Surgically Managed Ovarian Masses at the Royal Children's Hospital, Melbourne -19 Year Experience.

BACKGROUND/PURPOSE: To describe the clinicopathological characteristics and management of surgically removed ovarian masses at the Royal Children's Hospital, Melbourne from 1993 to 2012. METHODS: Medical records were reviewed retrospectively. Data regarding clinical findings, imaging and surgical management were evaluated. RESULTS: There were 266 ovarian masses found in 258 surgeries (eight had bilateral masses). Most were benign (246/266, 92.5%), 2.3% (6/266) were borderline, and 5.3% (14/266) were malignant. The most common presenting symptom was abdominal pain for benign masses (169/246, 68.7%), and a palpable mass for borderline and malignant masses (12/20, 60.0%). Sensitivity and specificity of ultrasound for detection of malignancy was 64.7% and 52.9% respectively. Ovarian torsion occurred in 22.1% (n=57), none with malignancy, with seven cases diagnosed under one year of age. Sensitivity and specificity of ultrasound for ovarian torsion was 22.0% and 91.9%, respectively. The proportion undergoing ovarian cystectomy rather than oophorectomy has increased from 56.3% during 1993-1997 to 93.8% during 2008-2012 (p<0.005). Ovarian torsion was managed with ovarian conservation in 82.6% of cases between 2008-2012. CONCLUSION: The majority of pediatric and adolescent ovarian masses were benign. Sensitivity of ultrasound was fair for detection of malignancy, and poor for ovarian torsion. Conservative surgeries are increasingly common. LEVEL OF EVIDENCE: Level IV - case series with no comparison group TYPE OF STUDY: Retrospective Study.

Remote physiological monitoring in an austere environment: a future for battlefield care provision?

Wearable technologies are making considerable advances into the mainstream as they become smaller and more user friendly. The global market for such devices is forecasted to be worth over US$5 billion in 2018, with one in six people owning a device. Many professional sporting teams use self-monitoring to assess physiological parameters and work rate on the pitch, highlighting the potential utility for military command chains. As size of device reduces and sensitivity improves, coupled with remote connectivity technology, integration into the military environment could be relatively seamless. Remote monitoring of personnel on the ground, giving live updates on their physiological status, would allow commanders or medical officers the ability to manage their soldiers appropriately and improve combat effectiveness. This paper explores a proof of concept for the use of a self-monitoring system in the austere high altitude environment of the Nepalese Himalayas, akin to those experienced by modern militaries fighting in remote locations. It also reviews, in part, the historical development of remote monitoring technologies. The system allowed for physiological recordings, plotted against GPS position, to be remotely monitored in Italy. Examples of the data recorded are given and the performance of the system is discussed, including limitations, potential areas of development and how systems like this one could be integrated into the military environment.

The effects of acute hypoxia on tissue oxygenation and circulating alarmins in healthy adults.

The binding of high-mobility group box-1 (HMGB-1) to the membrane receptor for advanced glycation end-products (mRAGE) is a key early mediator of non-infectious inflammation and its triggers include ischaemia/hypoxia. The effects of acute hypoxia on soluble RAGE (sRAGE) are unknown. Fourteen healthy adults (50 % women; 26.6+/-3.8 years) were assessed at baseline normoxia (T0), followed by four time-points (T90, 95, 100 and 180 min) over three hours of continuous normobaric hypoxia (NH, 4,450 m equivalent) and again 60 min after return to normoxia (T240). A 5-min exercise step test was performed during NH at T90. Plasma concentrations of HMGB-1, sRAGE VCAM-1, ICAM-1, VEGF IL-8 and IL-13 were measured using venous blood. Arterial and tissue oxygen saturations were measured using pulse oximetry (SpO(2)) and near-infrared spectroscopy (StO(2)), respectively. NH led to a significant reduction in SpO(2), StO(2), sRAGE and VEGF, which was compounded by exercise, before increasing to baseline values with normoxic restoration (T240). NH-exercise led to a paired increase in HMGB-1. sRAGE inversely correlated with HMGB-1 (r=-0.32; p=0.006), heart rate (r=-0.43; p=0.004) but was not linked to SpO(2) or StO(2). In conclusion, short-term NH leads to a fall in sRAGE and VEGF concentrations with a transient rise post NH-exercise in HMGB-1.

Power supplies and equipment for military field research: lessons from the British Service Dhaulagiri Research Expedition 2016.

