bluuebunny/crossref_metadata_2025 huggingface dataset:
A Survey of Primary Health Care Provision at a Forward Operating Base in Afghanistan During Operation HERRICK 10
Authors: Hawksley O J , Jeyanathan J , Mears K , Simpson R
Published: March 2013

Objectives

To record and discuss patient morbidity treated in a Forward Operating Base in Afghanistan and explore who delivers the care.

Methods

Prospective case series of all patients presenting to the Regimental Aid Post during a summer tour of Afghanistan.

Results

1903 episodes of care were delivered over a 6-month period in 2009. Afghan patients represented 32.8% of all cases seen. The majority of cases were related to primary care. The most common types of presentations were dermatological, other general medical conditions, other injuries and disorders of the digestive tract. Combat Medical Technicians (CMT) were able to deal with 47% of all cases using the CMT protocols.

Conclusions

Primary care in forward areas involves patients from a spectrum of backgrounds with multiple morbidities and diagnoses. Consideration should be given for further research into the area of the consultation at the front line to aid patient care. Combat Medical Technicians were able to treat nearly 50% of all cases by themselves but this left a significant number where the assistance of a Medical Officer was required. Consideration should be given for further research into preparation of Combat Medical Technicians for autonomous working at the front line.
Changing Patterns In Tobacco Consumption Among Spanish Military Personnel Under Stressful Conditions
Authors: Granda-Orive José Ignacio de , López-Aguilar JC , García-Río F , Solano-Reina S , Jiménez-Ruiz CA , Roig-Vázquez F
Published: March 2013

Objective

A study is made to determine the prevalence of smoking and its variation over time in a group of Spanish military personnel (MP) under stressful conditions.

Methods

A questionnaire specifically designed for this study was administered to the entire MP contingent assigned to Banghis province (Afghanistan) between July and October 2009. A descriptive analysis was made (p < 0.05, 95%CI).

Results

The study sample comprised 254 MP (males 239; mean age 32 years (SD 9)). A total of 39.8% (95%CI; 33.7 – 45.8) were smokers, while 3.1% (95%CI; 1.0 – 5.3%) were former smokers. Regarding smoking habit before and at the end of deployment, one-half (50.5%) of the smokers declared that they smoked the same as before, 20.8% more than before, and 18.8% less than before. In turn, 5.9% of the smokers claimed to have started to smoke in the course of deployment, while 4% of the former smokers declared that they had quit smoking. The MP who quit smoking were younger than those who began to smoke (24 ± 5 vs 39 ± 9 years, p = 0.038). Moreover, the heavy smokers (≥ 15 cigarettes/day) reduced tobacco consumption, while the less heavy smokers increased the habit (p < 0.0001).

Conclusions

The prevalence of daily smokers is high among MP. The majority of smokers smoke the same at the end of deployment. Those who quit smoking during the mission are significantly younger than those who begin to smoke. In turn, heavy smokers reduced their habit, while less heavy smokers increased smoking.
Initial Extremity War Wound Debridement: A Multidisciplinary Consensus
Authors: Guthrie HC , Clasper JC , Kay AR , Parker PJ
Published: March 2013

A joint meeting of the Limb Trauma and Wounds Working Groups resulted in the establishment of 29 consensus recommendations for the conduct of initial extremity war wound debridement. Pre-operative, operative and post-operative phases of debridement were considered along with wound irrigation and dressings. Wounds where a different surgical approach is required, such as superficial soft tissue wounds at one end of the spectrum and complex wounds sustained in close proximity to explosions at the other, were also discussed. The recommendations represent the consensus opinion of orthopaedic, vascular and plastic surgeons, as well as nursing officers, from across the Defence Medical Services and are intended to provide useful guidance to the deploying surgeon, regardless of their own personal experience.
Multiple Limb Compartment Syndromes in a Recruit With Sickle Cell Trait
Authors: Way Adam , Ganesan S , McErlain M
Published: March 2013

Sickle cell trait, as opposed to the disease, is a rare condition with fewer medical complications. We present a case of a 24 year old Army recruit, who required multiple fasciotomies for limb compartment syndrome, associated with sickle cell trait. We discuss the management, complications and screening programmes of the condition and make suggestions for the training of sickle cell trait personnel in planning a career in the Armed Forces.
Fleas on Operations in Afghanistan – Environmental Health Measures on the Front Line
Authors: Naumann DN , Baird-Clarke CD , Ross DA
Published: March 2013

Flea bites can cause irritating symptoms, secondary infections, and may potentiate the spread of vector-borne disease. Flea infestation and bites may also cause significant psychological distress, and can reduce the morale and fighting fitness of deployed military personnel. The problem of flea infestation was highlighted during Op HERRICK 12 in two ‘front line’ Check Points (CPs) where the entire population of soldiers suffered from multiple symptoms due to flea infestation and bites. Several attempts at infestation control initially succeeded but later lead to recurrence. Such failure was due to the incomplete killing of all stages of the flea life cycle, and due to constraints on education, training, communication, and resupply in the isolated and austere environment of the CPs. A dedicated operation (designated Op Insecticide) was put into action in order to eradicate the problem and return the affected troops back to full fighting fitness. Op Insecticide was thorough, systematic and sustainable, and lead to an eradication of the flea infestation problem at the affected CPs.
An Observational Study into the Levels of Evidence Presented at the Combined Services Orthopaedic Society Annual Meeting
Authors: Bonner Tim , Mountain A , Eardley WGP , Clasper JC
Published: March 2013

