 2013

Occupational Health (OH) in the Army is provided as part of an integrated primary healthcare service. When compared to the International Labour Organisation criteria for the provision of OH, it can be seen that the Army provides all of the OH elements expected in a large national organisation. However, there is a need to enhance the clinical element of the service and to provide a focus for implementing OH policy at unit level. The use of qualified OH nurses based at GP group practices and providing a visiting service to units would rectify this balance as this would enable workplace assessments to be carried out on a regular basis, enhance the ability to carry out occupational health assessments and facilitate health surveillance data collection. The result would be the improved delivery of OH services to Army personnel, thus helping to maximise the number of soldiers and officers fit to carry out their military duties.
The Dangers of Sport on an Operational Deployment
Authors: Clasper J C
Published: March 2013

This study, a retrospective review of the orthopaedic outpatient work from a multinational hospital in Bosnia, further confirms the dangers of sport on an operational tour. Sports injuries were shown to be a major cause of morbidity, affecting both the operational effectiveness of the force and also resulting in a number of career-threatening injuries. In particular, football was shown to be the most common cause of injury and the wisdom of allowing this sport during operational tours must be questioned.
Trismus due to bilateral mandibular coronoid hyperplasia.
Authors: Gibbons A J , Byrne A J , Key S J
Published: March 2013

Bilateral mandibular coronoid hyperplasia is a rare cause of restricted mouth opening. Diagnosis of the condition prior to general anaesthetic is essential, as oral intubation may be impossible. The reported case illustrates the role of computed tomography in assessment of the disorder and effective treatment by coronoidectomy.
Developing Evidence-Based Clinical Guidelines For Military Use: Case Study Of Smoking Cessation Guidelines
Authors: Croft A M , Geary K G , Irvine D , Brutus E C
Published: March 2013

Objective:

To develop evidence-based clinical guidelines on smoking cessation, for use throughout the British military.

Method:

A ten-member, multiprofessional smoking cessation working group met five times between October 2000 and July 2001 to develop targeted smoking cessation guidelines for use by military health professionals in the clinical setting. The guidelines were based on the best available scientific evidence at that time, mainly systematic review of controlled trials, and individual randomised trials.

Results:

The agreed military guidelines on smoking cessation were promulgated in July 2001. Three tiers of support were defined. Military health professionals have a key role as nonsmoking models and advocates, and should be trained to use ‘brief intervention’ at every clinical encounter with a military smoker. ‘Intermediate support’ (defined as a specialist service delivered by military health professionals who have undergone specific training and continuation training) is to be available at local level. The most heavily addicted military smokers will require referral to civilian smoking cessation clinics. Effective technologies for use at any one of the three levels of care are: nicotine skin patches, nicotine gum, nicotine lozenges and bupropion.

Conclusions:

These are the first ever clinical guidelines for military use which meet accepted modern quality criteria. Informal monitoring of the uptake of these guidelines between July 2001 to December 2001 suggests that they have been well received by military health professionals. An audit of their impact on smoking patterns within the UK Armed Forces will commence in 2002. The guidelines will be updated 5-yearly, or sooner.
Sexuality And Soldiery Combat & Condoms, Continence & Cornflakes
Authors: Palmer I
Published: March 2013

The results of a short sexual health study of 75 male soldiers undertaking humanitarian aid relief in Africa are presented in an historical context relating to sexuality and soldiery.
The Discovery Of Viral Hepatitis: A Military Perspective
Authors: Martin N A
Published: March 2013

Viral hepatitis is one of the most common infectious diseases and over the years the jaundice associated with it has been known by many names. Several viruses are now known to cause hepatitis in humans, but sixty years ago, these viruses were unknown. In the years before and during the Second World War, there emerged a significant understanding of the clinical and epidemiological nature of the disease due to the dedicated efforts of doctors and scientists around the world. By the end of the war years, the discrete entities of Hepatitis A and B had been identified and preventative measures were proving to be effective. However, the bane of viral hepatitis was far from being resolved.
Bioterrorism: Preparing For The Unthinkable
Authors: Alexander DA
Published: March 2013

Terrorism is not a new concept but our need to prepare for the effects of bioterrorism has achieved a particular urgency. The use of biological agents provides a new set of challenges to professional caregivers, emergency personnel and Governments. These agents are generally not readily identified through the senses, have delayed effects and have the power to generate fear and panic. They are also intended to demonstrate that Governments and other organisations are not able to protect their citizens and members.

