bluuebunny/crossref_metadata_2025 huggingface dataset:
Identification of Multilocus Genetic Heterogeneity in Anaplasma marginale subsp. centrale and Its Restriction following Tick-Borne Transmission
Authors: Herndon David R. , Ueti Massaro W. , Reif Kathryn E. , Noh Susan M. , Brayton Kelly A. , Agnes Joseph T. , Palmer Guy H.
Published: March 2013

Anaplasma marginale
subsp.
centrale
was the first vaccine used to protect against a rickettsial disease and is still in widespread use a century later. As its use preceded development of either cryopreservation or cell culture, the vaccine strain was maintained for decades by sequential passage among donor animals, excluding the natural tick-borne transmission cycle that provides a selective pressure or population “bottleneck.” We demonstrated that the vaccine strain is genetically heterogeneous at 46 chromosomal loci and that heterogeneity was maintained upon inoculation into recipient animals. The number of variants per site ranged from 2 to 11 with a mean of 2.8/locus and a mode and median of 2/locus; variants included single-nucleotide polymorphisms, insertions/deletions, polynucleotide tracts, and different numbers of perfect repeats. The genetic heterogeneity is highly unlikely to be a result of strain contamination based on analysis using a panel of eight gene markers with a high power for strain discrimination. In contrast, heterogeneity appears to be a result of genetic drift in the absence of the restriction of tick passage. Heterogeneity could be reduced following tick passage, and the reduced heterogeneity could be maintained in sequential intravenous and tick-borne passages. The reduction in vaccine strain heterogeneity following tick passage did not confer an enhanced transmission phenotype, indicating that a stochastically determined population bottleneck was likely responsible as opposed to a positive selective pressure. These findings demonstrate the plasticity of an otherwise highly constrained genome and highlight the role of natural transmission cycles in shaping and maintaining the bacterial genome.
Postexposure Subunit Vaccination against Chronic Enteric Mycobacterial Infection in a Natural Host
Authors: Santema Wiebren , Rutten Victor , Segers Ruud , Poot Jacqueline , Hensen Selma , Heesterbeek Hans , Koets Ad
Published: March 2013

The control of chronic bacterial diseases with high prevalence in areas of endemicity would strongly benefit from availability of postexposure vaccines. The development of these vaccines against mycobacterial infections, such as (para)tuberculosis, is hampered by lack of experience in natural hosts. Paratuberculosis in cattle is both a mycobacterial disease of worldwide importance and a natural host model for mycobacterial infections in general. The present study showed beneficial effects of therapeutic heat shock protein 70 (Hsp70) vaccination in cattle with naturally acquired chronic infection with
Mycobacterium avium
subsp.
paratuberculosis
. Vaccination-induced protection was associated with antibody responses, rather than with induction of specific T helper 1 cells. Targeted therapeutic postexposure vaccination complementary to selective use of antibiotics could be an effective approach for control of chronic mycobacterial infections.
Roux-en-Y gastric bypass in the treatment of non-classic congenital adrenal hyperplasia due to 11-hydroxylase deficiency
Authors: Kalani Amir , Thomas Nithin , Sacerdote Alan , Bahtiyar Gül
Published: March 2013

Non-classic adrenal hyperplasia (NCAH) has been associated with insulin resistance (IR). Therapies such as metformin, thiazolidinediones and lifestyle alterations improve IR and also ameliorate the biochemical and clinical abnormalities of NCAH, much as they do in polycystic ovarian syndrome (PCOS). More recently, bariatric surgery, such as Roux-en-Y gastric bypass (RYGBP), has also been associated with improvement in IR and amelioration of PCOS and may, therefore, be beneficial in NCAH. We report a case of a 39-year-old, deaf-mute, obese woman with NCAH due to 11-hydroxylase deficiency who underwent RYGBP followed by improvement of NCAH manifestations. She was initially treated with metformin and pioglitazone, which lowered serum 11-deoxycortisol from 198 ng/dl (<51) to 26 ng/dl. Five weeks after undergoing RYGBP her body mass index fell from 44.18 kg/m2to 39.54 kg/m2and, despite not taking metformin or pioglitazone, serum 11-deoxycortisol remained normal at <40 ng/dl. Concurrently and subsequently, her NCAH symptoms, for example, alopecia, hirsutism and irregular menses normalised as well. We conclude that RYGBP, like other interventions that reduce IR, may be another way of treating non-classic 11-hydroxylase deficiency in selected patients.
Lessons from the first operational deployment of emergency medicine
Authors: Hodgetts T J , Kenward G , Masud S
Published: March 2013