Objectives

The role of Evidence Based Medicine in clinical care is to provide a framework for the integration of expertise, current evidence and the needs of the individual patient. Research presented at scientific meetings is an important source of such evidence, informing clinical decision making both on military operations and in home nation health care systems. The aim of this study is to review the levels of evidence presented at the Combined Services Orthopaedic Society (CSOS) and two other related scientific meetings.

Methods

Retrospective review of abstracts presented at the annual scientific meetings of the CSOS, Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. Research abstracts were categorised according to the Centre for Evidence- Based Medicine’s (CEBM) hierarchy of evidence. Statistical comparison was performed to investigate differences in evidence levels presented at each scientific meeting and between each year of the CSOS meeting.

Results

596 abstracts met the inclusion criteria for this study (179 CSOS, 173 SOMOS, 244 BTS). Level IV evidence accounted for the majority of presented abstracts at each meeting (72.6% CSOS, 69.4% SOMOS, 68.9% BTS). Level I evidence was uncommon at each meeting (6.1% CSOS, 5.2% SOMOS, 2.9% BTS). There was no statistical difference in the evidence levels presented at the three scientific meetings.

Conclusions

The proportion of comparative clinical studies (Levels I-III) presented at military or trauma societies’ scientific meetings reflects the difficulty of performing research in emergency surgery. This is further exacerbated in the military environment where operational commitments and delivery of care take priority. However, the future value of comparative clinical research in battlefield healthcare could have an enduring legacy that shapes trauma care for many decades.
Penetrating Paediatric Thoracic Injury
Authors: Coley E , Roach P , Macmillan AI , West ATH , Johnston A McD
Published: March 2013

Paediatric penetrating chest trauma is common in conflict, but rarely seen in peacetime. We describe the successful hospital management of a five year old female civilian casualty with life threatening penetrating thoracic trauma caused by a fragment from an explosive device.
Critical Decision-making and Timelines in the Emergency Department
Authors: Smith Jason E , Russell RJ , Horne S
Published: March 2013

The resuscitation of severely injured patients has evolved during the last decade. Patients are now surviving injuries that previously were thought to be unsurvivable. Systems have been put in place, that reflect the intensity of workload and severity of injury of patients presenting to deployed medical treatment facilities. This paper aims to describe some of the elements that may differ from routine practice in the resuscitation room, and in particular the role of timelines in the management of such patients.
The Clinical Outcome of UK Military Personnel Who Received a Massive Transfusion in Afghanistan During 2009
Authors: Allcock Edward , Woolley T , Doughty H , Midwinter M , Mahoney PF , Mackenzie I
Published: March 2013

Objectives

The UK Defence Medical Services has developed a Massive Transfusion Protocol (MTP) that forms part of the initial Damage Control Resuscitation process for severely injured combat casualties. The key objectives of this retrospective review of MTP recipients are to document the survival rates, level of critical care support required and the blood components transfused as part of the Massive Transfusion Protocol in Afghanistan during 2009. In addition to providing a measure of our current effectiveness it should also provide a reference point for future reviews as the MTP continues to evolve.

Methods

This was a collaborative project involving the Royal Centre for Defence Medicine and the Critical Care Department, University Hospitals Birmingham. It was limited to UK military personnel who were injured in 2009 and received massive transfusions (defined as the transfusion of 10 or more units of packed red blood cells over a 24-hour period) at Camp Bastion Role 3 Medical Facility, Afghanistan.

Results

During the 12-month period, 59 personnel received massive transfusions. 51 (86%) personnel survived to be discharged from hospital in the UK. 48 (92%) personnel required ventilatory support for a median of 3 (2-8) days. The longest period of ventilation was 40 days; 29 (55%) personnel required vasopressor support and eight personnel (15%) required renal replacement therapy. The median total transfusion of blood components was 45 (28.5-62) units. There were seven transfusions of more than 100 units. Five of the personnel in this group (including the recipient of a 237-unit transfusion) survived to be discharged from University Hospitals Birmingham. On average, 1.21 (SD 0.28) units of packed red blood cells were transfused for every unit of fresh frozen plasma.

Conclusions

The use of the current MTP was associated with a high rate of survival. Survivors require a continuity of critical care with a median demand for 3 days. The early use of plasma and platelets can be successfully delivered in the battlefield despite operational and logistic constraints.
General Practice - Reflection on Five Years of Multidisciplinary Training at Medical Centre Gütersloh
Authors: van den Heuvel HGJ
Published: March 2013

Background

Medical Centre Gütersloh is a primary care setting which provides the full range of general practice care for British Forces Germany Health Service (BFG HS). The aim of this article is to evaluate the multidisciplinary training organised by the author there, to exchange information and to provide suggestions for improvement and development.