What evidence there is suggests bioterrorist incidents have the potential to create higher levels of psychopathology than physical injury. Therefore, the authorities must identify and rehearse suitable methods of psychoprophylaxis and intervention.
Consensus Statement On The Early Management Of Crush Injury And Prevention Of Crush Syndrome
Authors: Greaves I , Porter K , Smith JE
Published: March 2013

Crush Syndrome remains rare in European practice. It is however common in areas of civil disorder and where the normal structures of society have given way to civil war or natural disaster. Western Doctors are becoming increasingly involved in such situations and there is no reason to believe that instances due to more conventional causes, such as collapse in the elderly or road traffic accidents will cease. For all these reasons it is important that clinicians who deal infrequently with crush syndrome have access to appropriate guidelines. This consensus report seeks to provide such advice.
The Experience Of The Intensive Care Unit In A British Army Field Hospital During The 2003 Gulf Conflict
Authors: Roberts MJ , Fox MA , Hamilton-Davies C , Dowson S
Published: March 2013

Over the last few years the Surgeon General’s Department has overseen a major update in equipment scales for medical units in the field; anaesthesia and intensive care. This is to meet the aspiration of the Defence Chiefs, that injured servicemen on active service should receive the same standard of care as available in the United Kingdom.

This paper discusses the experiences of the Intensive Care Unit operating within a Field Hospital both during the initial war fighting phase and subsequent peace keeping phase of the 2003 Gulf conflict (OP TELIC). Observations are made on patient activity, treatment strategy, and equipment adequacy.
Management Of A Snake Bite In The Field
Authors: Krysa-Clark J , Lewis S , Waterworth TA
Published: March 2013

We present a case of an 18-year-old British soldier who was bitten by an unidentified snake whilst stationed on the Iran/Iraq border. He was evacuated to the closest Role 2+ medical facility. Within 2 days he had developed bruising and a haematoma at the bite site. An improvised measure of clotting status, the bleeding time, was employed, showing that his blood was severely anticoagulated. He was transferred to the Field Hospital where coagulation screen revealed a DIC picture. He required 5 units of cryoprecipitate and 2 doses of antivenom. This case report demonstrates the need for prompt evacuation to a Role 3 facility in such cases, whether symptomatic or not.
Early Failure Of External Fixation In The Management Of War Injuries
Authors: Clasper J C , Phillips S L
Published: March 2013

Objective

To review external fixation in the management of war injuries.

Method

We prospectively followed up 15 external fixators (14 patients) applied in the management of war injuries. All these patients were treated at 202 Field Hospital during the 2003 Gulf Conflict.

Results

Of the 15 fixators, 13 (86.7%) required early revision or removal due to complications of the injury or the fixator. Instability was a problem with 10 fixators (67%), pin loosening was noted with 5 fixators (33%) involving twelve pins, and a significant pin track infection developed at 14 pin sites (3 fixators – 20%), which failed to resolve despite intravenous antibiotics.

Conclusions

This study demonstrates a very high early complication rate of external fixation in the management of military injuries and cautions against its universal acceptance. If used, consideration must be given to the optimum time of frame application, whether at the time of initial debridement or at a later operation, and the optimal frame design, which will depend on the specific bone and fracture pattern. Pin site care must also be considered, particularly with the restrictions imposed by the military environ-ment.
Forward Surgery On Operation Telic – Iraq 2003
Authors: Parker P J , Adams S A , Williams D , Shepherd A
Published: March 2013

Two Air Assault Surgical Groups (AASGs) from 16 Close Support Medical Regiment deployed to Kuwait on Operation Telic in February 2003. Each AASG was comprised of a four-table resuscitation facility, a two table FST and a twin-bedded ITU facility. An A+E Consultant and nurse, an experienced radiographer and laboratory technician with two further RGNs and CMTs provided resuscitation support. Each FST had an orthopaedic and a general surgeon, two anaesthetists and eight operating department practitioners. Further equipment consisted of a Polymobil 111 X-ray unit, a Sonosite 180 ultrasound scanner and an ISTAT gas, haematocrit and electrolyte analyser. 100 units of mixed blood were carried by each AASG.

Fifty-one surgical procedures were performed on thirty one patients. Twenty one of these patients were Iraqi prisoners of war or civilians. Seventeen wound debridements, five amputations, five laparotomies, four insertions of Denham pins with Thomas splintage for femoral fracture, three external fixations and one axillary artery repair formed the basis of the major cases undertaken. The first field use of activated factor VII by the British Army was successful in the resuscitation of a patient with exsanguinating haemorrhage after an open-book (APC-III) pelvic fracture and a ruptured intrapelvic haematoma. The other cases included eleven manipulations under anaesthetic/application of plaster and four finger terminalisations.

Forward military surgery has a continued role to play on the modern fast moving battlefield. 16 Close Support Medical Regiment normally supports 16 Air Assault Brigade with its remit for expeditionary operations and SF support. Its experience on Op Telic should influence planning for future deployment.
Human Bite Injury In North East England – The Impact Of Alcohol Intake On A Mode Of Violent Assault
Authors: Eardley WGP , Harrison M H , Coady MSE
Published: March 2013

Ninety-two retrospective cases of human bite injury referred to a Plastic Surgery department are presented. Particular emphasis is placed on the relationship of alcohol intake to these injuries, their distribution and subsequent management. A review of the literature is conducted.

