bluuebunny/crossref_metadata_2025 huggingface dataset:
Laparoscopic resection of a large mixed epithelial-stromal tumour of the seminal vesicle: a rare entity and review of the current literature
Authors: Debnath Abhik , Cheriyan Abhilash , Daniel Sherin , John Nirmal Thampi
Published: February 2021

Mixed epithelial-stromal tumours (MESTs) of the seminal vesicle (SV) are a rare neoplasm, with biological behaviour ranging from benign to malignant. Due to their rarity, there are no established guidelines for their treatment. We report a 37-year-old man with a large MEST of the SV which was successfully resected by laparoscopic transperitoneal approach. Amidst the controversy regarding the nomenclature and grading of MESTs in literature, we reclassified the previous reports of MESTs incorporating both the WHO and Reikieet algrading.
Polyangiitis overlap syndrome: a novel presentation of microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis
Authors: Rasheed Nidaa , Ahuja Rahul , Borneo Hena
Published: February 2021

Polyangiitis overlap syndrome (POS) is a diagnostic term coined by Leavitt and Fauci that characterises patients with overlapping features of more than one vasculitis. Prior case studies of antineutrophil cytoplasmic antibodies (ANCA)-associated POS have only been published in patients with eosinophilic granulomatosis with polyangiitis (EGPA) and granulomatosis with polyangiitis alongside proteinase-3/cytoplasmic (C)-ANCA positivity. We present a case of a 60-year-old woman with dyspnoea, hemoptysis, positive perinuclear-ANCA and renal biopsy demonstrating evidence of microscopic polyangiitis. In addition, our patient also had asthma, mononeuritis multiplex, eosinophilia and migratory pulmonary infiltrates, thus fulfilling the criteria for EGPA. This novel case report suggests that POS is not limited to C-ANCA positivity and has variable presentations.
Rete middle cerebral artery: a rare association with anterior cerebral artery aneurysm rupture
Authors: Hosur Bharat , Bhatia Vikas , Kumar Ajay , Karthigeyan Madhivanan
Published: February 2021

Haemodynamic flow-related stress at the vessel curvatures is an important risk factor for intracranial aneurysmal growth and rupture. The rete middle cerebral artery (MCA) is a rare entity causing hyperdynamic blood flow into the ipsilateral anterior cerebral artery (ACA), especially when the contralateral A1-segment is non-dominant. Ruling out the clinicoradiological mimics like vasculitis, moyamoya and chronic occlusive disease with vessel wall imaging and detailed investigations helps manage the clinical entity effectively. We present a successfully managed case of ruptured ACA aneurysm at the acute curvature of the A1–A2 junction associated with ipsilateral rete MCA. Pre-emptive diagnosis of the rete MCA can aid preventive strategies to manage rupture and regrowth of the aneurysm at the points of flow-related stress.
Changing mindsets about side effects
Authors: Leibowitz Kari A , Howe Lauren C , Crum Alia J
Published: February 2021

Given research showing that the very act of communicating side effects can increase their likelihood, how can providers inform patients about side effects while upholding their oath to do no unnecessary harm? An emerging approach provides a potential solution: truthfully describe certain minor side effects as a sign the treatment is active and working in the body. This approach focuses on instilling adaptive mindsets about the meaning of side effects while still keeping patients informed. This article describes existing research suggesting that this approach can be helpful in improving experience and outcomes in treatments for pain, hypertension and allergy. Compared with control groups given a standard, empathetic message about side effects, patients who were informed that side effects are a sign treatment is working were less anxious about side effects and rated them as less threatening and intense. A longitudinal, randomised controlled trial of this approach in patients receiving oral immunotherapy for food allergies found that describing side effects as a sign treatment was working reduced the rate at which patients contacted providers with concerns about side effects and led to greater increases in a biomarker of allergic tolerance from pretreatment to post-treatment (peanut-specific blood IgG4). In unveiling this approach, this article also raises important issues regarding which treatments and symptoms this approach should be applied to. Finally, we outline questions future research should address to further understand and leverage this approach.
Cross-sectional survey for assessing cancer care providers’ characteristics and attitudes on smoking cessation in Colombia and Mexico
Authors: Tami-Maury Irene , Suchil Laura , Reynales-Shigematsu Luz Myriam , Garcia-Gomez Leonor , Chen Mixing , Shete Sanjay , Betancur Alejandro , Cinciripini Paul M , Hawk Ernest , Garcia Hector
Published: February 2021

Objective

Cancer care providers’ (CCPs) attitudes towards smoking cessation are influenced by many factors, including their smoking status and knowledge. Our objective was to assess CCPs’ characteristics, tobacco use and smoking cessation practices in two Latin American cancer centres.

Design

Cross-sectional survey.

Settings

Two urban cancer centres located in Colombia and Mexico.

Participants

A total of 238 CCPs.

