bluuebunny/crossref_metadata_2025 huggingface dataset:
Objective Measurement of Physical Activity Attributed to a Park-Based Afterschool Program
Authors: Booth Ja’mese V. , Messiah Sarah E. , Hansen Eric , Nardi Maria I. , Hawver Emily , Patel Hersila H. , Kling Hannah , Okeke Deidre , D’Agostino Emily M.
Published: February 2021

Background: Only 24% of US youth meet physical activity recommendations set by the Centers for Disease Control and Prevention. Research demonstrates that community-based programs provide underresourced minority youth with opportunities for routine physical activity, although limited work draws from accelerometry data. This study objectively assessed youth physical activity attributable to participation (vs nonparticipation) days in a park-based afterschool program in Miami-Dade County, Miami, FL. Methods: Participants’ (n = 66; 60% male; 57% white Hispanic, 25% non-Hispanic black, 14% Black Hispanic, mean age = 10.2 y) physical activity was assessed April to May 2019 over 10 days across 7 park sites using Fitbit (Charge 2) devices. Separate repeated-measures multilevel models were developed to assess the relationship between program daily attendance and total (1) moderate to vigorous physical activity minutes and (2) step counts per day. Results: Models adjusted for individual-level age, sex, race/ethnicity, poverty, and clustering by park showed significantly higher moderate to vigorous physical activity minutes (β = 25.33 more minutes per day; 95% confidence interval, 7.0 to 43.7, P < .01) and step counts (β = 4067.8 more steps per day; 95% confidence interval, 3171.8 to 4963.8, P < .001) on days when youth did versus did not attend the program. Conclusions: Study findings suggest that park-based programs may support underserved youth in achieving daily physical activity recommendations.
Parasite-Host Dynamics throughout Antimalarial Drug Development Stages Complicate the Translation of Parasite Clearance
Authors: Burgert Lydia , Zaloumis Sophie , Dini Saber , Marquart Louise , Cao Pengxing , Cherkaoui Mohammed , Gobeau Nathalie , McCarthy James , Simpson Julie A. , Möhrle Jörg J. , Penny Melissa A.
Published: February 2021

Ensuring continued success against malaria depends on a pipeline of new antimalarials. Antimalarial drug development utilizes preclinical murine and experimental human malaria infection studies to evaluate drug efficacy.
Self-Collected Saline Gargle Samples as an Alternative to Health Care Worker-Collected Nasopharyngeal Swabs for COVID-19 Diagnosis in Outpatients
Authors: Goldfarb David M. , Tilley Peter , Al-Rawahi Ghada N. , Srigley Jocelyn A. , Ford Geoffrey , Pedersen Heather , Pabbi Abhilasha , Hannam-Clark Stephanie , Charles Marthe , Dittrick Michelle , Gadkar Vijay J. , Pernica Jeffrey M. , Hoang Linda M. N.
Published: February 2021

We assessed the performance, stability, and user acceptability of swab-independent self-collected saliva and saline mouth rinse/gargle sample types for the molecular detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in adults and school-aged children. Outpatients who had recently been diagnosed with COVID-19 or were presenting with suspected COVID-19 were asked to have a nasopharyngeal (NP) swab collected and provide at least one self-collected sample type.
Harnessing Machine Learning To Unravel Protein Degradation in Escherichia coli
Authors: Nagar Natan , Ecker Noa , Loewenthal Gil , Avram Oren , Ben-Meir Daniella , Biran Dvora , Ron Eliora , Pupko Tal
Published: February 2021

Bacteria use protein degradation to control proliferation, dispose of misfolded proteins, and adapt to physiological and environmental shifts, but the factors that dictate which proteins are prone to degradation are mostly unknown. In this study, we have used a combined computational-experimental approach to explore protein degradation in
E. coli
.
Supplemental Material: Reappraisal of the Mesozoic tectonic transition from the Paleo-Tethyan to Paleo-Pacific domains in South China
Authors: Gan Chengshi , Zhang Yuzhi , al. et
Published: February 2021

Synthesis of the formation ages of the Triassic and Jurassic mafic rocks, shoshonitic rocks and granitoids in the Southeastern South China Block; Table S2: Major oxide (wt%) and trace element (ppm) compositions for the Triassic and Jurassic mafic rocks, shoshonitic rocks and high-Mg andesite and granitoids in the Southeastern South China Block; Table S3: Sr-Nd isotope compositions for the Triassic and Jurassic mafic rocks, shoshonitic rocks and high-Mg andesite and granitoids in the Southeastern South China Block; Table S4: Zircon Hf isotope compositions for the Triassic and Jurassic mafic and shoshonitic rocks and granitoids in the Southeastern South China Block; Figure S1: (A) Ta/Yb-Ce/Yb diagram for the Triassic and Jurassic shoshonitic rocks and (B) SiO2-MgO diagram for the Jurassic high-Mg andesite in the Southeastern South China Block; Figure S2: The variations of high field strength elements (HFSE) with loss on ignition (LOI) for the Jurassic mafic rocks in the Southeastern South China Block.
Rare case of osteomyelitis caused byGardnerella vaginalisandStreptococcus parasanguinisin a postmenopausal woman
Authors: Kim Jin-Ju , de Castro Junior Ricardo Lessa , Schauer Mark , Bauler Laura D
Published: February 2021