The human bite is a leisure time injury of the young single male in the North East. It has been shown that there is a clear link to alcohol and in particular weekend drinking. Prompt operative intervention and wounds located at the head and neck have been shown to be associated with a decreased risk of subsequent infection, which reflects findings in the earlier literature.

Fifteen cases were infected. One was the result of a postoperative complication. The remainder were infected on admission. The majority of infected cases were upper limb bites and were associated with a delayed presentation.
Ruptured Distal Biceps In Military Personnel
Authors: Hargrove R , Griffiths DE , Clasper J
Published: March 2013

Early operative repair is the currently accepted treatment of distal biceps rupture. However, we describe 6 patients (with 7 ruptures), 5 of whom are in the armed forces with distal biceps tendon ruptures who, as a result of delays in presentation, were treated non-operatively. The subsequent clinical success of these patients (with three excellent, three good and one poor result), has led us to question whether the role of non-operative treatment has been underestimated within the orthopaedic, military and sports medicine literature. The more rapid rehabilitation of conservatively treated ruptures may well have implications for treatment of armed forces personnel.
The Organisation of the RAMC during the Great War
Authors: Atenstaedt RL
Published: March 2013

Introduction

At the 90 year anniversary of the Battle of the Somme, it is important to remember the members of the RAMC who served in the Great War, especially the more than one thousand Medical Officers who gave their lives.

Leadership

The RAMC during the First World War was a Corps led by some able officers such as Sir Arthur Sloggett in France and Sir Alfred Keogh in London. Sir Douglas Haig was in overall command, his leadership style impacting on the RAMC.

Recruitment of MOs

There were problems in filling the ranks of the Corps, both before the conflict, as well as well as during the War, and a significant number of civilian medical practitioners were recruited to the RAMC. Shortages were only really addressed when the Americans joined the conflict.

Training of Civilian MOs

The great need for MOs meant that there was little time for formal training of civilian MOs and many felt unsuited for war work. This was recognised by the authorities, who gradually set up centres of instruction.

Work of RMOs

The workhorse of the organisation was the Regimental Medical Officer, who had an important role in disease prevention and the conservation of manpower, in a type of conflict (trench) that required a ready supply of personnel. Although an important role, some doctors found the job frustrating.

Casualty Evacuation

During the War, the RAMC managed to improvise an efficient system for handling casualties, the aim to give speedy treatment and to return the men to the front in the shortest possible time.

Conclusions

The RAMC during the Great War was a highly structured and efficient organisation, geared towards maximising its available manpower, important in trench warfare.
Assessing Airway Patency And Breathing In NBC Category 4R - The RG Method.
Authors: Tong JL , Taylor A , House J , Smith JE
Published: March 2013

Introduction

Confirming airway patency and the presence of breathing has significant limitations when both the casualty and medical personnel are in NBC category 4R. In casualties with limited signs of breathing, IPE may adversely affect the efficiency of clinical assessment, and when the triage sieve is used this could result in the misdiagnosis of death. This manuscript describes and evaluates the Respirator-Glove (RG) method, of assessing airway patency and breathing in NBC category 4R.

Methods

Amedical examination glove was fitted over the primary speech module of the S10 NBC respirator of a volunteer casualty dressed in 4R. Two groups were studied; the first used an intact glove the second used a glove minus one finger. Breathing patterns A, B and C, representing normal breathing, hypoventilation and apnoea respectively, were randomly performed by the casualty for 15 seconds. A blinded observer recorded the glove inflation and movement and using these signs determined if breathing was present.

Results

All of the randomly performed breathing pattern simulations were correctly identified in both groups, with glove inflation only occurring during exhalation. In the perforated glove group, the large expiratory air leak through the hole limited the development of continuous positive airway pressure and the respirator seal wasmaintained. In the non-perforated glove group the respirator seal was compromised. No difficulty was encountered attaching the gloves to the respirator speech module.