Methods

Description of the training scheme and analysis of routinely collected management data.

Results

The training scheme is based on adult education principles with a focus on interactive learning. Over the period November 2005 – July 2010 a total of 1201 members of staff from various disciplines participated in 86 documented training sessions. The majority of the attending staff considered the training to be relevant, interesting and well presented. A substantial proportion indicated that they would change their practice as a result of the training. These views remained stable over time. The majority of facilitators consisted of medical centre employees.

Conclusions

This article provides an overview on five years of multidisciplinary training in a general practice setting. Overall feedback from staff suggests that the training has been highly valued over those years. However, it is recognised that this evaluation has its limitations and suggestions are made regarding how these types of training schemes can be improved and developed further.
Endoscopic Evaluation of a Complex Ballistic Injury
Authors: Eardley Will , Beaven A , Sargeant I
Published: March 2013

The current conflict in Afghanistan is characterised by significant injuries resulting from the use of Improvised Explosive Devices. Increasing survivability from battlefield injury, escalating musculoskeletal ballistic trauma and the use of blast weaponry combine to produce an injury profile which defines contemporary combat casualty care. Such complex multi-system trauma challenges current wound care rationale. Ballistic injury of the perineum, often associated with proximal femoral injury and significant tissue loss, raises particular management difficulties. These cases demand an individualised, flexible approach due both to the extent of their wounds, logistical issues with positioning and often limited surgical approaches. Routine positioning and approaches around the pelvis may not be available to the surgical team due to presence of external fixators and tenuous skin bridges. The availability of donor skin to cover soft tissue defects is limited and as such, approaches to wounds with minimal additional tissue trauma are of particular use. We describe the benefits of endoscopic techniques and equipment in the evaluation and management of such an injury.
Proceedings of the DMS Medical Ethics Symposium
Authors: O’Reilly David
Published: March 2013

This article presents the proceedings of a symposium on medical ethics held at the Royal Centre for Defence Medicine in October 2010. The nature of current operations continually generates challenging ethical problems, many of which are unique to the military environment. This article is intended to generate a debate on these difficult issues and readers are encouraged to contribute to this debate by emailing the Editor.
Tactical Aeromedical Evacuation
Authors: Bricknell Martin CM , Kelly LM
Published: March 2013

This paper discusses the principles of tactical aeromedical evacuation (TACEVAC) planning and execution with specific consideration of the command and control arrangements for TACEVAC. UK personnel may be familiar with TACEVAC procedures using UK national aircraft and aeromedical evacuation crews between national medical facilities. Recent operations, most particularly in Afghanistan, have illustrated the requirement to understand TACEVAC within a multi-national context as both our military hospitals have moved patients using other nations aircraft and medical escort crews, and UK aeromedical aircraft and crews have moved other nations’ patients.
Medical Lessons from OPERATION MOSHTARAK Phase 2
Authors: Bricknell Martin CM
Published: March 2013

This paper is a narrative description of the planning and execution of the medical support plan for OP MOSHTARAK, the Combined Team security operation in the towns of Nad Ali and Marjah of Central Helmand in February and March 2010. The aim is to describe the key events that influenced the development of the medical plan and how these unfolded during the operation in order to identify observations and lessons learned to improve processes for managing medical support to future operations. The paper illustrates how the principles for planning and managing medical operations are applied in practice.
Casualty Rates Among Danish Soldiers in Iraq and Afghanistan
Authors: Jørgensen HO , Høier-Madsen K. , Stokkebye JE
Published: March 2013

In 2002 – 2009 Danish forces suffered a mortality rate of 0.09% in Iraq and 0.38% in Afghanistan, and a morbidity rate of 0.30% in Iraq and 1.01% in Afghanistan, as a result of weapons effects. In Afghanistan the survival rate is 97.0% for Danish wounded who were alive on arrival at UK R3 Hospital. British data from Afghanistan are compared to the Danish figures and there is no significant difference. We found an increase in injuries and deaths caused by mines/ IEDs from 33% in 2006 to 72.7% in 2009 of all weapon effects causes. The more offensive war fighting posture of the Danish forces in Afghanistan has resulted in greater numbers of casualties. The study also indicates that the great majority of fatalities occur almost immediately at the point of injury. Most of the wounded survive, and a large of number of them are only lightly injured with a partial incapacity level of less than five percent. Haemostatic’s and active employment of tourniquets, improved first aid training and training of medics, better evacuation methods including optimised in-flight diagnostics and treatment (including blood transfusion) by Medical Emergency Response Teams, Damage Control Surgery as well as access to quicker diagnostic methods have increased survivability.
Multinational Medical Support to Operations: Challenges, Benefits and Recommendations for the Future
Authors: Cordell RF
Published: March 2013