Vertebral osteomyelitis is an infection of the vertebrae that can lead to spinal degeneration, most commonly caused byStaphylococcus aureus. Here, we report an unusual case of pyogenic osteomyelitis caused byGardnerella vaginalisandStreptococcus parasanguinisin a 61-year-old postmenopausal woman. The patient presented with a 2-week history of worsening lower back pain and fever and a recent episode of cystitis following re-engagement of sexual activity. Imaging revealed a deterioration of vertebrae discs and spinal canal stenosis at the L3-L4 levels with a formation of abscess in the right psoas muscle. Needle aspiration of the abscess identifiedG. vaginalisandS. parasanguinisand the patient was successfully treated with a 6-week course of ceftriaxone and metronidazole. This case describes an unusual coinfection of two pathogens that normally reside in the urogenital tract and oral cavity, respectively, and highlights the risk posed when these organisms breach the body’s normal barriers.
Fournier’s gangrene with dapagliflozin in a rural hospital: a case report
Authors: Elbeddini Ali , Tayefehchamani Yasamin , Davey Michelle , Gallinger Jodi , Hooda Naushin , Aly Ahmed , Erickson Dawn , Lee Stephanie
Published: February 2021

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which are used for treatment of type 2 diabetes, are associated with risk of urogenital infections. FDA issued a black box warning about multiple case reports of Fournier’s gangrene (FG) observed in patients taking SGLT2 inhibitors. FG is a type of necrotising fasciitis that occurs in the anogenital area. We report a case of a 71-year-old woman with type 2 diabetes on dapagliflozin, presenting with foul-smelling discharge and a large abscess in the perianal area. Her risk factors for FG included her advanced age, obesity, diabetes and trauma to the site. During her stay, dapagliflozin was discontinued and she received procedural debridement, wound care and broad-spectrum intravenous antibiotics. Due to possible association between FG and SGLT2 inhibitors, patients presenting with signs and symptoms of FG who are taking SGLT2 inhibitors should be examined for infection in the urogenital area and treated promptly.
Localised laryngotracheal amyloidosis: a differential diagnosis not to forget
Authors: Mira Catarina , Montalvão Pedro , Fonseca Isabel , Borges Alexandra
Published: February 2021

We present a case of multifocal laryngotracheal amyloidosis (LTA) in a 43-year-old man with persistent and progressive dysphonia and dyspnoea, and a first inconclusive histology. Although laryngeal amyloidosis accounts for fewer than 1% of all benign laryngeal tumours, it is in fact the most common site of amyloid deposition in the head, neck and respiratory tract. The clinical scenario is non-specific and diagnosis depends on a high degree of suspicion and on histology. Imaging is useful in mapping lesions, which are often more extensive than they appear during laryngoscopy. Despite being a benign entity, the prognosis is variable with a high-rate and long-latency recurrences, requiring long-term follow-up.
Management of aggressive posterior retinopathy of prematurity in oculocutaneous albinism
Authors: Panchal Bhavik , Gulati Megha
Published: February 2021

A male infant, born preterm at 32 weeks of gestation, was referred at 36-week postmenstrual age for retinopathy of prematurity (ROP) screening. He had nystagmus, generalised hypopigmentation of skin, hair and eyes with preaxial polydactyly. The fundus was depigmented with prominently visible choroidal vessels. The retinal vessels were dilated, tortuous at zone 1. There was presence of arcading, shunting of vessels with presence of vitreous haemorrhage in the left eye. A diagnosis of aggressive posterior retinopathy of prematurity (APROP) in association with oculocutaneous albinism (OCA) was made.

Half-dose intravitreal bevacizumab was used to treat the vascular condition. After 2 weeks, there was complete regression of APROP with a completely mature retina observed at 4 months post-treatment. Herein, we describe the role of red-free light for screening ROP in infants with OCA; challenges in the management of ROP with laser photocoagulation compared with intravitreal anti-vascular endothelial growth factor therapy.
A case of SARS-CoV-2 reinfection in a patient with obstructive sleep apnea managed with telemedicine
Authors: Sicsic Jr Isabelo , Chacon Andres R , Zaw Moe , Ascher Kori , Abreu Alexandre , Chediak Alejandro
Published: February 2021

The novel coronavirus (SARS-CoV-2) has produced millions of infections and deaths worldwide. It is believed that adaptive immunity to the virus occurs although with variation in its pattern and duration. While uncommon, confirmed reinfection with the novel coronavirus has been reported. Telemedicine has emerged as a viable tool for the delivery of healthcare in lieu of in-person patient contact. The variable and occasionally rapid course of clinical disease raises safety concerns of using telemedicine in the clinical management of acute infection with the novel coronavirus. We present a case of novel coronavirus infection in an immunocompetent individual with obstructive sleep apnea (OSA) who failed to manifest an adaptive immune response to acute infection and was subsequently reinfected. The case highlights the use of telemedicine in managing novel coronavirus respiratory disease and the potential role of OSA as a disease facilitator.
Adherence in leading medical journals to the CONSORT 2010 statement for reporting of binary outcomes in randomised controlled trials: cross-sectional analysis
Authors: Nunan David , Watts Isabella , Kaji Furqaan Ahmed , Hansjee Shanil , Heneghan Carl
Published: February 2021