Discussion

As an aid to clinical examination, the Respirator-Glove (RG) method provides a reproducible visual assessment of airway patency and spontaneous ventilation in unconscious 4R casualties. It can be utilised at any point in the evacuation chain, may improve the identification of T1 casualties and could reduce the risk of death being misdiagnosed. The efficiency of clinical assessment in 4R will improve by introducing the RG method into CBRN medical training programmes.
Haematology
Authors: Fletcher A
Published: March 2013

This article examines some of the recent advances in haematology in both themalignant and non-malignant areas of the speciality. Improvements in survival rates after effective chemotherapy now present the haematologist with the challenges of how to minimise therapeutic side effects without affecting outcome and the role of stratification as well as specific monitoring of enzyme activity are discussed. Many treatments for haematological malignancy have significant late effects which are only now becoming a problem - what these are, how to identify them and how they can be limited are examined. The increased knowledge of the altered pathways that lead to malignancy has allowed a whole slew of new therapies to be developed often with excellent results. The role of new iron chelation agents and the so called ‘universal haemostatic agent’ activated factor VII are also discussed.
Stability operations and the implications for military health services support
Authors: Bricknell Martin CM , Hanhart N
Published: March 2013

This paper examines the implications of the new military campaign type – Stability Operations – on military health service support. The paper uses the format of the medical estimate process and shows how the health service support planning factors of Mission Analysis; Ground; Enemy forces; Friendly forces; Time and Space; Security; Casualty Estimate; Medical Command, Control, Communication, Computers and Information (C4I); Medical Capabilities; Medical Force Protection; Medical Logistics; and Medical CBRN are affected by this change. The paper also identifies two new roles for military medical services, assistance to security sector reform and assistance to reconstruction and development. These two new roles will be discussed more fully in later papers.
Health Risk Management Matrix - A Medical Planning Tool
Authors: Bricknell MCM , Moore GW
Published: March 2013

This paper describes the Health Risk Management Matrix. This is a planning tool, developed at the Defence Medical Services Training Centre, to teach students how to develop and write a Medical Force Protection Plan. The tool covers 5 stages: hazard identification, identification of the population at risk, risk assessment, control measures (divided into information training and policy, medical counter-measures, and treatment) and monitoring activities. The paper provides a worked example using malaria as a hazard.
Is Methoxyflurane a Suitable Battlefield Analgesic?
Authors: McLennan Jacqueline
Published: March 2013

Anecdotal reports of mechanical failure of morphine autojets have triggered a review of possible alternatives. Methoxyflurane is one such alternative already widely used by the Australian and New Zealand Defence Forces. The potential benefits and likely significant drawbacks of methoxyflurane are reviewed with the aim of stimulating discussion.
Lisinopril-Induced Acute Pancreatitis
Authors: Brown KV , Khan A Z , Paterson I M
Published: March 2013

Drugs are an uncommon but well-recognised cause of acute pancreatitis and new agents of drug-induced pancreatitis continue to be reported. We describe only the 10th reported case of lisinopril-induced pancreatitis in a young female patient.
Use of Nasogastric Tubes in Trauma Patients – A Review
Authors: Spurrier EJ , Johnston AMcD
Published: March 2013

Traditionally, suspected basal skull fractures have been considered a relative contra-indication to inserting a nasogastric tube (NGT). In patients with basal skull fractures the Advanced Trauma Life Support protocol recommends that an orogastric tube (OGT) be inserted rather than a nasogastric tube (NGT). This article reviews the available literature. We conclude that in patients with suspected or confirmed basal skull fractures numerous case reports confirm that nasogastric tube insertion may lead to intracranial placement which, although the causal relationship is unclear, is associated with patient death.
Management of Shoulder Instability in a Military Population
Authors: Pimple MK , DaCosta A , Clasper JC
Published: March 2013

Objectives

Recurrent instability is common after shoulder dislocation in the young, particularly those engaged in physical jobs or sport. The management of recurrent traumatic shoulder instability is predominantly operative. However, the best method of surgery i.e. open or arthroscopic is still a matter of debate. We have developed an algorithm to decide on the choice of surgery and the aim of this study is to report this and compare the two different groups of military patients.

Methods

A retrospective review of all shoulder stabilisations performed on military personnel, by a single surgeon, between August 2004 and August 2005 at a district general hospital serving both military and civilian population was undertaken. The presentation, clinical and operative findings were noted and compared in the groups treated by arthroscopic or open stabilisation.

Results

Using our protocol 39 shoulder stabilisations were performed in military personnel. Of the shoulders, 25 (64%) underwent arthroscopic and 14 (36%) underwent open stabilisation. The indication for surgery was more than 2 episodes of shoulder dislocation. Open surgery was found to be more common in those who had their first dislocation at a younger age. Bilateral shoulder laxity was the most common indication to choose the open method. Both open and arthroscopic stabilisation gave good results in the high demand military population. Only one patient had recurrent instability after arthroscopic procedure. However, this was not statistically significant when compared with open stabilisation.
D-Day on Board a Tank Landing Ship: Meat, Cheese and Blood Transfusion
Authors: Demetriades Andreas K , Gavalas M C , Ryan J
Published: March 2013

Tank Landing Ships were used as evacuation station hospitals during D-Day of World War Two. This historical vignette describes how difficulties were overcome in blood transfusion and trauma surgery aboard these ships. Their place in the evacuation chain is discussed in relation to previous experiences in military medicine.