Measures

Online survey consisted of 28 close-ended questions adapted from the 2012 International Association for the Study of Lung Cancer survey and the Global Adult Tobacco Survey developed by the WHO. Means, frequencies and proportions were reported for each country. Factors associated to providing of smoking cessation treatment or referral at initial visit were evaluated using logistic regression.

Results

Current smoking prevalence was 10.5% and 12.3% among Colombian and Mexican CCPs, respectively. Around three quarters of the Colombian (86.4%) and Mexican CCPs (66.1%) considered to have inadequate training in smoking cessation. Approximately two-thirds of Colombian (67.5%) and Mexican CCPs (63.9%) reported always or most of the time asking patients about tobacco use during the initial visit. In Colombia and Mexico, the most relevant barriers for providing cessation services were (1) difficulties for motivating patients with cancer, (2) patient resistance in quitting smoking, (3) lack of local resources or referral centres for smoking cessation and (4) lack of training in smoking cessation. CCPs appointed at Instituto Nacional de Cancerología were less likely to provide cessation treatment or referral to their patients if they had less than 50% of their time devoted to patient care and were former or current smokers. The regression model for Instituto de Cancerología did not retain statistically significant variables.

Conclusion

Our findings highlight an urgent need for assisting Latin American CCPs in their quitting efforts as well as expanding formal smoking cessation training specifically tailored to these professionals for improving patients’ cancer prognosis and quality of life.
The management of renal colic
Authors: Leong M , Mackie S
Published: February 2021

Renal colic can be a challenging cause of abdominal pain in the military population. This review highlights the management of renal colic in the Royal Navy’s operational setting. It provides an overview of the diagnosis, treatment options and occupational health issues in the deployed (Role 1) and hospital environments (Role 2 and 3).
The acutely swollen knee. Part two – Management of traumatic pathology
Authors: Guyver PM , Arthur CHC , Hand CJ
Published: February 2021

The acutely swollen knee is a common presentation of knee pathology in the emergency department and the primary care setting, whether on board ship, in a Regimental Aid Post, or in a Medical Centre. The swollen knee has both traumatic and atraumatic (systemic) causes, all of which can be accurately diagnosed with an understanding of the underlying injury patterns and patho-anatomy. In Part 2 of this paper we consider the traumatic causes and also suggest a combined approach to managing an acutely swollen knee. The taking of a detailed history combined with thorough clinical examination will establish the diagnosis or at least the narrow differential diagnosis in the majority of cases. The use of specialist examination techniques, diagnostic imaging and arthrocentesis can further assist the clinician in confirming the correct diagnosis and thus prescribing the appropriate treatment. This review will endeavour to give a consensus of opinion and structured guidelines in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.
The principles of managing open fractures
Authors: Walker R , Middleton S , Stapley S A
Published: February 2021

Any fracture of a bone which communicates with the outside environment via a wound in the skin is classified as an open fracture. This may be from penetration by sharp objects from the exterior, laceration caused by the fracture fragments, or shearing forces that tear or de-glove soft tissue from a limb. These injuries vary in mechanism and severity, ranging from a broken finger caught in a bulkhead door to a catastrophic lower limb fracture suffered from an improvised explosive device (IED). We address the management principles that can be applied to all open fractures regardless of cause.
Noise pollution and detaining captured persons at sea
Authors: Nixon S , Milner R
Published: February 2021

During the course of military operations, the UK Armed Forces may have to capture and detain individuals. International law sets down a framework for the minimum basic standards that are applicable in these circumstances, and it is the responsibility of the UK Armed Forces to understand and implement these. This case review looks at a specific example of this issue related to noise pollution and appropriate detention facilities during anti-piracy operations, and how a flexible approach combined with good understanding of the regulations ensured compliance with these basic standards.
The adverse effects of mefloquine in deployed military personnel
Authors: Adshead S
Published: February 2021

Introduction

Mefloquine (Lariam®) is an effective anti-malarial prescribed to over 35 million travellers world-wide as chemoprophylaxis. However, it has been the subject of increased scrutiny and media attention due to its association with significant neuropsychiatric adverse events. Anecdotal evidence suggests that patient trust in the drug is waning.

Methods

A prospective questionnaire-based cohort study of 150 deployed military personnel prescribed mefloquine as anti-malaria chemoprophylaxis. The primary study objective was to assess the rate of adverse reactions. In addition, an audit of mefloquine prescriptions and subsequent patient follow-up was conducted.

Results

Among a cohort of 111 individuals taking mefloquine, 54% reported at least one adverse effect and 13% required a change in prescription to a second-line anti-malarial, due to significant side-effects. All females prescribed mefloquine reported at least one adverse reaction. There were two cases of clinically significant adverse reactions.