The first operational deployment of emergency medicine in the UK Defence Medical Services was in support of a 50-bed field hospital during OP AGRICOLA, Kosovo, from 25 June-26 August 1999. In preparation, new equipment scales were designed to extend the traditional surgical-based approach to the reception of patients. The organisation of the front end of a field hospital was modified to reflect the current UK peace-time practice of emergency medicine. Specialist emergency medicine trained doctors and nurses provided the core personnel. 1189 patients were treated in the 2-month deployment. 903 were KFOR troops (862 BRITFOR), 187 Kosovo-Albanian, 69 Serbian and 30 derived from United Nations or nongovernment organisations. There were 63 resuscitations, with 21 relating to KFOR troops. 42 patients met the criteria for a trauma team activation; age was 33.4 ± 18.7 years (mean ± SD). Mean Injury Severity Score (ISS) was 16.3 ± 18.6; mean New Injury Severity Score (NISS) was 22.5 ± 20.5. 14 of 42 were ‘major trauma’ characterised by ISS ≥16; 22 had a NISS ≥16. 36% of the major trauma by ISS was gunshot wound (GSW), 7% blast and fragmentation, and 57% blunt; age was 33.3 ± 20.4 years (mean ± SD for ISS ≥16 group). Standardised Mortality Ratio was 1.50. The Effectiveness E value for outcome was 0.85. NISS detected 3 further patients with GSW, 3 with blast/fragmentation, and 2 with blunt injury. A diverse range of medical emergencies was encountered. The extended role of the emergency physician was exploited to include coordination of major trauma audit and clinical feedback, local and national disaster planning, and co-ordination of humanitarian support to design, build and equip an emergency department at the University Hospital of Pristina. The operational value of emergency medicine within UK Defence Medical Services has been firmly established.
The Interaction of Projectiles with Tissues and the Management of Ballistic Fractures
Authors: Clasper J
Published: March 2013

Wounds to the limbs are the commonest injuries seen during armed conflict and injury results from the transfer of energy from the missile to the tissues. There are a number of factors that determine the transfer of energy, and thus the extent of wounding. These include the velocity of the missile, its shape and stability, and the tissue through which the missile passes. Many of the wounds involve bone, and because of the interaction of missiles with bone, significant fractures can occur.

In many previous conflicts amputation was considered the treatment of choice for many limb injuries, but with recent advances in the management of severe open fractures, many of these limbs are now salvageable. Whilst the basic principles of the initial débridement remain unchanged, techniques of fracture stabilisation and definitive soft tissue cover have changed, and it is necessary to consider these in relation to military fractures. Definitive soft tissue closure can be safely delayed until evacuation further down the medical chain, but stabilisation of the fracture must be considered at the time of initial surgery. Many of the advances in fracture management may be unsuitable for use in a military environment due to logistical constraints. In addition it is likely that wound infection will be more common with military injuries, and this will influence the treatment.

This paper considers the interaction of missiles with soft tissue and bone, and discusses possible methods of fracture stabilisation in the military environment.
Rescue of the Remnants: The British Emergency Medical Relief Operation in Belsen Camp 1945
Authors: Trepman Elly
Published: March 2013

The British Army liberated the German concentration camp at Belsen on April IS, 1945. The thousands of inmates (estimates range from 60,000 to 78,900 inmates), mostly Jews from eastern Europe, were dying at a rate of 500-600 per day from disease, and many more were being killed by the German guards and co-workers. Diseases prevalent included typhus, tuberculosis, nutritional and infective diarrhoea, severe malnutrition and starvation, and others. Despite huge obstacles including the ongoing war effort, shortages of supplies, and limited numbers of workers, a relict operation was rapidly organized to control the typhus epidemic and salvage as many inmates as possible. The 10,000 emaciated corpses which had been lying all over the camp were collected and buried in mass graves. Inmates were disinfected with D.D.T., scrubbed in a “human laundry,” and evacuated from the typhus-ridden Horror Camp (Camp 1) to a hospital organized in the barracks of the Panzer Training School (Camp 2). Feeding of the inmates was carefully regulated, and some basic medical treatment organized. The relief operation was performed by British Army units, detachments of the British Red Cross, British and Belgian medical students, and other volunteers including those from among the less debilitated inmates. Although 13,000 inmates died after the libération despite the relief operation, thousands of others were rescued.
Write a Case Report
Authors: Greaves Ian
Published: March 2013

Case reports are often seen as a relatively easy way of getting published. Despite this, much wasted time and effort on the part of authors, reviewers and editors might be saved if intending authors followed some simple guidelines before committing themselves to paper. The rejection rate for case reports is extremely high. There are two main reasons for this: inappropriate case selection and inadequate attention to detail in case preparation. This article aims to offer a template to the clinician who is considering writing a case report, in order to make the most efficient use (in terms of published results) of the time available.
Medical Confidentiality: The Right Of A Commanding Officer To Know
Authors: Gibson TM , Coker W J
Published: March 2013

Recent changes in the law and in patients’ expectations have necessitated alterations to the way doctors maintain the medical confidentiality of their patients. This paper investigates the ethical and legal aspects of medical confidentiality in general, examines their relation to the military context and analyses the guidance offered. Military personnel give up some individual rights on enlistment. The requirement for the medical officer to share patients’ medical information, without consent if necessary, with the Commanding Officer is ethically and legally acceptable provided recruits are adequately warned of this restriction to human rights before joining. Although the paper concentrates on the guidance given in the RAF, the principles are common to the 3 Armed Forces’ medical services.
Sports And Training Injuries In British Soldiers: The Colchester Garrison Sports Injury And Rehabilitation Centre
Authors: Strowbridge NF , Burgess KR
Published: March 2013

Objectives

To record and analyse the injuries and conditions requiring referral to the Colchester Garrison Sports Injury and Rehabilitation Centre over a three year period, with special reference to type and site of injury, aetiology, and outcome.