Clinicians and lay people tend to overestimate the effectiveness of a treatment when only the relative effect is presented, particularly if the relative effect is large, but the absolute effect is small. In recognition of this problem, item 17b of The Consolidated Standards of Reporting Trials (CONSORT) 2010 statement stipulates authors present both absolute and relative effects for binary outcomes in randomised controlled trials (RCTs). Adherence to item 17b and the effect of differing levels of CONSORT endorsement by journals on adherence is not well known. We assessed the extent to which item 17b is adhered to in 258 RCTs published in five leading medical journals (Annals of Internal Medicine,BMJ,JAMA,The LancetandThe New England Journal of Medicine) between January and December 2019 that all endorsed the CONSORT statement to varying degrees. Only 53 of 258 (20.5%; 95% CI 15.8% to 26.0%) included studies adhered fully to item 17b. Proportional adherence was higher in journals that endorsed the statement more strictly (BMJandJAMA, 47.4% [34.0% to 61.0%]) compared with journals less strict in their endorsement (NEJMandAnn Intern Med, 12.2% [7.0% to 19.3%];The Lancet, 14.1% [7.3% to 23.8%]). Journals that only recommend author adherence to CONSORT had a greater proportion of studies reporting only relative effects in the main results section (62.6%) and abstract (64.2%) compared with journals that require authors to submit a completed checklist (24.6% and 29.8%, respectively). The majority of RCTs (79.5%) with binary primary outcomes published in five leading medical journals during 2019 do not report both absolute and relative effect estimates as per item 17b of the CONSORT guideline despite its universal endorsement. Differences in adherence were observed between journals that endorsed the CONSORT statement to differing extents.
Three-year review of a capacity building pilot for a sustainable regional network on food, nutrition and health systems education in India
Authors: Buckner Luke , Carter Harrison , Ahankari Anand , Banerjee Rinku , Bhar Somnath , Bhat Shivani , Bhattacharya Yagnaseni , Chakraborty Debashis , Douglas Pauline , Fitzpatrick Laura , Maitra-Nag Sudeshna , Muhkerjee Sagarika , Ray Sabyasachi , Roy Ananya , Saha Aparjita , Sayegh Marietta , Rajput-Ray Minha , Tsimpli Ianthi , Ray Sumantra
Published: February 2021

Background

In Kolkata (India), there are high rates of malnourished children (45.9%) under the age of three, impacting growth, organ development, function, and cognition. Mothers have a major role to play during this crucial development stage, with research showing nutrition knowledge, attitudes and practices (KAP) of mothers are important determinants of childhood malnutrition.

Aims

To document 3 years of capacity building towards a sustainable nutrition education network in Kolkata, India, while assessing the ability to perform data collection in the form of needs assessments, impact assessments and capacity reviews.

Methods

Descriptive review and analysis of engagement and impact from 3 years of work by the NNEdPro Global Centre for Nutrition and Health, initiating locally led nutrition education interventions. Mapping to the Indian National Nutrition Strategy was also performed to review adherence to nationwide priorities surrounding nutrition and determine the wider application potential of the network.

Results

Two simultaneous projects were taken forward by a team of local healthcare professionals and student champions. Project 1—medical college workshops for medical student nutrition education with added focus on underserved populations, Project 2—preparation for a ‘Mobile Teaching Kitchen’ (MTK) in marginalised communities to empower local women as nutrition educators.

Data collection methods used for analysing markers of impact and sustainability were semi-structured interviews of the community members, and KAP questionnaires to assess response to educational sessions.

Conclusion

With local support it is possible to create and sustain fieldwork for an extended period with meaningful outputs and impact. This initiative demonstrates that it is possible to use healthcare professionals, students and volunteers with low-intensity training and a low-cost approach to produce action research with considerable impact and results in rapid, reliable and robust manner.
Neonatal and perinatal palliative care pathway: a tertiary neonatal unit approach
Authors: Akyempon Abena N , Aladangady Narendra
Published: February 2021

A lack of well-structured guideline or care pathway results in inadequate, inconsistent and fragmented palliative care (PC) for babies and their families. The impact on the families could be emotionally and psychologically distressing. Not all neonatal units have specialist PC clinicians or teams, and such units will benefit from a well-planned perinatal PC pathway. In this article, we discuss a tertiary neonatal unit perinatal care pathway which provides guidance from the point of diagnosis and establishment of eligibility of a baby for PC through to care after death and bereavement support for families. Planning PC with families which encourages family-centred and individualised approach is also discussed.
British Intestinal Failure Alliance (BIFA) guidance - haematological and biochemical monitoring of adult patients receiving home parenteral nutrition
Authors: Mercer-Smith Gavin William , Kirk Colette , Gemmell Lisa , Mountford Christopher , Nightingale Jeremy , Thompson Nick
Published: February 2021

Home parenteral nutrition (HPN) is necessary for patients with prolonged intestinal failure which can be secondary to a variety of pathophysiological mechanisms or surgical resection. HPN is needed to supply micronutrients, macronutrients and water to reduce morbidity and mortality and to maximise the patient’s quality of life.