This paper considers the strategic aspects of medical support to military operations as delivered through multi-national collaboration. The military medical services are in essence a people organisation; the purpose of the organisation is primarily to support the people engaged in military operations, and also the people providing healthcare to them. Increasingly, supporting the latter also includes preparation for the ethical dilemmas that they will face. Providing health advice and healthcare on operations is now usually undertaken on a multinational basis, in order to generate sufficient medical capacity to meet the requirement with assets of the appropriate (and NATO mandated) capability. This will be an enduring feature, particularly in light of increasing costs of providing high quality healthcare and the operational and logistic challenges of delivering this capability in adverse environments, and in the context of medical personnel being a limited resource. The key to overcoming the challenges, often the result of the “people issues” such as cultural differences, is to recognise the value that the inherent diversity of multinational healthcare provision brings. The benefit is realised through sharing best practice, and the lessons from challenges met, as well as through burden sharing, and to understand that challenges are most commonly the result of misunderstandings, such as those inherent in language differences. The advice for those bringing a multinational team together includes considering the implications of culture (noting differences in national and military perspectives, and in medical processes such as clinical governance), to ensure effective communication, and to utilise feedback to confirm understanding. It is important not to prejudge or denigrate others. Share information and knowledge, provide positive reinforcement when things go well, and recognise that there will inevitably be challenges and use these as an opportunity to learn. Above all, the personal touch builds a culture within the multinational team that transcends national culture; celebrating success breeds success and thus optimal outcome for patients.
Anaesthetic and Other Treatments of Shell Shock: World War I and Beyond
Authors: McKenzie Alistair
Published: March 2013

Post-traumatic stress disorder (PTSD) is an important health risk factor for military personnel deployed in modern warfare. In World War I this condition (then known as shell shock or ‘neurasthenia’) was such a problem that ‘forward psychiatry’ was begun by French doctors in 1915. Some British doctors tried general anaesthesia as a treatment (ether and chloroform), while others preferred application of electricity. Four British ‘forward psychiatric units’ were set up in 1917. Hospitals for shell shocked soldiers were also established in Britain, including (for officers) Craiglockhart War Hospital in Edinburgh; patients diagnosed to have more serious psychiatric conditions were transferred to the Royal Edinburgh Asylum. Towards the end of 1918 anaesthetic and electrical treatments of shell shock were gradually displaced by modified Freudian methods – psychodynamic intervention. The efficacy of ‘forward psychiatry’ was controversial. In 1922 the War Office produced a report on shell shock with recommendations for prevention of war neurosis. However, when World War II broke out in 1939, this seemed to have been ignored. The term ‘combat fatigue’ was introduced as breakdown rates became alarming, and then the value of pre-selection was recognised. At the Maudsley Hospital in London in 1940 barbiturate abreaction was advocated for quick relief from severe anxiety and hysteria, using IV anaesthetics: Somnifaine, paraldehyde, Sodium Amytal. ‘Pentothal narcosis’ and ‘narco-analysis’ were adopted by British and American military psychiatrists. However, by 1945 medical thinking gradually settled on the same approaches that had seemed to be effective in 1918. The term PTSD was introduced in 1980. In the UK the National Institute for Health and Clinical Excellence (NICE) guidelines for management (2005) recommend trauma-focussed Cognitive Behavioural Therapy and consideration of antidepressants.
Effects of an Eight Week Military Training Program on Aerobic Indices and Psychomotor Function
Authors: Hickey JP , Donne B , O’Brien D
Published: March 2013

This study assessed the effects of eight weeks of military training on aerobic fitness indices, military skills and neuropsychological function. Thirty five (n=35) male Irish Defence Forces personnel, divided into training (n=20) and control (n=15) subgroups, completed tests of military aptitude (Kim’s games, judging distance, fire order, map reading, weapon assembly) and neuropsychological function (Symbol digit modalities test (SDMT), Trail making test, Stroop test and grooved pegboard test) pre- and post-intervention. The repeated measures study design sought to account for any learning effect. Participants also completed a 10km route march, a two mile run and three by 20m shuttle run tests at both time points to quantify changes in fitness variables. The training sub-group significantly (P<0.001) improved mean 20m shuttle-run distance and consequently estimated VO2 max pre- to post-intervention (49.8±1.0 vs. 52.4±0.9 mL.kg-1.min-1). Two mile run time was not significantly improved. Mean %HRmax during the 10km route march was significantly higher in both training (P<0.001) and control (P<0.01) sub-groups post-intervention (71±1 and 83±1%) compared to pre-intervention (65±1 and 77±1%). However, the training sub-group conducted the route march at a significantly faster speed on the second occasion. Military training significantly improved performance in 3/18 neuropsychological test components and 2/12 military skills test components. Training significantly improved ability to estimate both short (error; 36±6 vs. 12±1%) and intermediate (error; 72±12 vs. 11±3%) distances post-intervention. The training sub-group significantly (P<0.01) improved SDMT score and mean Trail 1 time pre- to post-intervention (58.0±2.8 vs. 69.5±3.4; 18.1±0.8 vs. 14.4±0.8s, respectively). In Part 3 of the Stroop test, time mediated a significant (P<0.05) and selective improvement in the training sub-group (51.3±3.2 vs. 63.8±5.4). In conclusion, aerobic fitness and a minority of neuropsychological and military skills tests improved following 8 weeks of military training.
Non-Operative Management of Liver Trauma
Authors: Swift C , Garner Jeff
Published: March 2013