Conclusions

There was a higher rate of adverse events reported amongst deployed military personnel than has been reported among civilian patients. This may be partly due to the stressful environment in which deployed personnel operate.
The recognition and management of body temperature disturbances in Royal Navy personnel
Authors: Angus DJC , Oakley EHN
Published: February 2021

This article discusses hypothermia and hyperthermia, described together as thermal illness. These conditions are seen within the United Kingdom (UK) Armed Forces population at home and abroad and may endanger life, with significant implications for both the individual and the chain of command. Recognition and management from initial presentation to return to duty is discussed and guidance given on occupational considerations.
Non-freezing cold injury
Authors: Glennie JS , Milner R
Published: February 2021

Non-freezing cold injury can be a diagnostic challenge for clinicians in the United Kingdom Armed Forces. It is associated with operations in adverse climatic conditions, and may result in significant long-term morbidity. In this article we discuss the operational importance of this condition and the current best practice in its management and prevention.
Shin-splints: Common exercise-related syndromes affecting the lower leg
Authors: Williamson BL , Arthur CHC
Published: February 2021

Lower leg pain is a common complaint of athletically active individuals, often limiting physical activities. As such, the group of lower leg conditions related to athletic pursuits and physical exercise confer considerable operational implications for the military. Whilst acute injuries to the lower limb are commonly encountered and are clearly of significance, this article focuses instead on chronic conditions related to physical activity. These include insults to bone such as stress fractures and medial tibial stress syndrome, and those related to the soft tissues such as chronic exertional compartment syndrome. In this article we will examine the presentation and management of these conditions.
Musculoskeletal injury patterns associated with military operations
Authors: Scott P J I
Published: February 2021

Musculoskeletal injury represents a significant attritional threat to troops on deployment and comprises a significant proportion of aeromedical evacuations from theatre. Whilst the incidence and outcome of battle injury (BI) is increasingly well understood, the picture regarding non-battle injury (NBI) is less clear despite the significantly higher incidence rate. This paper outlines and compares current evidence regarding the incidence, contributing factors and functional outcome of recent operational BI and NBI and highlights the need for further study into UK specific data and demographics.
Acute transfusion reactions: an update
Authors: Scorer T , Doughty H
Published: February 2021

Over the last decade the use of blood products by the United Kingdom (UK) military has increased significantly; with the increase in transfusion comes an increased incidence of transfusion-related incidents. Acute transfusion reactions (ATRs) are a common consequence of transfusion, which vary widely in their severity and are likely to be under-reported, although reporting is a regulatory requirement. This paper discusses the importance of identifying ATRs and managing them appropriately. It introduces a flowchart (due to be incorporated in the next version of Joint Service Publication (JSP) 999, Clinical Guidelines for Operations (CGOs)), which is designed to assist the military multi-disciplinary team caring for patients in the operational environment.
Infective skin conditions in an adult sea-going population
Authors: Tanzer J , Macdonald A , Schofield S
Published: February 2021

Infective skin conditions represent a significant element of the caseload for sea-going and shore-side clinicians. They are common within the wider military setting due to the frequent requirement to live in close proximity to others in conditions which favour the spread of skin and soft tissue infections (SSTI) (1, 2). Within the UK civilian population, 24% of individuals see their family doctor for skin conditions each year, accounting for 13 million primary care consultations annually. Of these, almost 900,000 were referred to dermatologists in England in 2009-2010 and resulted in 2.74 million secondary care consultations (3).

Several recent articles have highlighted the problem of Panton-Valentine Leukocidin Staphylococcus aureus (PVL-SA) infection and carriage in sailors on submarines, and soldiers deployed to Afghanistan (4, 5). However, the majority of published articles relate to land-based military personnel. This article aims to provide an overview of the most common infective skin conditions presenting among Naval personnel (based on the authors’ experience), illustrated by several case studies, together with an approach to their diagnosis and management.
Sports & Exercise Medicine
Authors: Wilson P , Welch J F
Published: February 2021

Sport-related eye injuries are a common cause of acute ocular injury. This article provides a basic clinical overview of the diagnosis and immediate medical management of sport-related eye injuries, and is relevant to all Armed Forces primary care and emergency medicine practitioners.
Operation PATWIN: HMS DARING’s experience of providing humanitarian disaster relief following super-Typhoon Haiyan.
Authors: Butterworth S J
Published: February 2021

Super-Typhoon Haiyan struck the Philippines on 7 November 2013. The initial reports estimated 10 000 fatalities and four million displaced persons. As the United Kingdom’s initial response to this disaster, HMS DARING was diverted from her deployment to take part in humanitarian aid, named Operation PATWIN. This article will outline the medical aspects of the relief effort undertaken and aim to identify any lessons that may inform future operations.
The operational role of the Royal Marines Band Service during the contingency era: lessons from Op GRITROCK
Authors: Brisley CR , Duggan A
Published: February 2021

The Royal Marines Band Service (RMBS) deploys in support of the Royal Naval Medical Service in a variety of operational roles. This article describes the roles that RMBS personnel performed whilst deployed on board RFA ARGUS during the recent Operation GRITROCK. The article is divided into five main sections, each describing one aspect of the work that RMBS ranks were asked to undertake: casualty handling; working within Primary Casualty Receiving Facility (PCRF) departments; personal protective equipment (PPE) monitoring and drills; temperature monitoring; and last, but not least, musical support. This will provide the reader with an insight into what the RMBS have achieved whilst deployed on board ARGUS and also what skills they are able to bring, both to contingency operations and operations in the medical environment.
PCRF Pathology, OP GRITROCK – A biomedical scientist’s perspective
Authors: Robinson JP
Published: February 2021