Methods

An ongoing prospective study in which data on the diagnosis, cause of injury, and treatment of all patients referred to the Centre was coded and stored on a database. A total of seventeen variables were recorded.

Subjects

All patients were trained, serving soldiers in the British Army referred via their General Practitioner to the Sports Injury and Rehabilitation Centre.

Results

A total of 3921 referrals were made over the three-year period. The most common specific condition seen was low back pain (22.2%) followed by sprain of the ankle (15.1%). Lower limb conditions, both overuse and traumatic, accounted for over half (55.8%) of all referrals. Military training was the most common cause of all conditions (35.2%) followed by organised or personal sport (28.5%). In addition to medical treatment and physiotherapy, 30% of patients required formal rehabilitation.

Conclusions

This is the first full review of the data collected by the Sports Injury and Rehabilitation Centre. It defines the injury patterns for trained soldiers rather than military recruits. Low back pain is identified as a major cause of morbidity in this population. The review serves as a benchmark in the planning of injury prevention strategies and the establishment of future rehabilitation services.
Bullet Markers - A Simple Technique To Assist In The Evaluation Of Penetrating Trauma
Authors: Brooks A , Bowley DMG , Boffard K D
Published: March 2013

Radio-opaque markers in penetrating trauma are useful in both the clinical evaluation of the injuries and in the permanent record of the location of the wounds. The use of an unfolded paperclip taped over the wound as a marker is recommended as a valuable adjunct in the radiological evaluation of penetrating trauma.
The Alcohol Hangover And Its Potential Impact On The UK Armed Forces: A review Of The Literature On Post-alcohol Impairment
Authors: Barker CT
Published: March 2013

Objective

To raise awareness within the Defence Medical Services regarding the potential effect of post-alcohol impairment / alcohol hangover.

Method

Literature relating to post-alcohol impairment / alcohol hangover, and the evidence for impairment is reviewed, with discussion relating to UK Armed Forces.

Conclusion

The evidence for performance impairment during alcohol hangover is not conclusive. Until further evidence is available policy should acknowledge the potential for impaired functioning, particularly the morning after a heavy drinking session, and even when blood alcohol has returned to zero. Recommendations for clinical practice and areas for further research are presented.
An Unusual Case Of Segmental Clavicle Fracture
Authors: Heywood R , Clasper J
Published: March 2013

Fracture of the clavicle is a common traumatic injury and comprises 4% of all fractures in adults. Amongst these, midshaft injuries account for the majority and medial fractures are uncommon (1). Whilst segmental fractures have been reported in the literature, concurrent lateral and medial injuries are very rare. These injuries are, therefore, susceptible to being missed, due to failure to look for a second injury after the initial diagnosis, and difficult X-ray interpretation around the area of the medial clavicle. The nature of segmental fractures can pose a difficult management problem for numerous reasons, and initial operative fixation is usually indicated. Early diagnosis is therefore imperative, and as such, clinical examination is essential even if an obvious mid or lateral shaft fracture is seen on X-ray. This unusual case of combined lateral and medial fractures was initially missed and the presentation and management is discussed.
Ballistic Fractures During The 2003 Gulf Conflict – Early Prognosis And High Complication Rate
Authors: Hinsley D E , Phillips SL , Clasper J C
Published: March 2013

Background

Ballistic fractures are devastating injuries often necessitating extensive reconstructive surgery or amputation, particularly if associated with high-energy transfer wounds. Infective complications are common, particularly in the austere environment encountered in war. We present the management and early outcome of these injuries with reference to the mechanism of injury and bony injury.

Method

Data on ballistic fractures was collected prospectively during the ‘warfighting’ phase of the 2003 Gulf Conflict, between 19th March and 20th May. Fractures were scored using the Red Cross Fracture classification and early outcome analysed.

Results

Thirty-nine patients, with 50 ballistic fractures, were treated by British military surgeons. Patients were predominantly Iraqi (90%) and 50 per cent of ballistic fractures were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. There were seven traumatic amputations, and a further 2 limbs were amputated primarily. Methods of primary stabilisation for the remaining 41 fractures were: external fixation (22%), POP (14.5%), K-wires (14.5%) traction (10%), and no stabilisation (39%).

Seven individuals were evacuated early after primary surgery, hence 43 ballistic fractures were available for follow-up. 13/43 (30%) of wounds became infected, 5/43 (11.5%) were deep infections necessitating surgical drainage. There were 4 late amputations (9.5%), 3 of which had initially been managed by external fixation. Infection occurred significantly more often in gunshot fractures (10/21, 48%), wounds closed primarily – against the principles of war surgery (4/5, 80%) and intra-articular fractures (3/3, 100%) (p=0.022, 0.024 and 0.023 respectively). Differing methods of stabilisation had no bearing on the rate of postoperative infection.