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.
Can Adventurous Training Have a Role in Improving Clinical Outcomes?
Authors: Mellor Adrian , Jackson S , Hardern R
Published: March 2013

The aim of military adventurous training (AT) is“to develop, through authorised challenging pursuits and within an outdoor environment, leadership and the qualities necessary to enhance the performance of military personnel during peace and war”. An increasing amount of effort is being applied by all three services to increase participation in AT to achieve these, largely immeasurable, aims. Existing guidance to Commanding Officers dictates that, where possible, 20% of a unit strength should undertake some form of AT annually with 5% taking part in an overseas expedition. In a speech in 2008 Alan Johnson, the then Secretary of State for Health, acknowledged that for Armed Forces medical personnel“just as important as clinical skills are issues such as leadership, communication, adaptability and teamwork.” Controlled exposure to risk, discomfort and personal hardship is a common theme for both AT activities and military deployments. Both General Medical Council competencies for all doctors and the Royal College of Anaesthetists military module include elements which can effectively be taught and developed through training in an outdoors environment. These skills include communication skills, leadership, risk assessment and interdisciplinary working. In this review the value of AT in training doctors to develop those attributes is examined.
A Comparison of Performance Between Teflon® and Polyurethane Safety Cannulae at Extremes of Operating Temperatures
Authors: Jeyanathan J , Webster BB , Hawksley OJ , Mellor A J
Published: March 2013

Objectives

In the United Kingdom, approximately eight million peripheral cannulations are performed each year. Intravenous cannulae are made from either polytetrafluoroethylene (Teflon®) or polyurethane. Polyurethane has a lower incidence of thrombophlebitis, however the physical characteristics of polyurethane may make the cannulae difficult to use at higher ambient temperatures. This effect maybe of importance to those involved in cannulation in extreme environments and especially for military doctors deployed in current theatres of operations.

Methods

In a randomised single blinded study we investigated the different characteristics of Teflon® and polyurethane cannulae (Vasofix® Safety Cannulae, B Braun) at three different temperatures (-10ºC, 21ºC and 40 ºC).

Results

There is no statistically significant difference in the ease or speed of cannulation of either polyurethane or Teflon® safety cannulae in extremes of temperature.

Conclusions

This study provides evidence that performance of polyurethane safety cannulae are not impaired by temperature extremes.
Successful Surgical Treatment of Q Fever Endocarditis with Mitral Valve Repair
Authors: Khan JN , Tapp LD , Glancy JM , Prasad N , Bailey MS , Graham Timothy R
Published: March 2013

We report a case of successful surgical treatment of Q fever endocarditis with mitral valve repair in a 66-year old retired British soldier. Valve replacement is invariably undertaken in Q fever endocarditis due to the degree of valvular damage and concerns about eradicating the organism,Coxiella burnetii. Our unique case allowed valve repair since pre-existing myxomatous degeneration and subsequent posterior mitral valve leaflet prolapse resulted in significant excess valve tissue, allowing quadrangular resection of the damaged and perforated P2 portion of this leaflet. Follow-up at four years (including three years of antibiotic treatment) has confirmed excellent valve repair, with no echocardiographic, clinical or microbiological evidence of recurrence. We are only the second group to describe valve repair in a patient with chronic Q fever endocarditis. Valve repair is preferable to valve replacement for Q fever endocarditis,if technically possible.
Self-Assessment Exercises in Emergency Radiology I – Abdominal Trauma
Authors: Archer J , Russell Rob , Perry J
Published: March 2013

This is the first of three self-assessment articles which aim to further readers’ understanding of diagnostic imaging and its integral role in the management of patients with emergency conditions, through a series of case studies.
General Practice in the Armed Forces: A Definition and Model
Authors: Mears KP , Morgan-Jones DJ , Richardson JC , Simpson R , Wall C
Published: March 2013

Armed Forces General Practice is in an unprecedented time of challenge with the demands of contiguous worldwide operations in austere environments, reorganisation of defence, budgetary constraints and manpower shortfalls. We propose a model of this crucial area of military medical care as a key academic and practical reference point, which will help retain, and perhaps even enable, the development of this clinical speciality over the next decade. It provides a formalised definition and a basis for education, training and research in Military General Practice; it also has the advantage of highlighting the all-encompassing nature of military primary care when compared to the nearest equivalent model - that of civilian General Practice.
British Military Snake-bite Guidelines: Pressure Immobilisation
Authors: Wall Colin
Published: March 2013

Snake-bite is a significant problem worldwide. Despite frequent deployments and exercises to countries where venomous snakes are endemic there are few reported cases of British Army personnel being bitten. Clinical Guidelines for Operations includes direction on the treatment of snakebite, including the application of pressure immobilisation. This article reviews the history and development of pressure immobilisation, the optimum equipment and the efficacy of training in order to inform future guidelines. It is the conclusion of this review that pressure immobilisation should be advocated in all snakebites where the snake species is not known. In addition guidelines should advocate the use of Sam splints and Emergency Bandages in the application of pressure immobilisation.
The Role of a Royal Navy General Duties Medical Officer in Helicopter Assault Force Operations: A Reflective Article
Authors: Ritson JE , Wall C
Published: March 2013