The Primary Casualty Receiving Facility (PCRF) Pathology Department was deployed on Operation GRITROCK from October 2014 to April 2015 to support the medical treatment facility on RFA ARGUS. The department deployed with enhanced microbiology capability and effectively became the microbiology reference laboratory for the Joint Operations Area (JOA). A platelet apheresis capability was delivered in the maritime environment for the first time on an active operation.
Medical supply on contingency military operations: experience from Operation GRITROCK
Authors: Robinson JP
Published: February 2021

Medical supply during military operations has the ability to affect the efficacy of the operation being undertaken, either negatively or positively. An appropriately-managed maritime platform with a robust medical supply chain during transit and on arrival in theatre is the main aim. A secure supply chain will reduce any implications that logistics may have with regard to capability, and negate the effects of deficiencies of short shelf life items occurring over time and during use in high tempo operations.
Nurse-delivered focused echocardiography to determine intravascular volume status in a deployed maritime critical care unit
Authors: Hutchings S , Bisset L , Cantillon L , Keating-Brown P , Jeffreys S , Muzvidziwa C , Richmond E , Rees P
Published: February 2021

Focused echocardiography is increasingly used by clinicians to guide fluid resuscitation. The UK Defence Medical Services (DMS) have adopted focused echocardiography as a tool to guide flow assessment and resuscitation in deployed critical care. We aimed to explore whether two focused echo techniques, namely Inferior Vena Cava (IVC) and Left Ventricular Outflow Tract Velocity Time integer (LVOT VTi) respiratory variability could be taught to a group of critical care nurses without previous exposure to ultrasound imaging. After a five-week program of training, validation was carried out on healthy volunteers. The mentor, an accredited focused echo trainer, and six nurses performed a total of forty-eight scans on eleven volunteers. The mentor and students acquired subcostal long axis views of the IVC and apical five chamber views using a high frequency linear ultrasound probe. Mean values from three measurements were obtained for IVC diameter and LVOT VTi. Minimum and maximum values were recorded for both variables across a full respiratory cycle. Echo images were saved and at least two images for each student were reviewed offline by an accredited echo-training supervisor. In all cases students were able to obtain adequate echo windows. There was good correlation between values recorded by the mentor and students for both IVC diameter (r=0.90, p<0.001) and LVOT VTi (r=0.77, p<0.001). Bland Altman analysis showed good correlation with minimal bias for VTi measurements. There was some increase in bias for IVC measurements below 1.2 cm. In summary, we found that these skills for assessing intravascular volume status could be acquired in a relatively short time by specialist nurses without previous experience, and that results were comparable to those produced by an experienced practitioner.
Medical reconnaissance for the Defence Medical Services Dhaulagiri Expedition 2016
Authors: Winchester J , Coombs B
Published: February 2021

The formation of a clear and well-informed medical plan is critical to the safe planning and execution of any expedition in remote locations. We performed a reconnaissance of medical facilities in Nepal in March 2015 prior to a large Defence Medical Services (DMS) expedition to the Dhaulagiri area in 2016. Visiting relevant medical facilities in person provides invaluable information and experience of what healthcare services may be relied upon in managing an expedition casualty, in scenarios ranging from minor illness to major trauma. We describe the principles, practice and level of detail required for performing such a medical reconnaissance and illustrate this with examples of our findings from Nepal.
Exercise HIMALAYAN SERPENT: feedback article
Authors: France K , Mellor A
Published: February 2021

Exercise HIMALAYAN SERPENT was open to junior doctors from the United Kingdom (UK) Armed Forces and aimed to educate potential expedition doctors on aspects of high altitude and wilderness medicine as well as conducting adventurous training (AT) and medical research. This was the first time such an exercise had been undertaken and this article explores the views of those junior doctors taking part to assess whether the exercise met the aims and objectives it set out.
The management of unexplained collapse in service age personnel
Authors: Martin AS , Edgar IA , Walker J
Published: February 2021

Unexplained collapse is a common presentation to medical practitioners, with a wide range of differential diagnoses making assessment problematic. Without a methodical approach to the patient presenting with unexplained collapse, potentially life-threatening conditions may not be recognised, whilst benign presentations can be over-investigated. This article will review the assessment, differential diagnosis and management of unexplained collapse, whilst considering the impact in the military environment.
A brown dog tick (Rhipicephalus sanguineus) bite at sea
Authors: Stachow E
Published: February 2021

Medical Officers (MOs) and Medical Branch Ratings (MBRs) must maintain an awareness of the risk of vector-borne diseases among deployed personnel.