HPN requires close monitoring by a dedicated multidisciplinary team and is vital to minimise complications; both catheter related and metabolic. A regular comprehensive review is required including history, examination including anthropometry and blood testing. The focus of this review is on the monitoring of haematological and biochemical parameters.

There is a paucity of evidence-based literature on the biochemical monitoring of HPN and existing guidance is sourced mostly on expert opinion and lower grade studies. Sources offering guidance on the frequency of biochemical monitoring for the stable adult HPN patient are the British Association for Parenteral and Enteral Nutrition, the European Society for Parenteral and Enteral Nutrition, the National Institute for Health and Care Excellence and the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN).

The aim of this work is to review and collate this existing guidance into one clear and concise review. It is recommended that biochemical parameters are checked at baseline, thereafter more frequently if concerns arise and less frequently when the patient’s condition is stable, as assessed by the multidisciplinary team with expertise in HPN.
Global longitudinal strain predicts cardiovascular events after coronary artery bypass grafting
Authors: Olsen Flemming Javier , Lindberg Søren , Pedersen Sune , Iversen Allan , Davidovski Filip Soeskov , Galatius Søren , Fritz-Hansen Thomas , Gislason Gunnar Hilmar , Søgaard Peter , Møgelvang Rasmus , Biering-Sørensen Tor
Published: February 2021

Objective

To determine the prognostic value of global longitudinal strain (GLS) after coronary artery bypass grafting (CABG).

Methods

We performed a retrospective cohort study on patients undergoing CABG between 2006 and 2011 who had an echocardiogram available for strain analysis. The patients were followed up through nationwide registries for development of all-cause mortality, cardiovascular death (CVD) and major adverse cardiovascular events (MACEs) defined as heart failure hospitalisation and/or CVD. Multivariable Cox regression was applied to adjust for the European System for Cardiac Operative Risk Evaluation II (EuroSCORE-II). Additive value was assessed by Net Reclassification Index (NRI) improvement.

Results

Of the 709 patients included, 80 died during a median follow-up of 3.8 years. Of these, 45 had CVD, and 72 patients experienced MACE. Mean age was 68 years and 85% were men. Left ventricular ejection fraction (LVEF) was 50% and GLS was −13%.

GLS was an independent predictor when adjusted for the EuroSCORE-II (all-cause mortality: HR=1.07 (1.01–1.13), p=0.018; CVD: HR=1.11 (1.03–1.20), p=0.007; MACE: HR=1.12 (1.06–1.19), p<0.001, per 1% absolute decrease). GLS significantly improved the NRI score by 0.30 when added to the EuroSCORE-II for predicting MACE, but not significantly for the other endpoints.

LVEF modified the association between GLS and outcomes (p for interaction<0.05 for CVD and MACE). GLS remained an independent predictor of outcomes in patients with preserved LVEF (LVEF≥50%) and improved the NRI score when added to the EuroSCORE-II for predicting CVD and MACE, but not all-cause mortality in these patients.

Conclusion

GLS is an independent predictor of long-term outcomes after CABG. The predictive value appears strongest among patients with preserved LVEF.
Postchallenge Glucose Increment Was Associated with Hemoglobin Glycation Index in Subjects with No History of Diabetes
Authors: Wang Jun-Sing , Lee I-Te , Lee Wen-Jane , Lin Shih-Yi , Lee Wen-Lieng , Liang Kae-Woei , Sheu Wayne Huey-Herng
Published: February 2021

We investigated the association between postchallenge glucose increment and hemoglobin glycation index (HGI), the difference between observed and predicted glycated hemoglobin (HbA1c), in subjects with no history of diabetes. We enrolled 1381 subjects who attended our outpatient clinic for an oral glucose tolerance test (OGTT) to screen for diabetes. HGI was defined as observed HbA1c minus predicted HbA1c. The predicted HbA1c was calculated by entering fasting plasma glucose (FPG) level into an equation [HbA1c(%)=FPG(mg/dL)*0.029+2.9686] determined from an HbA1c versus FPG regression analysis using data from an independent cohort of 2734 subjects with no history of diabetes. The association between 2-hour glucose increment and HGI was analyzed using linear regression analyses with adjustment of relevant parameters. Overall, the proportions of subjects with normal glucose tolerance, pre-diabetes, and newly diagnosed diabetes were 42.3%, 41.3%, and 16.4%, respectively. Compared with subjects who had an HGI≤0, subjects with an HGI>0 had a lower FPG (95.0±13.3 vs 98.5±15.3 mg/dL, p<0.001) but a higher 2-hour plasma glucose (151.1±52.8 vs 144.6±51.4 mg/dL, p=0.027) and 2-hour glucose increment (56.1±46.1 vs 46.1±45.0 mg/dL, p<0.001). The 2-hour glucose increment after an OGTT was independently associated with HGI (β coefficient 0.003, 95% CI 0.002 to 0.003, p<0.001). Our findings suggested that postchallenge glucose increment was independently associated with HGI in subjects with no history of diabetes.
Immunotherapy for sarcomas: new frontiers and unveiled opportunities
Authors: Birdi Harsimrat Kaur , Jirovec Anna , Cortés-Kaplan Serena , Werier Joel , Nessim Carolyn , Diallo Jean-Simon , Ardolino Michele
Published: February 2021