INTRODUCTION: The British Service Dhaulagiri Research Expedition (BSDMRE) took place from 27 March to 31 May 2016. The expedition involved 129 personnel, with voluntary participation in nine different study protocols. Studies were conducted in three research camps established at 3600, 4600 and 5140 m and involved taking and storing blood samples, cardiac echocardiography and investigations involving a balance plate. Research in this remote environment requires careful planning in order to provide a robust and resilient power plan. In this paper we aim to report the rationale for the choices we made in terms of power supply, the equipment used and potential military applicability. METHODS: This is a descriptive account from the expedition members involved in planning and conducting the medical research. RESULTS: Power calculations were used to determine estimates of requirement prior to the expedition. The primary sources used to generate power were internal combustion engine (via petrol fuelled electric generators) and solar panels. Having been generated, power was stored using lithium-ion batteries. Special consideration was given to the storage of samples taken in the field, for which electric freezers and dry shippers were used. All equipment used functioned well during the expedition, with the challenges of altitude, temperature and transport all overcome due to extensive prior planning. CONCLUSIONS: Power was successfully generated, stored and delivered during the BSDMRE, allowing extensive medical research to be undertaken. The challenges faced and overcome are directly applicable to delivering military medical care in austere environments, and lessons learnt can help with the planning and delivery of future operations, training exercises or expeditions.

The effect of high altitude on central blood pressure and arterial stiffness.

Central arterial systolic blood pressure (SBP) and arterial stiffness are known to be better predictors of adverse cardiovascular outcomes than brachial SBP. The effect of progressive high altitude (HA) on these parameters has not been examined. Ninety healthy adults were included. Central BP and the augmentation index (AI) were measured at the level of the brachial artery (Uscom BP+ device) at <200 m and at 3619, 4600 and 5140 m. The average age of the subjects (70% men) were 32.2±8.7 years. Compared with central arterial pressures, brachial SBP (+8.1±6.4 mm Hg; P<0.0001) and pulse pressure (+10.9±6.6 mm Hg; P<0.0001) were significantly higher and brachial diastolic BP was lower (-2.8±1.6 mm Hg; P<0.0001). Compared with <200 m, HA led to a significant increase in brachial and central SBP. Central SBP correlated with AI (r=0.50; 95% confidence interval (CI): 0.41-0.58; P<0.0001) and age (r=0.32; 95% CI: 21-0.41; P<0.001). AI positively correlated with age (r=0.39; P<0.001) and inversely with subject height (r=-0.22; P<0.0001), weight (r=-0.19; P=0.006) and heart rate (r=-0.49; P<0.0001). There was no relationship between acute mountain sickness scores (Lake Louis Scoring System (LLS)) and AI or central BP. The independent predictors of central SBP were male sex (coefficient, t=4.7; P<0.0001), age (t=3.6; P=0.004) and AI (t=7.5; P<0.0001; overall r2=0.40; P<0.0001). Subject height (t=2.4; P=0.02), age (7.4; P<0.0001) and heart rate (t=11.4; P<0.0001) were the only independent predictors of AI (overall r2=0.43; P<0.0001). Central BP and AI significantly increase at HA. This rise was influenced by subject-related factors and heart rate but not independently by altitude, LLS or SpO2.

The Adrenocortical Response to Synthetic ACTH Following a Trek to High Altitude.

Gradual ascent to high altitude is typically associated with reduced resting aldosterone and unchanged cortisol, features that may facilitate acclimatization but are poorly understood. The aim of the study was to investigate the cortisol and aldosterone response to adrenocorticotrophic hormone at altitude. Eleven subjects underwent a 250 µg short synacthen test at sea-level and again after trekking to 3 600 m in Nepal. Cortisol and aldosterone were measured by conventional assay from blood samples taken immediately prior to the administration of synacthen (T0) and then 30 (T30) and 60 (T60) min later. At 3 600 m resting basal cortisol and aldosterone levels were both significantly lower than they were at sea-level (p=0.004, p=0.003, respectively). Cortisol values at T30 and T60 were not different between sea-level and 3 600 m but the increment after synacthen was significantly greater (p=0.041) at 3 600 m due to a lower basal value. Aldosterone at T30 and T60 was significantly lower (p=0.003 for both) at 3 600 m than at sea-level and the increment following synacthen was also significantly less (p=0.003) at 3 600 m. At 3 600 m there appears to be a divergent adrenal response to synthetic adrenocorticotrophic hormone with an intact cortisol response but a reduced aldosterone response, relative to sea-level. This may reflect a specific effect of hypoxia on aldosterone synthesis and may be beneficial to acclimatization.

An essential role of Ffar2 (Gpr43) in dietary fibre-mediated promotion of healthy composition of gut microbiota and suppression of intestinal carcinogenesis.