Personnel working in the maritime environment may not expect to be at risk of tick bites, as ticks typically occupy habitats with dense vegetation such as forests or scrub land. However, tick-borne pathogens can cause serious and sometimes fatal disease, and therefore the risk of tick bites and associated diseases should be recognised.

We present a case of a tick bite in a member of a ship’s company eight days after leaving port. The tick was identified as a brown dog tick (Rhipicephalus sanguineus), a species known to thrive indoors. We describe several important tick-borne diseases which can be transmitted byR. sanguineusand explore best practice for tick removal and aftercare. Finally, we outline the appropriate management of suspected tick-borne disease in deployed personnel in the maritime environment.
The end for the ‘Roman Sandal’: an observational study of methods of securing chest drains in a deployed military setting
Authors: Howes RJ , Calder A , Hollingsworth A , Jones A
Published: February 2021

Introduction

There is ongoing debate regarding the optimal method of securing chest drains in trauma patients. Various courses describe methods for chest drain insertion, but little has been published to identify the best method to secure the drain.

Aim

This article aims to examine differences in approach to securing chest drains and the security of the methods used.

Method

Whilst in a deployed medical treatment facility, 26 clinicians from various specialties and nationalities were asked to secure a pre-placed drain. A 32F drain was placed in a manikin and the clinicians were given a chance to prepare their equipment. They were given a choice of suture and their attempts were observed by one of the researchers. The attempts were timed and photographed. A second researcher, who had not observed the technique, then assessed the security of the drain.

Results

15/26 clinicians used a ‘Roman Sandal’ technique with 5/26 proving to be insecure. Other techniques used showed no failure. The rate of consultant‐secured failure was 12.5% compared to 40% for registrars and 33% for General Duties Medical Officers.

Conclusions

The type of suture used made no difference, but the traditional ‘Roman Sandal’ method was insecure. Knots tied close to the skin and those that bit into the drain were shown to be most effective.
Molecular weight of Hydroxyethyl Starch Molecules influences Coagulation Profile measured by thrombelastography
Authors: Felfernig M , Virmani S , Weintraud M , Oberndorfer U , Zimpfer M , Veen H , Blaicher A M
Published: February 2021

Background

The consensus about the ideal intravenous fluid in trauma patients remains open. However, hypertonic saline and hydroxyethyl starch (HES) seems to have advantages in terms of immuno-modulatory and haemodynamic effects. Nevertheless clotting abnormalities are frequently reported in association with the use of HES. We investigated the influence of light, medium and heavy molecular weight (MW) hydroxyethyl starch (HES) on coagulation in 29 healthy subjects.

Methods

Ringer’s lactate (RL) served as a control solution. Thrombelastography using Haemoscope’s Thrombelastograph® (TEG®) hemostasis system was used to assess the effect of HES polymers and RL. TEG analysis was performed using recalcified native whole blood both with and without the addition of platelet activating factor IV (PAF IV) before and immediately after infusion of one of the
solutions.

Results

Infusion of RL or one of the three HES solutions exerts an anticoagulant effect as demonstrated by a increase in clot formation time (R) and a decrease in maximum amplitude (MA), and the angle. The addition of PAF IV reversed these changes.

Conclusions

This data indicate clear evidence of platelet activity per se or platelet interaction with the plasmatic coagulation system. Key words: Coagulation, thrombelastography, platelets, hydroxyethyl-starch
Research Presentations: Institute of Naval Medicine SpR Study Day 2011
Authors: Wood A M
Published: February 2021

Abstracts

Bismuth Thiols potentiate the effect of systemic antibiotics on infection in an animal model of contaminated open fracture
Aggressive Soft Tissue Infections and Amputation in Military Trauma Patients
Authors: Penn-Barwell JG , Fries CA , Sargeant ID , Bennett PM , Porter K
Published: February 2021

Due to the nature of IED injuries, during the conflicts in Iraq and Afghanistan The traditional, two-stage amputation for unsalvageable combat lower limb injuries has evolved into a strategy of serial debridement and greater use of plastic surgical techniques in order to preserve residual limb length. This study aimed to characterise the current treatment of lower limb loss with particular focus on the impact of specific wound infections. The UK military trauma registry and clinical notes were reviewed for details of all lower limb amputation identifying: 51 patients with 70 lower limb amputations. The mean number of debridements per stump prior to closure was 4.1 (95% CI 3.5-4.7). A final more proximal amputation level was required in 21 stumps (30%). Recovery of A. hydrophillia from wounds was significantly associated with a requirement for a more proximal amputation level (p=0.0038) and greater number of debridements (p=0.0474) when compared to residual limb wounds without A. hydrophillia.
Surgical Training in Camp Bastion, Afghanistan
Authors: Fries CA , Rickard RF
Published: February 2021

Introduction

Surgical trauma care on operations is delivered by consultants. The DMS presently delivers training to surgeons to enable them to deliver this care as newly-qualified consultants. Deploying as a trainee is one of many training evolutions available to achieve this competency. This paper describes the process involved in trainees deploying, and the training received by the first author (CAF) during a recent deployment.