Sarcomas are a rare malignancy of mesenchymal tissues, comprizing a plethora of unique subtypes, with more than 60 types. The sheer heterogeneity of disease phenotype makes this a particularly difficult cancer to treat. Radiotherapy, chemotherapy and surgery have been employed for over three decades and, although effective in early disease (stages I–II), in later stages, where metastatic tumors are present, these treatments are less effective. Given the spectacular results obtained by cancer immunotherapy in a variety of solid cancers and leukemias, there is now a great interest in appliying this new realm of therapy for sarcomas. The widespread use of immunotherapy for sarcoma relies on immuno-profiling of subtypes, immunomonitoring for prognosis, preclinical studies and insight into the safety profile of these novel therapies. Herein, we discuss preclinical and clinical data highlighting how immunotherapy is being used in soft tissue sarcoma and bone sarcomas.
Breast lumps in service women
Authors: Pengelly S , Lambert AW , Khan M , Groome J
Published: February 2021

Introduction

Breast cancer is uncommon in a young population but it does occur. 80% of breast cancer occurs after 50 yrs of age. This article uses current guidelines and evidence to advise military medical staff on how best to investigate and manage servingage women presenting with breast symptoms. Male breast changes will be dealt with in a future article.

Differential Diagnosis

Young females presenting with breast lumps are unlikely to have cancer. In order of frequency the causes are likely to be benign breast change; fibroadenoma; abscesses in 20-30 year olds; cysts in 30-40 year olds; and lastly cancer. The UK sees 48,000 new cases of breast cancer in women every year; breast cancer can also occur in men but is very rare.

Diagnosis and Management

Management in the deployed, primary and secondary care settings are described. It may be reasonable in young women to wait and see if a lump resolves after the patient’s next menstrual cycle before referring the patient. Once referred, current guidelines recommend that all patients are seen by a breast surgeon within two weeks. Within this group, a subgroup of patients with ‘red-flag’ lumps is identified who need to be referred urgently. The remaining patients have lumps that can be considered non-urgent: however, hospitals will still endeavour to see these patients within two weeks..

Conclusions

Breast cancer is more difficult to diagnose in the younger patient. In primary care, breast lumps are still simple to manage if the points in this article are followed. Anxious patients can be reassured that cancer is unlikely. However, cancer in this young age group is associated with worse outcomes than breast cancer in older patients.
The psychopharmacological treatment of depression in primary care in the Royal Navy
Authors: Coetzee RH
Published: February 2021

Depression is a common mental health condition in the UK Armed Forces. Although psychopharmacology is usually a second line intervention, there is a place for antidepressants in the management of depression in primary care. This article will examine the diagnosis of depression, the indications for starting antidepressants, the choice of anti-depressants and the occupational considerations in the Royal Navy. The aim is to equip General Practitioners (GPs) and General Duties Medical Officers (GDMOs) with the clinical information needed to initiate psychopharmacological treatment for depression where indicated.
Op Patwin Part 2: HMS Illustrious’ medical response to typhoon Haiyan
Authors: Dew A
Published: February 2021

Operation PATWIN was the United Kingdom’s (UK) response to the disaster caused by Typhoon Haiyan. The UK deployed a force including HMS DARING and HMS ILLUSTRIOUS and this article describes the medical response including the deployment of a Role 2 medical team and the hosting of a UK civilian medical team UK Med. The deployment followed humanitarian guidelines in UK doctrine and contained in the Oslo guidelines, but demonstrated a unique example of a civilian team supported by the military.
Multiple casualties in the Bastion UK Role 3 hospital: personal reflections on the positive evolution of deployed military hospital care
Authors: Ross RA , Selwood P
Published: February 2021

In this article a snapshot of casualty presentations to the UK Role 3 hospital in Camp Bastion, Afghanistan, will be briefly described. The observations allow reflection on the advances and strength of clinical provision at the time of the incident, written from a medical command perspective.
Eczema and dermatitis in the afloat population: an overview of the assessment and management of the common erythematous skin conditions encountered in adults deployed on afloat platforms
Authors: Lundie A , Turner M
Published: February 2021

Skin conditions constitute a large proportion of the workload of deployed medical staff. Dermatology is an area where pattern recognition is key, and making a diagnosis can sometimes be difficult for deployed medical staff, who may have limited experience of dermatology. This article provides a structure to assess patients presenting with skin rashes, as well as a summary of the key features and management of common types of dermatitis that may be encountered when deployed afloat: atopic eczema; irritant contact dermatitis; pompholyx; scabies and plaque psoriasis.
The acutely swollen knee Part 1: Management of atraumatic pathology
Authors: Guyver P M , Arthur C H C , Hand C J
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, a Regimental Aid Post or 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 One, we will be examining the management of non-traumatic causes, followed by Part Two, looking at traumatic causes, in the next issue of the Journal. A detailed clinical history combined with thorough clinical examination will establish the diagnosis, or at least the narrow differential diagnosis in the majority of cases. The uses 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 related to atraumatic pathology.
The management of lower back pain
Authors: Morrow LJ , Smith S
Published: February 2021