Royal Navy General Duties Medical Officers (RN GDMOs) are employed in land operations in Afghanistan in much the same way as British Army GDMOs. In this article the author explores how time with a Royal Marine Commando unit and completion of Commando training in parallel to thorough medical training are beneficial for the roles a RN GDMO is expected to undertake in Helicopter Assault Force Operations.
An Audit of the Quality of Deployed DMICP Records on Operation HERRICK 14
Authors: Batham DR , Wall CM
Published: March 2013

Background:

Troops deploying to remote and hostile environments are exposed to numerous threats to their health and wellbeing. Medical care is provided by dedicated but often inexperienced young doctors, nurses and medics. This audit looks at the quality of medical records that are available to these deployed clinicians and the quality of their record keeping against nationally set guidance for the Summary Care Record (SCR) and Out of Hours record keeping.

Methods:

The data was collected from consecutive GP and nurse medical consultations at Camp Bastion Primary Health Care Centre during Op HERRICK 14.

Results:

Only 21.7% of personnel had an imported medical record from the UK and only 1% had a summary fitting the guidance for the SCR. Additionally the quality of record keeping for consultations did not conform to standards set by the Royal College of General Practitioners ‘Out of Hours Clinical Audit Tool’.

Conclusions:

The low numbers and poor quality of imported medical records into Op HERRICK 14 along with the inexperience of clinicians in keeping medical records compliant with relevant standards is of primary importance in the context of patient safety on operations. This audit highlights a number of areas of potential concern for the Defence Medical Services and areas for enhancement of pre-deployment training.
The Use of Clinical Audit During a Successful Medical Engagement in Afghanistan
Authors: Smith Adam Hewitt
Published: March 2013

Objectives:

To describe a successful medical engagement during counter-insurgency operations in Afghanistan, and to demonstrate that a full audit cycle can be used in this environment to support improvements to local healthcare delivery.

Methods:

In the district of Nad-e-Ali, Helmand Province, Afghanistan, the management of children under five years of age (under-5s) who presented with diarrhoea to a Ministry of Public Health (MoPH) Basic Health Centre was audited. Staff then attended a training course on the Integrated Management of Childhood Illnesses (IMCI) in Kandahar. After further medical engagement to reinforce this training, the audit was repeated.

Results:

A lack of knowledge of the Afghan government’s MoPH guidelines during the initial audit resulted in 90% of under- 5s with acute diarrhoea being given unnecessary antibiotics and none receiving zinc as recommended. Following the training course and on-going engagement, there was a 67% reduction in the number of under-5s prescribed antibiotics and a 74% increase in the number who received zinc.

Conclusions:

Opportunities for successful medical engagement during operations are limited but this example demonstrates that in conjunction with host nation facilities, sustainable improvements in healthcare are possible. Secondly, it shows that use of the audit cycle can provide objective evidence that may help encourage local staff to improve their standards of patient care.
Population-Based Screening of Ophthalmic Disorders in a Cohort of Nigerian Army Personnel
Authors: Eze B I , Okoye O , Hussain NA , Mba CN
Published: March 2013

Objectives:

To assess the burden and spectrum of ophthalmic disorders among army personnel at the 82 Division of the Nigerian Army, Enugu, South Eastern Nigeria.

Methods:

A population-based screening survey in July 2010 in the 82nd Division, Nigerian Army. Data on participants’ sociodemographics, past medical and ophthalmic history, and findings on ophthalmic examination and refraction were noted according to a defined protocol and analysed statistically using p<0.05 as the level of significance.

Results:

There were 254 participants (223 males, p<0.05) with a mean age of 36.2 + 9.7 SD years (range 19 -63 years). The prevalence of ophthalmic disorders in the study cohort was 34.6 %. These were mainly refractive abnormalities (22.0%) and anterior segment disorders (13.8%). The refractive abnormalities comprised myopia (51.8%), hypermetropia (28.6%) and astigmatism (16.1%).

Conclusions:

The prevalence of ophthalmic disorder among army personnel at the 82nd Division, Enugu, is comparatively high. Spherical refractive error and anterior segment disorders are the commonest ophthalmic disorders. These have implications for needs-based and cost-effective provision of eye care services to this military formation and probably to the rest of the Nigerian Army as well. To generate broad-based comparative data, future multi-centre surveys are warranted.
Military Healthcare Battlefield Immunity
Authors: Kelly JC
Published: March 2013