Methods

Pre-deployment training and the process for gaining recognition of training time by the GMC are described. All surgical procedures performed by the first author were recorded prospectively, together with the level of supervision.

Results

The first author performed 210 procedures in 124 operations on 87 patients in a seven week deployment. This was prospectively recognised for training by the GMC. All procedures were supervised by consultant trainers. Procedures included trauma surgical procedures and those under the specialties of Plastic Surgery, Orthopaedic Surgery and General Surgery.

Conclusions

Deploying on operations as a trainee is invaluable in preparing DMS juniors for their future roles as consultants in the DMS. Training is received not only in a breadth of surgical and resuscitative procedures, beyond a trainee’s “base specialty”, but also in other critical aspects of deployments including Crew Resource Management.
Delay in Diagnosis of Neck of Femur Stress Fracture in a Female Military recruit.
Authors: Thomas R , Wood AM , Watson J , Arthur CHC , Nicol AM
Published: February 2021

We report the delay in diagnosis of a Neck of Femur (NOF) stress fracture in mixed sex basic military training. Stress fractures are common in military training with the incidence reported as ranging between 3.2-31%. NOF stress fractures, whilst only representing around 8% of stress fractures are associated with a high morbidity. It is imperative that medical officers looking after military recruits have a sound knowledge of the potential signs, symptoms and presentation of these injuries. Medical officers should always remains vigilant for stress fractures especially in mixed military training.
The management of acute musculoskeletal pain
Authors: Bone J , Beard D
Published: February 2021

Musculoskeletal pain is a common presentation in military patients. If not managed effectively it can have a detrimental effect on both the individual and the ship/unit. This article aims to examine how to thoroughly assess a military patient presenting with acute musculoskeletal pain; to provide the practitioner with a framework for effective pain history taking, and to help identify and exclude rare but serious causes of pain – ‘red and yellow flag concepts’. Key management steps and appropriate interventions for managing acute, benign musculoskeletal pain are discussed and related to the varying environments where the patient may be encountered.
The Royal Naval Medical Services: delivering medical operational capability. The ‘black art’ of Medical Operational Planning
Authors: Faye M
Published: February 2021

This article looks to dispel the mysteries of the ‘black art’ of Medical Operational Planning whilst giving an overview of activity within the Medical Operational Capability area of Medical Division (Med Div) within Navy Command Headquarters (NCHQ) during a period when the Royal Naval Medical Services (RNMS) have been preparing and reconfiguring medical capability for the future contingent battle spaces. The rolling exercise program has been used to illustrate the ongoing preparations taken by the Medical Operational Capability (Med Op Cap) and the Medical Force Elements to deliver medical capability in the littoral and maritime environments.
Penetrating brain injury: a case of survival following blast fragmentation injuries to the head
Authors: McKinlay J , Smith JE
Published: February 2021

We present a case of penetrating head injuries caused by blast fragmentation, along with other serious injuries (including to the arms, face and neck), where a good recovery was made despite an Injury Severity Score (ISS) of 75. We suggest that survival and outcome are reliant on several factors and cannot be predicted from ISS, velocity of penetrating injury or presenting Glasgow Coma Scale (GCS) alone.
The management of acute shortness of breath in young adults
Authors: Ahuja V Y , Freshwater D
Published: February 2021

Shortness of breath (SOB), or dyspnoea, is a common presenting symptom in acute care, responsible for 8% of all 999 calls to the ambulance service and ranking as the third most common type of emergency call (1). It may be associated with significant pathology, so prompt identification and appropriate management are therefore imperative. Although a formal diagnosis guides risk stratification, prognostication and treatment, it must not delay resuscitation. Rather, the management of an acutely short of breath (ASOB) patient must follow an algorithm incorporating simultaneous assessment and resuscitation. This article discusses both of these aspects in some detail, as well as key features in the history and the differential diagnosis, before concluding with some consideration of how the different operational environments in which such patients can present may affect their management.
Arctic coastal erosion: UAV-SfM data collection strategies for planimetric and volumetric measurements
Authors: Clark Andrew , Moorman Brian , Whalen Dustin , Fraser Paul
Published: February 2021

Above average warming in the Arctic is leading to increasing permafrost temperatures and a reduction in sea ice cover, which are expected to contribute to increasing rates of Arctic coastal erosion and sediment release. We studied a 1.5 km stretch of coastline off Richard’s Island, Northwest Territories, Canada, consisting of multiple retrogressive thaw slumps (RTSs) with varying degrees of activity over a one-year period. Multi-temporal 2D and 3D geomorphic analysis was based on unmanned aerial vehicle-Structure-from-Motion (UAV-SfM) data sets collected in 2018 and 2019. Over the observation period, −3.9 m and −1.1 m of planimetric cliff edge and toe retreat occurred, respectively, and corresponded to an average volumetric change of 8.1 m3 m−1. The accuracy of UAV-SfM-derived digital elevation models was tested using 12 data collection and processing scenarios, testing the influence of off-nadir camera angle, flight pattern, and georeferencing strategy. We found that oblique imaging and georeferencing strategy had a large influence on vertical accuracy and variability across the study site and has implications for studying volumetric changes in RTSs. This study furthers the geomorphological understanding of RTS processes by highlighting the complex relationship between planimetric and volumetric change along rapidly retreating Arctic coasts, and demonstrates advancements in measurement practices for UAV-SfM data sets.
High energy QCD: multiplicity dependence of quarkonia production
Authors: Gotsman E. , Levin E.
Published: February 2021