Lower back pain (LBP) is one of the most common musculoskeletal conditions, with an estimated 60-70% of the adult population experiencing a back problem at some point in their lives. It can have a significant social and occupational impact on a patient, and therefore is a major concern to both civilian and military populations. The impact of low back pain in the military setting, regardless of chronicity, can result in considerable restrictions on a patient’s ability to perform his or her job. This may have important ramifications for deployability, medical category and, potentially, a patient’s future career.

This article will consider the diagnosis and classification of lower back pain (LBP) in the pre-shore, pre-hospital and hospital settings. It will detail management options including investigations, pain management and referral options; furthermore, the potential occupational implications of lower back pain will be detailed.
Optimising the management of severe Traumatic Brain Injury in the military maritime environment
Authors: Edgar IA , Hadjipavlou G , Smith JE
Published: February 2021

Severe Traumatic Brain Injury (sTBI) is a devastating cause of morbidity and mortality, especially among those aged less than 45 years. Advances in clinical practice continue to focus on preventing primary injury through developing ballistic head and eye protection, and through minimising secondary brain injury (secondary prevention).

Managing sTBI is challenging in well-developed, well-resourced healthcare systems. Achieving management aims in the military maritime environment poses even greater challenges.

Strategies for the management of sTBI in the maritime environment should be in keeping with current best evidence. Provision of specialist interventions for sTBI in military maritime environments may require alternative approaches matched to the skills of the staff and environmental restrictions.
The differential diagnosis and management of headaches in primary care and their relevance in the UK armed forces
Authors: Laird J , Evershed MC
Published: February 2021

As with the general population, headaches are commonly suffered by members of the United Kingdom Armed Forces. These are often managed by patients with over-the-counter medication without the involvement of healthcare professionals. Patients may present to medical teams when deployed because of limited access to over-the-counter medication or because of concerns about the cause of the headache. This article will examine the differential diagnosis and management of headaches in primary care as well as considering the occupational and operational aspects related to the Royal Navy (RN). The aim is to equip General Practitioners (GPs) and General Duties Medical Officers (GDMOs) with the clinical knowledge to diagnose various common forms of headaches and to detect the red flag symptoms that warrant further investigation. This article will also make specific reference to the service person and the impact of headaches on occupational functioning and operational capability.
The treatment of haematemesis and upper gastrointestinal bleeding in United Kingdom Armed Forces and other deployed units
Authors: Woodward Arr , Khan M
Published: February 2021

Introduction

Upper Gastro-intestinal (UGI) bleeding is a significant cause of morbidity worldwide. United Kingdom Armed Forces (UKAFs) are not immune to this condition. There is a substantial body of conflicting evidence regarding initial management and risk stratification.

Aim

To provide the background knowledge and treatment pathways required to assess and manage a patient adequately during the first 24 hours of an episode of UGI bleeding.

Assessment

Clinical grading of hypovolaemic shock is inaccurate, but is a broad indicator of severity; the Rockall Score must not be used to assess requirement for intervention. Where laboratory assets are available, the Blatchford score is adequate to assess requirements for intervention.

Management

The principles of hypotensive resuscitation (target systolic blood pressure 90 mmHg for the first hour) hold true for UGI bleeds. In areas where endoscopy is available within four hours, a restrictive pattern of packed Red Blood Cell (pRBC) transfusion may be beneficial. Despite limited evidence of benefit, Proton Pump Inhibitors (PPIs) should be given routinely in UKAFs. Where available, in cases of variceal and non-variceal UGI Haemorrhage without locally available endoscopy, administration of tranexamic acid and somatostatin or octreotide should be considered.
Contraception in sea-going service personnel
Authors: Hawkins DM , Booth R
Published: February 2021

The right to make an informed choice about contraception should be afforded to every individual serving within the United Kingdom (UK) Armed Forces. This article looks at the responsibilities and approach that healthcare professionals should take within a Primary Care setting, summarises the common contraceptive options available, discusses the associated advantages and disadvantages of each technique, and considers operational factors in a military environment that combine to influence the final contraceptive choice an individual makes.

Case Study

A 19-year old Able Rate joined the Royal Navy (RN) and at her joining medical it was noted that she had been on Microgynon™ combined oral contraceptive pill for approximately three years. During this time, her menstrual periods remained light; she never experienced adverse effects, demonstrated good compliance, and was happy to remain on this contraceptive regimen.