Conclusion

Ballistic fractures remain a challenge for trauma surgeons in times of war and still have a poor prognosis. Further work is required to determine the optimal treatment of these injuries during conflicts. In addition, there still seems to be a continued need to re-learn the principles of war surgery in order to minimise complications and optimise functional recovery.
An Unusual Case Of Talonavicular Dislocation With Associated Ipsilateral Foot Fractures
Authors: Ede Newton , Miller C , Malik MHA , Khan SA
Published: March 2013

We describe a previously unreported form of a talonavicular dislocation complicated by navicular, talar neck and open calcaneal fractures.

Prompt recognition and rapid reduction of fractures and dislocations gives the best possible outcome. The presence of serious distracting injuries can alter priorities, however the “lesser” injuries often lead to long term morbidity after recovery from the life-threatening injuries.
Managing The Open Abdomen
Authors: Haldipur N , Cooper B , Sanyal S
Published: March 2013

The management of patients with an open abdomen is challenging. Control of intra-abdominal fluid secretion, facilitation of abdominal exploration and preservation of fascia for abdominal wall closure can test even the most experienced surgeon. Over the years various techniques have been tried to minimise complications and expedite closure with VAC® therapy (KCI Medical, Witney, Oxford UK) being the newest. This article provides an overview of the techniques available for the management of the open abdomen from towel clips to VAC®.
Contact Dermatitis After Henna Skin Tattooing
Authors: Ballard MS
Published: March 2013

A case of contact dermatitis resulting from temporary tattooing with henna is described. The skin was stained using a dye described as ‘black’ henna. This is produced by the addition of paraphenylenediamine (PPD) to traditional henna dye in order to make temporary skin tattoos appear darker. Sensitisation to PPD may also cause sensitivity to printers’ inks, clothing dyes, hair dyes, local anaesthetics, sulphonamides, and para-aminosalicylic acid. The case of contact dermatitis described responded to application of topical steroid with no sequelae; however patients may be left with hypo- or hyper-pigmentation of the skin or even permanent scarring.
Edward Almroth Wright
Authors: Walker NM
Published: March 2013

Sixty years ago saw the passing of Edward Almroth Wright, Professor of Pathology at the Army Medical College between 1892 and 1902. Wright secured his place in the medical pantheon, and significant fame, with the discovery of an effective vaccine for typhoid in 1897. This article examine show he earned his place in medical history.
Roles for International Military Medical Services in Stability Operations (Security Sector Reform)
Authors: Bricknell Martin CM , Thompson D
Published: March 2013

This is the second in a series of three papers that examine the role of international military medical services in stability operations in unstable countries. The paper discusses security sector reform in general terms and highlights the interdependency of the armed forces, police, judiciary and penal systems in creating a ‘secure environment’. The paper then looks at components of a local military medical system for a counter-insurgency campaign operating on interior lines and the contribution and challenges faced by the international military medical community in supporting the development of this system. Finally the paper highlights the importance of planning the medical support of the international military personnel who will be supporting wider aspects of security sector reform. The paper is based on background research and my personal experience as Medical Director in the Headquarters of the NATO International Stability Assistance Force in Afghanistan in 2006.
Military Cold Injury During the War in The Falkland Islands 1982: An Evaluation of Possible Risk Factors
Authors: Craig RP
Published: March 2013

Throughout the history of war, there have been many instances when the cold has ravaged armies more effectively than their enemies. Delineated risk factors are restricted to negro origins, previous cold injury, moderate but not heavy smoking and the possession of blood group O. No attention has been directed to the possibility that abnormal blood constituents could feasibly predispose to the development of local cold injury. This study considers this possibility and investigates the potential contribution of certain components of the circulating blood which might do so. Three groups of soldiers from two of the battalions who served during the war in the Falklands Islands in 1982 were investigated. The risk factors which were sought included the presence or absence of asymptomatic cryoglobulinaemia, abnormal total protein, albumin, individual gamma globulin or complement C3 or C4 levels, plasma hyperviscosity or evidence of chronic alcoholism manifesting as high haemoglobin, PCV, RBC, MCV or gamma glutamyl transpeptidase (GGT).

No cases of cryoglobulinaemia were isolated and there was no haematological evidence to suggest that any of those men who had developed cold injury, one year before this study was performed, had abnormal circulating proteins, plasma hyperviscosity or indicators of alcohol abuse. Individual blood groups were not incriminated as a predisposing factor although the small numbers of negroes in this series fared badly.

Although this investigation has excluded a range of potential risk factors which could contribute to the development of cold injury, the problem persists.