In this paper we propose an approach which demonstrates the dependence of quarkonia production on the multiplicity of the accompanying hadrons. Our approach is based on the three gluon fusion mechanism, without assuming the multiplicity dependence of the saturation scale. We show, that we describe the experimental data, which has a dependence that is much steeper than the multiplicity of the hadrons.
Further Remarks on the Operational Nonterminal Complexity
Authors: Dassow Jürgen
Published: February 2021

For a regular language [Formula: see text], let [Formula: see text] be the minimal number of nonterminals necessary to generate [Formula: see text] by right linear grammars. Moreover, for natural numbers [Formula: see text] and an [Formula: see text]-ary regularity preserving operation [Formula: see text], let the range [Formula: see text] be the set of all numbers [Formula: see text] such that there are regular languages [Formula: see text] with [Formula: see text] for [Formula: see text] and [Formula: see text]. We show that, for the circular shift operation [Formula: see text], [Formula: see text] is infinite for all [Formula: see text], and we completely determine the set [Formula: see text]. Moreover, we give a precise range for the left right quotient and a partial result for the left quotient. Furthermore, we add some values to the range for the operation intersection which improves the result of [ 2 ].
System Reliability Optimization of Multi-Source Multi-Sink Stochastic Flow Networks With Budget Constraint
Authors: Hassan M. R.
Published: February 2021

In this paper, we investigate system reliability optimization of multi-source multi-sink flow networks subject to transmission budget constraints. More specifically, we present a mathematical model of the optimization problem and a genetic algorithm (GA) to solve it. The GA is based on determining the optimal set of lower boundary points that maximize system reliability such that transmission cost does not exceed a specified upper bound. Finally, to ensure the efficiency of our approach, we apply our proposed algorithm to various network examples.
Calibration of the Heston stochastic local volatility model: A finite volume scheme
Authors: Engelmann Bernd , Koster Frank , Oeltz Daniel
Published: February 2021

The two most popular equity and FX derivatives pricing models in banking practice are the local volatility model and the Heston model. While the former has the appealing property that it can be calibrated exactly to any given set of arbitrage free European vanilla option prices, the latter delivers more realistic smile dynamics. In this paper, we combine both modeling approaches to the Heston stochastic local volatility model. We build upon a theoretical framework that has been already developed and focus on the numerical model calibration which requires special care in the treatment of mixed derivatives and in cases where the Feller condition is not met in the Heston model leading to a singular transition density at zero volatility. We propose a finite volume scheme to calibrate the model after a suitable transformation of the model equation and demonstrate its accuracy in numerical test cases using real market data.
The Matter of Tools
Authors: Posch Irene , Fitzpatrick Geraldine
Published: February 2021

Tools, as extensions of hand and mind, prescribe defining properties for a practice. We anchor our tools research within a case study of electronic textiles (eTextiles), combining textile materials and electronic and computational functionality. While the field of eTextiles is expanding into new personal and ubiquitous applications, its tools as productive means, however, are rarely investigated. We fill this gap by both proposing and exploring new tools, aiming at an integrated eTextile craft practice across disciplinary boundaries. Results from a research through design process have been developed into research products and proposed to a wider community of novices and practitioners. Research insights from making, using and reflecting on our new tools show they not only guide habits of making, but also are formative to the understanding of eTextiles as a practice and a field. Their form and function matter for the skills, processes and users, ultimately prescribing the technologies that surround us.
ACM SIGSOFT Empirical Standards Released
Authors: Ralph Paul
Published: February 2021

In October 2020, The ACM SIGSOFT Paper and Peer Review Quality Task Force released its first empirical standards. An empirical standard is "a brief public document that communicates expectations for a specific kind of study (e.g. a questionnaire survey)" [1]. (All quotations below are from the Empirical Standards report [1] unless otherwise noted.)
Metabolic flux analysis of branched-chain amino and keto acids (BCAA, BCKA) and β-hydroxy β-methylbutyric acid across multiple organs in the pig
Authors: Ten Have Gabriella A. M. , Jansen Lisa , Schooneman Marieke G. , Engelen Marielle P. K. J. , Deutz Nicolaas E. P.
Published: February 2021