Over the course of the next eighteen months, she was reviewed by a number of Medical Officers and Civilian Medical Practitioners on a quarterly basis, with Microgynon™ re-prescribed on each occasion. The appropriate Defence Medical Information Capability Programme (DMICP) template was used, with weight, smoking status, compliance and any issues or comments documented accordingly. In December 2010, a discussion regarding long-acting reversible contraception (LARC) was documented for the first time. The patient agreed to give LARC some thought and a review appointment was made for one month. She was subsequently started on the progestogen-only pill Cerazette™. It was noted by the consulting doctor that both the patient’s mother and grandmother had a positive history of cerebrovascular events and the combined oral contraceptive pill was discontinued.

Upon review at two months, the patient reported that she was content on Cerazette™ and wished to continue with this medication. She was amenorrhoeic, highly compliant, had given up smoking and her weight and blood pressure were stable. However, due to supply issues, it was explained that Cerazette™ was no longer a viable option for her. She had no plans to start a family, and was keen to investigate other contraceptive options. Furthermore, she expressed a particular desire to remain amenorrhoeic, as she was due to deploy overseas in the coming months, and not only wanted to avoid the inconvenience of having her period, but also felt it preferable not to have to take a daily pill when considering the constantly changing time zones. She subsequently had the etonogestrel-releasing subdermal implant Nexplanon™ fitted without complication. She has remained amenorrhoeic throughout and this form of long-acting reversible contraception has particularly suited her busy working role and active lifestyle.
Vitamin D deficiency as a suspected causative factor in the failure of an immediately placed dental implant: a case report
Authors: Bryce G , MacBeth N
Published: February 2021

Aim

To discuss the influence of Vitamin D defi ciency in the osseointegration process of a dental implant by way of a case report.

A 29-year-old soldier attended clinic with a fractured mandibular premolar (tooth 44) that was traumatised following head trauma related to the detonation of an Improvised Explosive Device (IED) whilst serving on operational duty. The tooth was deemed unsalvageable and was extracted with immediate placement of a dental implant. The patient experienced no problems but at assessment, five months post-operatively, no osseo-integration of the implant was found. Concurrent medical investigations revealed that he was severely Vitamin D deficient and that this may have contributed to the implant failure.

Conclusion

Vitamin D deficiency may play a role in the failure of osseointegration in dental implants. The assessment of vitamin D status in patients who have been in long-term hospital care or rehabilitation should be considered, prior to the placement of dental implants.
Non-organic hearing loss in United Kingdom military personnel
Authors: Bailey K , Pearson C , Clack J
Published: February 2021

Non-organic hearing loss (NOHL) is a condition in which there is audiometric discrepancy between the real hearing threshold and the measured threshold of the patient, in the absence of any organic disease. It can, rarely, be the manifestation of a somatoform disorder when it is known as conversion deafness. We present a case of conversion deafness diagnosed following a five-year period of apparent fluctuating unilateral hearing loss, and discuss the diagnosis, clinical and occupational considerations of managing this condition in a military environment.
A modern-day solution to a 100-yearold problem: the use of a bespoke offloading brace in the rehabilitation of ‘Deck-Slap’ and other high-energy lower limb injuries
Authors: Osborne MA , Jarvis HL , Bennett N , Phillip RD
Published: February 2021

‘Deck-Slap’ is an injury pattern first described at the Battle of Jutland; it is still relevant today, with anti-vehicle mines a significant threat to Coalition troops. The effect of a device exploding beneath a vehicle produces a wave of high energy that is rapidly transmitted through the steel floor; this causes significant axial loading of lower limbs often resulting in severe fractures (notably of the calcaneum). Recent advancements in orthopaedic surgery have allowed for limbs that were destined for immediate amputation following significant trauma to be salvaged. However, despite intense rehabilitation, many of these salvaged limbs have subsequently gone on to delayed amputation, as functional outcomes are often poor. Technologically advanced prosthetic devices are available that afford good quality of life and allow for increased activity levels; these devices are, however, expensive to procure and maintain. This report describes a United Kingdom (UK) Armed Forces soldier who suffered a typical ‘deck-slap’ injury in Afghanistan with subsequent limb salvage. The use of the Bespoke Off-loading Brace (BOB) is discussed. The results presented here indicate that the biomechanical function of a patient with this type of injury improves when wearing the BOB. Further studies are needed to assess long-term clinical outcomes and the functional benefit of the device as a viable and cost-effective alternative to delayed limb amputation.
Preparing applications for specialty and general practice training in the Defence Medical Services
Authors: Rawlinson K , Stanning AJ
Published: February 2021

The specialty training application process can be a challenging time, and adequate preparation is essential. With the resources available, and with appropriate guidance from colleagues, experiences gained as a General Duties Medical Officer (GDMO) can be used to produce a highly competitive application. This paper aims to to provide guidance for Medical Officers (MOs) applying for specialty training.
The diagnosis and management of psychogenic non-epileptic seizures in the UK Armed Forces
Authors: Baker L D , Craner M , Coetzee R H
Published: February 2021

Psychogenic non-epileptic seizures (PNES) is a disorder that mimics epilepsy, but does not have the associated organic changes or abnormal neuronal discharge foci in the brain. In this article the diagnosis, management and clinical considerations of managing this condition in the UK Armed Forces are considered. The occupational and operational considerations for the military environment are also discussed.
The emergence of vascular surgery as a separate specialty: implications for the military
Authors: Ablett D
Published: February 2021