Two areas of further study are needed: the first involves research into the production of better protective clothing in the form of effective cold weather boots and gloves and the second requires the delineation of those dietary and ethnic factors which allow certain communities to adapt successfully to the cold. A review of the literature in this latter area is presented.
Combat “Category A” Calls: Evaluating The Prehospital Timelines in a Military Trauma System
Authors: McLeod J , Hodgetts T , Mahoney P
Published: March 2013

Aim

To establish the pre-hospital timelines for seriously injured UK military casualties on OP HERRICK.

Population

All consecutive MERT and MERT-E mobilizations from Camp Bastion, Helmand Province, between 04 May 06 and 18 Jun 07.

Methods

Interrogation of MS Access database compiled from paper patient report forms for each casualty transported.

Results

528 patients were transported. 84.6% (456) were battle casualties. There were 192 GSW and 233 casualties with blast/fragmentation injuries. 189 of 528 (35.7%) were UK Service personnel. Median time from injury to handover at the emergency department for UK military T1 casualty subset was 99 minutes.

Conclusion

The public perception of excessive timelines for pre-hospital care in Afghanistan has been distorted. The ground truth is a pre-hospital time less than one quarter of the cited 7 hours for the seriously injured subset of UK Service personnel.
Casualty Evacuation Timelines: An Evidence-Based Review
Authors: Parker Paul J
Published: March 2013

There is no tri-modal death distribution demonstrable in modern military conflict. Recent UK, Palestinian and Israeli data suggests that nine out of every ten injured soldiers that die do so within minutes of wounding from insurvivable, unsalvagable trauma.Having the surgeon on the battlefield with the soldier has been shown tomake no difference to these survival rates. Early definitive airway control using rapid sequence induction and intubation is of benefit to the head and airway injured. Once this airway is secured, these early survivors may be transported for up to 2 hours receiving intensive care level treatment: Hypotensive resuscitation with blood transfusion, administration of adjunctive clotting factors, hypothermia mitigation, administration of antibiotics, analgesics, novel haemostatics, splintage, FAST scanning can all be performed in flight. The second peak of death comes from truncal bleeding and CNS injury. Those with truncal (or junctional) bleeding require significant surgical, logistic and haemostatic support. Those with CNS injury require CT scanning and specialized neurosurgical care. These subgroups do best in large well-resourced hospital units which have the infrastructure, blood, climate control, knowledge and staffing levels to deal with them. Stopping elsewhere en-route to these larger centres is of uncertain benefit. Our resources must be optimised to save the many that could be saved, rather than dispersed for the few who will not. Wounded soldiers need to be undergoing surgery in the operating theatres of these large centres within three hours of wounding.
Femoral Neck Stress Fractures in Military Personnel – A Case Series
Authors: Talbot JC , Cox G , Townend M , Parker PJ , Langham M
Published: March 2013

Femoral neck stress fractures (FNSF) are uncommon, representing 5% of all stress fractures. In military personnel, FNSF represents one of the more severe complications of training, which can result in medical discharge. Clinical examination findings are often non-specific and plain radiography may be inconclusive - leading to missed or late diagnosis of FNSF. This paper highlights the significance of FNSFs in military personnel and alerts physicians to the potential diagnosis.

We identified all military recruits, aged 17 to 26, who attended the Infantry Training Centre (Catterick, UK), over a four-year period from the 1st July 2002 to 30th June 2006, who had suffered a FNSF. The medical records, plain radiographs, bone scans and MRIs of the recruits were retrospectively reviewed. Of 250 stress fractures 20 were of the femoral neck; representing 8% of all stress fractures and an overall FNSF rate of 12 in 10,000 military recruits.

FNSFs were most prevalent amongst Parachute Regiment recruits (1 in 250, p< 0.05). Onset of symptoms was most commonly between weeks 13 – 16 of training. The majority (17/20, 85%) of FNSFs were undisplaced, these were all treated conservatively. Three FNSFs were displaced on presentation and were treated surgically. Overall, the medical discharge rate was 40% (8/20).

FNSFs are uncommon and the diagnosis remains a challenge to clinicians and requires a high index of suspicion in these young athletic individuals. In such individuals early referral for MRI is recommended, to aid prompt diagnosis and treatment and to prevent more serious sequelae.
Hospex: A Historical View and the Need for Change
Authors: Cox CWFM , Roberts P
Published: March 2013

This article briefly describes the historical background of the Cold War Hospital Exercises from which the necessity for change was identified. The genesis of the current Role 3 Collective Clinical Training is outlined.
Traumatic Quadriceps Muscle Tears Among Israeli Special Forces Soldiers
Authors: Marom Tal , Itskoviz D , Kutikov S , Naftal JMD , Ostfeld I
Published: March 2013

Introduction: Quadriceps muscle tear, secondary to direct trauma, is an uncommon injury in a military setting. Signs and symptoms of this injury are usually non-specific and may resemble other, more common and benign overuse injuries.

Patients And Methods

Five Israeli Defense Forces Special Forces soldiers who were diagnosed with partial quadriceps muscle tears, following a “low-kick” exercise, aimed to the thigh, during “hand-to-hand combat” training. Diagnosis and follow-up were made using thigh sonography.