Branched-chain amino acids (BCAA) and their metabolites the branched-chain keto acids (BCKA) and β-hydroxy β-methylbutyric acid (HMB) are involved in the regulation of key signaling pathways in the anabolic response to a meal. Substantial differences are present in (inter)organ metabolism and transport among the BCAA and its metabolites BCKA and HMB. The presented data in a translation animal model are relevant for the future development of optimized clinical nutrition.
Articulatory‐to‐Acoustic Conversion of Mandarin Emotional Speech Based on PSO‐LSSVM
Authors: Ren Guofeng , Fu Jianmei , Shao Guicheng , Xun Yanqin
Published: February 2021

The production of emotional speech is determined by the movement of the speaker’s tongue, lips, and jaw. In order to combine articulatory data and acoustic data of speakers, articulatory‐to‐acoustic conversion of emotional speech has been studied. In this paper, parameters of LSSVM model have been optimized using the PSO method, and the optimized PSO‐LSSVM model was applied to the articulatory‐to‐acoustic conversion. The root mean square error (RMSE) and mean Mel‐cepstral distortion (MMCD) have been used to evaluate the results of conversion; the evaluated result illustrates that MMCD of MFCC is 1.508 dB, and RMSE of the second formant (F2) is 25.10 Hz. The results of this research can be further applied to the feature fusion of emotion speech recognition to improve the accuracy of emotion recognition.
Gain of HIF1 Activity and Loss of miRNA let-7d Promote Breast Cancer Metastasis to the Brain via the PDGF/PDGFR Axis
Authors: Wyss Christof B. , Duffey Nathalie , Peyvandi Sanam , Barras David , Martinez Usatorre Amaïa , Coquoz Oriana , Romero Pedro , Delorenzi Mauro , Lorusso Girieca , Rüegg Curzio
Published: February 2021

Early detection and adjuvant therapies have significantly improved survival of patients with breast cancer over the past three decades. In contrast, management of metastatic disease remains unresolved. Brain metastasis is a late complication frequently observed among patients with metastatic breast cancer, whose poor prognosis calls for novel and more effective therapies. Here, we report that active hypoxia inducible factor-1 (HIF1) signaling and loss of the miRNA let-7d concur to promote brain metastasis in a recently established model of spontaneous breast cancer metastasis from the primary site to the brain (4T1-BM2), and additionally in murine and human experimental models of breast cancer brain metastasis (D2A1-BM2 and MDA231-BrM2). Active HIF1 and let-7d loss upregulated expression of platelet-derived growth factor (PDGF) B/A in murine and human brain metastatic cells, respectively, while either individual silencing of HIF1α and PDGF-A/B or let-7d overexpression suppressed brain metastasis formation in the tested models. Let-7d silencing upregulated HIF1α expression and HIF1 activity, indicating a regulatory hierarchy of the system. The clinical relevance of the identified targets was supported by human gene expression data analyses. Treatment of mice with nilotinib, a kinase inhibitor impinging on PDGF receptor (PDGFR) signaling, prevented formation of spontaneous brain metastases in the 4T1-BM2 model and reduced growth of established brain metastases in mouse and human models. These results identify active HIF1 signaling and let-7d loss as coordinated events promoting breast cancer brain metastasis through increased expression of PDGF-A/B. Moreover, they identify PDGFR inhibition as a potentially actionable therapeutic strategy for patients with brain metastatis.

Significance:

These findings show that loss of miRNA let-7d and active HIF1 signaling promotes breast cancer brain metastasis via PDGF and that pharmacologic inhibition of PDGFR suppresses brain metastasis, suggesting novel therapeutic opportunities.
Abstract IA004: Challenges for future adjuvant studies and the role of immunotherapy in endometrial cancer
Authors: Nout Remi A.
Published: February 2021

Adjuvant therapy for endometrial cancer (EC) is recommended based on risk factors. In current clinical practice these are mainly based on classical pathological factors such as stage, grade and presence of LVSI. The Cancer Genome Atlas Group demonstrated that EC can be divided in four distinct subgroups with impact on prognosis. This has now been shown to be feasible using surrogate markers in multiple large cohorts. Analysis of the intratumoral immune infiltrate using a machine learning image-based algorithm, found that low intraepithelial density of CD8+ cells was an independent prognostic factor for recurrence free survival. Combining intraepithelial CD8+ cell density with molecular and pathological factors improved the risk stratification model. Exploratory analysis found a significant impact within the p53abnormal and no specific molecular profile subgroups. While in intermediate to high-intermediate risk the majority has no specific molecular profile, in high risk there are more patients with POLE hypermutated tumors, p53abnormal and mismatch repair deficient tumors. The question is how to bring these molecular factors to the clinic? Molecular stratification does present additional subgroups with a rationale for targeted approaches. It does however present a challenge for trial design and feasibility, An overview of current ongoing studies using targeted therapies is provided, with a focus on immune checkpoint inhibition.

Citation Format: Remi A. Nout. Challenges for future adjuvant studies and the role of immunotherapy in endometrial cancer [abstract]. In: Proceedings of the AACR Virtual Special Conference: Endometrial Cancer: New Biology Driving Research and Treatment; 2020 Nov 9-10. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(3_Suppl):Abstract nr IA004.