Vascular surgery is evolving from being a sub-specialty of general surgery to becoming a separate surgical specialty. This will have implications in terms of the training, skill-set and workload of surgeons working in the NHS. There are implications for the military too, as a deploying trauma team must have both general and vascular surgical capabilities. This article explores the reasons for the changes occurring and discusses the wider implications.
The new NEMOs - changes to initial medical officer training
Authors: McMenemy L , Laird J
Published: February 2021

It is desirable that a Royal Navy Medical Officer is not only medically competent but also a proficient Naval Officer with an ethos common to all Officers, irrespective of specialty or branch. In 2012 Britannia Royal Naval College (BRNC), in conjunction with the Institute of Naval Medicine (INM), modified the New Entry Medical Officer (NEMO) training course to comprise an initial phase at BRNC (15 weeks) followed by a second phase at INM (16 weeks). This is in contrast to the traditional training delivered at INM and Fort Blockhouse prior to joining BRNC for 7 weeks. The following article is a reflection of this experience.
Accessing the online archive for the Journal of the Royal Naval Medical Service
Authors: Angus D
Published: February 2021

Following work by the editorial team, notably Surg Lt Cdr M O’Shea, and with funding from the Wellcome Trust, every edition of this Journal dating back to the first edition in 1915 is available on our website. This article gives details of how to access it.
Devising a training programme and reviewing the lessons identified during contingency operations on board the Role 3 Maritime platform
Authors: Clarkson AM
Published: February 2021

The deployment of the Primary Casualty Receiving Facility (PCRF) to Sierra Leone in October 2014 in support of Operation GRITROCK was a contingency operation that required a very specific training programme. This article discusses the training and how it evolved beyond its original remit into a programme used as a management tool to meet the needs of the staff. The result was the implementation of a comprehensive package from which lessons can be drawn and used when planning future operations.
Platelet apheresis in a deployed maritime environment: experiences from Operation GRITROCK
Authors: Robinson MA , Bailey MJ
Published: February 2021

When the Primary Casualty Receiving Facility (PCRF) on Royal Fleet Auxiliary (RFA) ARGUS deployed to Operation GRITROCK in October 2014, platelet apheresis had yet to be proven as a sustainable and usable capability for improving provision of blood products on a maritime platform. This paper explores the difficulties encountered by nurses tasked with setting up this capability once deployed and the requirements needed to ensure that this capability is maintained for future operations.
From RAF to RN – the transition from Princess Mary’s RAF Nursing Service (PMRAFNS) to Queen Alexandra’s Royal Naval Nursing Service (QARNNS)
Authors: Masawi S K
Published: February 2021

I transferred from the Royal Air Force to the Royal Navy (RN) on 10 July 2014. I would like to share my experiences as a junior RN Officer during Op GRITROCK, looking at some of the similarities and differences between the two Services and their deployed environments: maritime and air.
A practical guide to expedition medical planning
Authors: Wilkins D , Handford C , Nicol A
Published: February 2021

Expedition medical planning is integral in ensuring participant safety and maximising the likelihood of achieving the expedition aims. The task of producing a medical plan will often fall to a medical officer of limited experience. The aim of this article is to provide a concise, practical guide to aid junior medical officers (MOs) in forming a robust and pragmatic medical plan.
Lessons learned while undertaking high altitude medical research in the Himalayas
Authors: Mackey J , Mellor A
Published: February 2021

Undertaking medical research during military adventurous training expeditions presents a unique set of challenges to medical personnel, and for those considering doing so in the future the task may seem daunting. This article details some of the challenges faced whilst undertaking high altitude research on a recent Defence Medical Services (DMS) adventurous training expedition to the Dhaulagiri circuit in Nepal. By discussing what led to some of the problems encountered, how they were overcome, and in some instances how they could have been avoided in the first place, it is hoped that the article will act as a guide for others who plan on undertaking future research in a similar environment.
A systematic review of the use of tourniquets and topical haemostatic agents in conflicts in Afghanistan and Iraq
Authors: Mawhinney AC , Kirk SJ
Published: February 2021

Introduction

The recent conflicts in Afghanistan and Iraq have seen increased use of tourniquets and topical haemostatic agents in the management of battlefield trauma. The aim of this paper is to review the available evidence for their efficacy and continued use.

Methods

A systematic review of the medical literature published as a consequence of conflicts in Iraq in Afghanistan was conducted to determine the clinical outcomes from the use of tourniquets and haemostatic agents for haemorrhage control in limb extremity injury.

Results

Studies were retrospective cohort or prospective observational studies by design. None were eligible for meta-analysis and control groups were rarely available for ethical reasons. Despite methodological limitations, tourniquets were shown to save lives if applied prior to the onset of shock or in a pre-hospital setting. Topical haemostatic agents were shown to be useful adjuncts in haemorrhage control with small numbers of complications.

Conclusion

In the military setting, tourniquet use in extremity trauma improves survival when used prior to the onset of shock. Topical haemostatic agents provide additional means of haemorrhage control, though further studies to identify the most effective types are necessary. Adequate training and protocols for use must be implemented to prevent complications through use.