The combatant soldier on the battlefield remains protected from any claim in negligence by the doctrine of combat immunity for any negligent act or omission they may make when fighting. In other words, the combatant soldier does not owe a fellow soldier a duty of care on the battlefield, as the duty of care is non-justiciable. However, the non-combatant Military Healthcare Professional, although sometimes operating in the same hostile circumstances as the fighting soldier, is unlikely to benefit from combat immunity for anyclinical negligenceon the battlefield. This is because they continue to owe their patient a duty of care, although this has not been tested in the courts. This paper considers if any military healthcare professional could ever benefit from combat immunity, which is unlikely due to their non-combatant status. Instead, this paper suggests that a modified form of immunity; namely, Military Healthcare Battlefield Immunity could be a new, unique and viable doctrine, however, this could only be granted in rare circumstances and to a much lesser degree than combat immunity.
Occupational Accidents In Greek Armed Forces In Evros County
Authors: Malliarou Maria , Sourtzi P , Galanis P , Constantinidis TC , Velonakis E
Published: March 2013

Aim:

The purpose of this study was to investigate risk factors for occupational accidents and the relationship between perceived and actual risk of occupational accidents in Greek soldiers.

Method:

A case-control study was conducted of military personnel in Evros county in Greece. Cases (n=250) were defined as enlisted personnel having had an accident at work and the control series (n=300) comprised of a simple random sample, stratified by age from the army population.

Results:

Conscripted soldiers (OR=3.8, 2.21 to 6.58, p<0.001) and professional soldiers (OR=2.2, 1.28-3.75, p=0.004) had higher frequency of occurrence of accidents in comparison to army officers. The degree of risk perception due to electrical hazards (OR=2.8, 1.81-4.18, p<0.001), lighting (OR=2.6, 1.74-3.97, p<0.001), falls (OR=2.9, 1.61-5.13, p<0.001) and inadequate safety signs (OR=3.3, 1.99-5.49, p<0.001) were associated with increased occurrence of accident. Regression analysis demonstrated a significant relationship between the accident and the age, time of service in the present unit, specialty, level of education, years of service and the overall military training.

Conclusion:

This study highlights the increased likelihood of occupational accidents among military personnel with lower rank and lower level of education, less working experience (fewer years of service) and less military training (conscripted and professional soldiers). The existence of occupational accidents in the workplace, civilian or military, creates the need for the adoption of policies for the protection of workers and the organization of occupational preventive services.
Non-organic Hearing Loss
Authors: Nelson Sarah
Published: March 2013

Annual hearing tests are compulsory in the British Armed Forces. This case report presents a 24- year old soldier who was found to have severe deterioration on her annual audiogram without any significant noise exposure. After two years of specialist audiological investigations she was diagnosed with non-organic hearing loss; further interrogation of her social circumstances suggested potential psychosocial triggers. This diagnosis should be considered early in military primary care in those with objective hearing loss on audiogram where there has been no exposure to significant noise.
Locked Bucket Handle Tears of the Medial and Lateral Menisci with Associated Chronic ACL Deficiency
Authors: Shepherd J , Abdul-Jabar HB , Kumar A
Published: March 2013

Bucket handle meniscal tears involving both the medial and lateral menisci are very rarely reported in the literature. Those that are, have generally been managed using a one-stage procedure, with concurrent reconstruction of the anterior cruciate ligament (ACL) in ACL-deficient cases. We report a case of an 18-year old male who presented with bi-compartmental bucket handle meniscal tears with an associated ACL deficiency, whereby the medial and lateral tears appear to have clearly occurred on separate occasions. A staged approach to management was adopted. We discuss the presentation and management of our case in comparison to previously reported cases.
Balkans Syndrome: A Potential Link Between Multiple Sclerosis and Hypervaccination
Authors: Vacchiano G , Vyshka Gentian
Published: March 2013

Balkans Syndrome is a recent term that has been widely used in the media to describe a heterogenous group of medical conditions that presented in soldiers following deployment on military operations to the former Yugoslavia and its neighbouring countries. These individuals had been subjected to an intense and protracted course of vaccinations (termed hypervaccination) prior to deployment, which has subsequently been implicated by the media as the cause of this disease. We describe the case of a 33- year old army officer, who received twenty vaccinations and boosters during the period 2000-2006, and was subsequently diagnosed with multiple sclerosis in 2008.
Emergency Radiology II – Head Trauma
Authors: Archer J , Russell Rob , Perry J
Published: March 2013

This is the second of three self-assessment articles which aim to further readers’ understanding of diagnostic imaging, and its integral role in the management of patients with emergency conditions, through a series of case studies.
Emergency Radiology III - Chest and Limb Trauma
Authors: Archer J , Russell Rob , Perry J
Published: March 2013

This is the final of three self-assessment articles which aims to further readers’ understanding of diagnostic imaging, and its integral role in the management of patients with emergency conditions, through a series of case studies.
Diagnosis, management and operational impact of panic disorder in the UK Armed Forces
Authors: Smith Fiona E , Coetzee R H
Published: March 2013

Panic Disorder, with or without agoraphobia, is a common anxiety disorder found in patients presenting in the Primary Care setting, and there is some evidence to suggest that it may not be a rare phenomenon in military populations. This article aims to discuss recognition of the disorder, awareness of its differential diagnoses, and management in Primary Care, particularly if secondary care referrals are not readily available. The National Institute for Clinical Excellence (NICE) Guidelines, both pharmacological and psychological, will be considered. Finally, the impact of Panic Disorder in relation to the Armed Forces in the training and deployed environment will be considered.
Energy expenditure and changes in body composition during exercise-based rehabilitation
Authors: Kristensen Jakob
Published: March 2013

Introduction

Exercise-based rehabilitation programmes have formed the cornerstone of the treatment currently delivered at the Defence Medical Rehabilitation Centre (DMRC) based at Headley Court.Increased operational activity in recent years has meant a concomitant increase in the pressure on Defence rehabilitation resources and a greater need for effective rehabilitation strategies. The aim of this research was to assess the effects of exercise-based rehabilitation on energy expenditure and body composition.