Results

Symptoms duration before diagnosis was 20.6±9.41 days (mean± SD, range: 7-35). Two of the soldiers were found to have myositis ossificans at the affected site, a known complication of muscle trauma. Treatment regime included a long rest and intensive physiotherapy, with a gradual return to active service. Downtime from diagnosis was 55.8±17.3 days (mean±SD, range: 24-73). All patients eventually fully recovered and returned to active service.

Conclusion

Quadriceps muscle tear is a rare injury with a delayed presentation and diagnosis in highly motivated soldiers. Sonography facilitates diagnosis and monitoring of healing. Early diagnosis may decrease morbidity and allow earlier return to work.
What is the Ideal Pre-Hospital Analgesic? – A Questionnaire Study
Authors: Smith JE , Russell R , Mahoney PF , Hodgetts T J
Published: March 2013

Aim

To determine clinical opinion of effectiveness of current battlefield analgesia and the realistic options to improve future analgesia in hostile environments.

Methods

Structured electronic questionnaire distributed to selected individuals in UK and on operations.

Population

122 UK Defence Medical Services and US Medical Corps doctors, nurses and combat medical technicians involved in the early management of severe trauma on deployment.

Results

54 (44%) agreed and 63 (52%) disagreed that intramuscular morphine had the ideal analgesic properties for the military pre-hospital environment. Over half of those with operational experience reported multiple instances of intramuscular morphine providing inadequate analgesia. 86 (70%) desired a more potent analgesic than morphine in the first hour following injury. 101 (83%) identified simplicity and reliability of use by a soldier as of high importance. 99 (81%) identified rapid onset of action of high importance. With regard to an acceptable route of drug self-administration, 88 (72%) supported a nasal spray; 78 (64%) supported a sustained release buccal tablet (adhesive to the gum); 61 (50%) supported a disposable inhaler of volatile gas (although 91%had no experience of the currently available drug in this formulation); and 55 (45%) supported a skin patch.

Conclusion

Intramuscular morphine does not meet the needs of the majority of clinical stakeholders. Alternative routes of self-administration are acceptable, but support for available commercial solutions is clouded by incomplete awareness. Anaesthetists and emergency physicians desire a multimodal approach to battlefield analgesia within the evacuation chain.
Pain Management During Royal Air Force Strategic Aeromedical Evacuations
Authors: Flutter C , Ruth M , Aldington D
Published: March 2013

The aim of this article is to outline the problems and solutions in pain management experienced during the transfer of patients. Although focusing on strategic aeromedical transfers many of the concepts will be of value regardless of the mode of transport.
The Diagnosis and Treatment of Non-Cardiac Thoracic Trauma
Authors: O’Connor JV , Adamski J
Published: March 2013

Penetrating and blunt force mechanisms frequently result in thoracic trauma. Thoracic injuries cover the spectrum from trivial to lethal, and more than half are associated with head, abdomen or extremity trauma. Fortunately over eighty percent of injuries can be managed non-operatively utilizing tube thoracostomy, appropriate analgesia and aggressive respiratory therapy. Patients requiring emergency thoracotomy are either in shock or have life threatening injuries and, as expected, have significant mortality and morbidity. Injury to the thorax directly accounts for approximately 25% of trauma related mortality and is a contributing factor in another 25%. Early mortality results from haemorrhage, catastrophic injury or associated head or abdominal trauma. Not unexpectedly, late deaths are related to sepsis and organ failure. Blunt injury to the thorax most commonly results from motor vehicle collisions, with motorcycle accidents, pedestrians struck and falls next in frequency. Stab wound and gunshot wounds comprise the vast majority of penetrating injuries. In general the mortality from penetrating injury is higher and related to vascular injury and shock. Mortality from blunt trauma often results from abdominal and, especially, head injury. Rapid assessment and interventions, such as tube thoracostomy and airway control, can be life saving. The patient’s haemodynamic status drives early treatment, often necessitating emergency surgery. Detailed imaging studies are reserved for haemodynamically stable patients. The evaluation and treatment of specific thoracic injuries will be discussed, as well as some general principles in treating thoracic trauma.
The Additional Value of a Pneumatic Leg Brace in the Treatment of Recruits with Medial Tibial Stress Syndrome; a Randomized Study
Authors: Moen Maarten Hendrik , Bongers T , Bakker EWP , Weir A , Zimmermann WO , van der Werve M , Backx FJG
Published: March 2013

Objective

To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits.

Methods

In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures.

Results

In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 ± 27.7 (mean ± SD) vs Non-Brace 57.9 ± 26.2 (mean ± SD,p= 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 ± 1.1 (mean ± SD) on a 1-10 scale for the brace group and 7.1 ± 0.7 (mean ± SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 ± 1.3 (mean ± SD) on a 1-10 scale.