Methods

A group of nine male volunteers (30±2.4 years) serving with the Armed Forces and suffering from a variety of musculoskeletal lower limb injuries underwent 17 days of exercise-based rehabilitation. Total daily energy expenditure (TEE) was assessed using a portable combined heart rate monitor/accelerometer (Actiheart).Changes in body composition were assessed using dual energy x-ray absorptiometry (DEXA).

Results

MeanTEE over the entire admission period was 2915±53 kcal/day with no significant difference in TEE observed between training week 1 (W1) and 2 (W2). However, a strong trend towards increased TEE in W1 was observed (p=0.06). No significant change was observed in fat mass (FM), lean body mass (LBM) or body-fat percentage despite the exercise-based rehabilitation programme.

Conclusions

These results suggest that 17 days of exercise-based rehabilitation is insufficient to observe significant changes in body composition, despite high energy expenditure.
Influence of netball-based exercise on energy intake, subjective appetite and plasma acylated ghrelin in adolescent girls
Authors: Rumbold Penny L.S. , St Clair Gibson Alan , Stevenson Emma J. , King James A. , Stensel David J. , Dodd-Reynolds Caroline J.
Published: March 2013

This study explored 5-day regulation of exercise-induced energy expenditure, energy intake, and hormonal appetite, via acylated ghrelin, after acute exercise. Using a randomized crossover design, 10 female adolescents (13–15 years old) completed two 7-day treatment weeks (2 days of maintenance, 1 day of treatment, and a 4-day follow-up), interspersed with a 1-week period. On day 3, 47 min of netball-based exercise or sedentary activity was imposed with a test meal 1 h later. Measures of energy expenditure, subjective appetite, test meal energy intake, plasma acylated ghrelin, insulin, and glucose were taken during this period. Energy intake compensation for the exercise period was calculated. Four-day follow-up measures were daily subjective appetite, energy intake, energy expenditure, and energy balance. Girls felt more full 20 min during the netball-based exercise bout compared with sedentary activity (87 ± 15 mm vs. 75 ± 24 mm). An energy intake compensation of 27% was identified for the netball-based exercise. Compared with immediately before exercise or sedentary activity, plasma acylated ghrelin was elevated 45 min after netball (103.8 ± 56.9 pg·mL−1 vs. 85.7 ± 26.9 pg·mL−1; n = 7) and sedentary activity (98.2 ± 27.1 pg·mL−1 vs. 60.8 ± 33.5 pg·mL−1; n = 7) but not different between treatments. Adolescent girls (13–15 years old) only partially compensated for the netball-based exercise-induced energy expenditure. The effect of exercise on appetite needs to be further explored in adolescents, whereby nutritional behaviour is tracked for more than 1 week to investigate full compensation for acute exercise.
Theoretical studies on vibrational spectra, thermodynamic properties, and detonation properties for 1,2,4,5-tetrazine derivatives
Authors: Li Xiao-Hong , Zhang Rui-Zhou , Zhang Xian-Zhou
Published: March 2013

A density functional theory calculation was performed to study the molecular structures, heats of formation (HOFs), infrared spectra, detonation properties, and thermodynamic properties for five 1,2,4,5-tetrazine derivatives. Based on the full optimized molecular structures at the B3LYP/6-311++G** level, the assigned infrared spectra of the studied compounds were obtained. The isodesmic reaction method was employed to calculate the HOFs of the derivatives. The detonation velocities and pressures were also evaluated by using Kamlet−Jacobs equations with the calculated densities and condensed HOFs. The result shows that 3,6-diazido-1,2,4,5- tetrazine may be a potential candidate of high-energy density materials (HEDMs). Natural bond orbital analysis indicated that the title compounds all have higher bond dissociation energies when compared with 1,3,5,7-tetranitro-1,3,5,7-tetrazocane and 1,3,5-trinitro-1,3,5-triazinane. The results may provide basis information for the molecular design of new HEDMs.
CONSTRUCTING PREMAXIMAL BINARY CUBE-FREE WORDS OF ANY LEVEL
Authors: PETROVA ELENA A. , SHUR ARSENY M.
Published: March 2013

We study the structure of the language of binary cube-free words. Namely, we are interested in the cube-free words that cannot be infinitely extended preserving cube-freeness. We show the existence of such words with arbitrarily long finite extensions, both to one side and to both sides.