Conclusions

No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.
Prehospital Analgesia: Systematic Review of Evidence
Authors: Park CL , Roberts DE , Aldington DJ , Moore RA
Published: March 2013

The purpose of this systematic review is to investigate current evidence for analgesic use in the prehospital environment using expert military and civilian opinion to determine the important clinical questions. There was a high degree of agreement that pain should be no worse than mild, that pain relief be rapid (within 10 minutes), that patients should respond to verbal stimuli and not require ventilatory support, and that major adverse events should be avoided. Twenty-one studies provided information about 6,212 patients; the majority reported most of the outcomes of interest. With opioids 60-70% of patients still had pain levels above 30/100 mm on a Visual Analogue Scale after 10 minutes, falling to about 30% by 30-40 minutes. Fascia iliaca blocks demonstrated some efficacy for femoral fractures. No patient on opioids required ventilatory support; two required naloxone; sedation was rare. Cardiovascular instability was uncommon. Main adverse events were dizziness or giddiness, and pruritus with opioids. There was little evidence regarding the prehospital use of ketamine.
Toxicology and Military Anaesthesia
Authors: Nicholson-Roberts TC
Published: March 2013

The combination of trauma and poisoning is a situation likely to be faced by a deployed force at some point. This article provides practical advice on how to deal with poisoned patients without deviating from the concept of damage control resuscitation. The constraints of limited diagnostics, both at the scene and clinically, and lack of antidotal therapy are fundamental to the practice of clinical toxicology. Some of the specific therapies such as atropine and oximes were not evaluated prior to their introduction and there are few randomised controlled trials of poisoned patients. Most of the diagnoses will be made on clinical grounds and most of the therapy will be supportive; this article aims to reassure military anaesthetists in the process of dealing with the poisoned trauma patient.
The Triservice Anaesthetic Apparatus: A Review
Authors: Frazer RS , Birt DJ
Published: March 2013

The Triservice Anaesthetic Apparatus was designed around 30 years ago as a robust and highly portable anaesthesia delivery system for medical support to airborne operations and it has been the core anaesthesia system for the Defence Medical Services since then. Over this period there have been a number of equipment changes but issues remain which are in part mitigated by recent training developments. This article reviews these changes and developments and considers the future of this equipment.
Undifferentiated Febrile Illnesses Amongst British Troops in Helmand, Afghanistan
Authors: Bailey Mark S , Trinick TR , Dunbar JA , Hatch R , Osborne JC , Brooks TJ , Green AD
Published: March 2013

Objectives

Undifferentiated febrile illnesses have been a threat to British expeditionary forces ever since the Crusades. The infections responsible were identified during the Colonial Era, both World Wars and smaller conflicts since, but nearly all remain a significant threat today. Undiagnosed febrile illnesses have occurred amongst British troops in Helmand, Afghanistan since 2006 and so a fever study was performed to identify them.

Methods

From May to October 2008, all undifferentiated fever cases seen at the British field hospital in Helmand, Afghanistan were assessed using a standard protocol. Demographic details, clinical features and laboratory results were recorded and paired serum samples were sent for testing at the UK Special Pathogens Reference Unit (SPRU).

Results

Over 6 months, there were 26 cases of “Helmand Fever” assessed and 23 diagnoses were made of which 12 (52%) were sandfly fever, 6 (26%) were acute Q fever and 5 (22%) were rickettsial infections. Four cases had co-infections and 7 cases were not diagnosed (mostly due to inadequate samples). The clinical features and laboratory results available at the British field hospital did not allow these diseases to be distinguished from each other. The exact type of rickettsial infection could not be identified at SPRU.

Conclusions

These cases probably represent the “tip of an iceberg” for British and Allied forces. More resources for diagnostic facilities and follow-up of patients are required to improve the management and surveillance of “Helmand Fever” cases; until then doxycycline 100 mg twice daily for 2 weeks should be given to all troops who present with an undifferentiated febrile illness in Helmand, Afghanistan. Patients with acute Q fever should be followed-up for at least 2 years to exclude chronic Q fever. Prevention of these diseases requires a better understanding of their epidemiology, but prophylaxis with doxycycline and possibly Q fever vaccine should be considered.
Sudden Cardiac Deaths in Young British Army Personnel
Authors: Vanezis AP , Suvarna SK , Vanezis P
Published: March 2013

Much attention has been paid to sudden cardiac death in young athletes which has led to the implementation of tighter screening controls in many sports at various levels. Less attention has been paid to this subject in young army recruits. We describe three cases of sudden cardiac death in young UK soldiers. The scale of the problem in the UK is unknown. We highlight issues regarding diagnostic testing to identify risk factors for sudden cardiac death and suggest potential additions to the current screening programme for new recruits to help increase the sensitivity of detecting cardiac pathology and reducing the rates of sudden cardiac death in this group.
A Kinematic and Kinetic Analysis of Drop Landings in Military Boots
Authors: Oliver Gretchen D. , Stone AJ , Booker JM , Plummer HA
Published: March 2013

Objective

The purpose of this study was to examine knee valgus in drop landings during three different footwear conditions and to examine the ground reaction forces exhibited during the drop landing in the three different footwear conditions.

Methods

Sixteen male and female Reserve Officer Training Corps (ROTC) university undergraduate cadets (21±3 yrs, 79±12 kg, and 172±10 cm) volunteered to participate in the study. Kinematic data were collected while participants performed drop landings in three conditions: bare feet, tennis shoes, and issued military boots.

Results

Significant differences among footwear for ground reaction forces (bare feet: 1646 ±359%, tennis shoe: 1880±379%, boot: 1833±438%; p < 0.05) were found, while there was no significant difference in knee valgus among footwear.

Conclusions

Though footwear conditions did not affect knee valgus, they did affect ground reaction forces. Participants in this study had yet to receive any military training on how to land properly from a specified height. Further research should be completed to analyze the kinematics and kinetics of the lower extremity during different landing strategies implemented by trained military personnel in order to better understand injury mechanisms of drop landings in this population. It is likely that injury prevention landing techniques would be beneficial if these were employed by the military and not just in the sporting community.
Preparation of the Resuscitation Room and Patient Reception
Authors: Horne S , Smith JE
Published: March 2013

Experience from the Role 3 Medical Treatment Facility in Afghanistan has allowed the development of a variety of processes to improve management of seriously injured patients. This review describes some of the techniques that facilitate the reception of the patient in the Emergency Department. In particular the preparation of the team and the resuscitation bay, and the way the team members work together to optimise assessment and resuscitation while minimising delay to imaging and surgery. Within this context the systems described have been refined and function effectively. Many of these lessons may be relevant to future deployments.
Major Military Trauma: Decision Making in the ICU
Authors: McNicholas James , Henning JD
Published: March 2013

The management of trauma in the field intensive care unit has evolved in recent years. Key issues in current practice and organisation are discussed, with particular attention to areas where civilian and military practice differs. Possible future improvements are explored.
Use of Imaging in Trauma Decision-Making
Authors: Gay DAT , Miles R
Published: March 2013

Damage Control Radiology describes the process where imaging aids the decision making process in a trauma setting and is an important part of Damage Control Surgery and Resuscitation. This article outlines how radiology fits in to the primary and secondary surveys and discusses the role of imaging modalities such as ultrasound and CT. The importance of deployed radiology to aid rapid diagnosis and decision making is described.
Paediatric Trauma Management on Deployment
Authors: Nordmann Giles R , McNicholas JJ , Templeton PA , Arul S , Woods K
Published: March 2013

There remains a significant paediatric workload through the military hospital in Camp Bastion. In this paper the authors review and discuss particular problems with resuscitation, investigation, anaesthetic and surgical issues in dealing with children suffering from ballistic injuries. Personal experience and recent papers are used for a qualitative analysis of difficult decisions in the management of paediatric ballistic trauma. Key questions are answered in separate paragraphs for each specialty. The information described in this paper should assist any deployed physician deal with paediatric casualties particularly if they are unaccustomed to paediatric patients in their normal practice.
Forward Medical Evacuation
Authors: Bricknell Martin CM , Johnson AG
Published: March 2013

This paper discusses the principles of medical evacuation planning and execution with specific consideration of the command and control arrangements for Forward medical evacuation. The current operational context has focussed efforts on helicopter medical evacuation as the main evacuation element of the pre-hospital military medical care system rather than the ground ambulance. This paper complements the significant number of papers recently published by RAMC clinical staff on pre-hospital care.
Deployed Hospital Care
Authors: Bricknell Martin CM , McArthur D
Published: March 2013

This paper discusses the organisational developments in hospital support to expeditionary military operations – Deployed Hospital Care (DHC). It discusses the evolution in deployed hospital care arising from operations in Iraq and Afghanistan and the limitations of current doctrine. It highlights the transition from deployable infrastructure to fixed infrastructure for medical units as a critical aspect of the adaptation from intervention operations to enduring operations. The paper closes by considering some of the emerging issues in the management of personnel within DHC units.
Executing Military Medical Operations
Authors: Bricknell Martin CM , dos Santos NM
Published: March 2013

This paper concentrates on the regulation of casualties through the medical system. It considers the casualty flow throughout the system looking at how demand (or access), capacity and evacuation must be balanced. If the balance is broken, either the medical system has been over-resourced, which is inefficient, or the medical system has been overwhelmed, which is ineffective. Finally the paper discusses how the medical system should respond to a casualty surge.
International Military Medical Engagement with the Indigenous Health Sector – Afghan Security Forces Medical Services
Authors: Bricknell Martin CM , Grigson E-J
Published: March 2013

This paper presents observations from the engagement of international military medical services with the Afghan security forces medical services. It starts by presenting a model for understanding the health sector of a country in crisis. It then summarises the efforts to develop the medical services of the Afghan National Army (ANA) and Afghan National Police (ANP) since 2001. The paper focuses on experiences and observations at the operational and tactical level from our engagement with the Afghan security forces in 2009/10. The paper concludes with examples of practical challenges and solutions in developing capacity and capability for the medical services of the ANA and ANP in the Southern region of Afghanistan.