Composition of the gut microbiota has profound effects on intestinal carcinogenesis. Diet and host genetics play critical roles in shaping the composition of gut microbiota. Whether diet and host genes interact with each other to bring specific changes in gut microbiota that affect intestinal carcinogenesis is unknown. Ability of dietary fibre to specifically increase beneficial gut microbiota at the expense of pathogenic bacteria in vivo via unknown mechanism is an important process that suppresses intestinal inflammation and carcinogenesis. Free fatty acid receptor 2 (FFAR2 or GPR43) is a receptor for short-chain fatty acids (acetate, propionate and butyrate), metabolites of dietary fibre fermentation by gut microbiota. Here, we show FFAR2 is down modulated in human colon cancers than matched adjacent healthy tissue. Consistent with this, Ffar2(-/-) mice are hypersusceptible to development of intestinal carcinogenesis. Dietary fibre suppressed colon carcinogenesis in an Ffar2-dependent manner. Ffar2 played an essential role in dietary fibre-mediated promotion of beneficial gut microbiota, Bifidobacterium species (spp) and suppression of Helicobacter hepaticus and Prevotellaceae. Moreover, numbers of Bifidobacterium is reduced, whereas those of Prevotellaceae are increased in human colon cancers than matched adjacent normal tissue. Administration of Bifidobacterium mitigated intestinal inflammation and carcinogenesis in Ffar2(-/-) mice. Taken together, these findings suggest that interplay between dietary fibre and Ffar2 play a key role in promoting healthy composition of gut microbiota that stimulates intestinal health.

High altitude adaptation and illness: military implications.

British military personnel are frequently exposed to high altitude (HA) (>1500m). Operations in Afghanistan have occurred at altitudes of up to 3000m and there remains the possibility of rapid deployment of non-acclimatised troops to HA areas. British military personnel also deploy to HA frequently on Adventurous Training (AT) and there are numerous expeditions every year to the Greater Ranges. As such, there remains a reasonable likelihood of the development of high altitude illness (HAI) with potentially life-threatening consequences. This article aims to provide an overview of the adaptive (acclimatisation) and pathological (acute HAI) responses to HA exposure, with particular reference to military deployments.

A guide to managing anaphylaxis for General Duties Medical Officers.

Anaphylaxis is a severe, life-threatening, generalised hypersensitivity reaction. It affects 1 in 1,333 (~0.08%) of the English population during their lives, with 1% of cases being fatal. Management, underpinned by guidance from the Resuscitation Council (UK), focuses on a thorough clinical assessment and prompt administration of intramuscular adrenaline. Symptoms may recur, so patients must be observed for a period of no less than six hours. In a deployed environment evacuation must be swift and into a safe environment capable of providing critical care support. There are clear occupational implications following a case of anaphylaxis, and a confirmed case may affect service personnel's fitness to deploy. This article will summarise the management of anaphylaxis in Royal Naval personnel.

Incidence of acute mountain sickness in UK Military Personnel on Mount Kenya.

BACKGROUND: Acute mountain sickness (AMS) is a common problem of trekkers to high altitude. The UK military train at high altitude through adventurous training (AT) or as exercising troops. The ascent of Point Lenana at 4985 m on Mount Kenya is frequently attempted on AT. This study sought to establish the incidence of AMS within this population, to aid future planning for military activities at altitude. METHODS: A voluntary questionnaire was distributed to all British Army Training Unit Kenya based expeditions attempting to ascend Mount Kenya during the period from February to April 2014. The questionnaire included twice daily Lake Louise and Borg (perceived exertion scale) self-scoring. All expeditions were planned around a 5-day schedule, which included reserve time for acclimatisation, illness and inclement weather. RESULTS: Data were collected on 47 participants, 70% of whom reached the summit of Point Lenana. 62% (29/47) self-reported AMS (defined as Lake Louise score (LLS) ≥3) on at least one occasion during the ascent, and 34% (10/29) suffered severe AMS (LLS ≥6). Those who attempted the climb within 2 weeks of arrival in Kenya had a higher incidence of AMS (12/15 (80%) vs 17/32 (53%), p=0.077). Participants recording a high Borg score were significantly more likely to develop AMS (16/18 vs 9/21, p=0.003). CONCLUSIONS: This represents the first informative dataset for Mount Kenya ascents and altitude. The incidence of AMS during AT on Mount Kenya using this ascent profile is high. Adapting the current ascent profile, planning the ascent after time in country and reducing perceived exertion during the trek may reduce the incidence of AMS.

Sudden onset hemiplegia at high altitude.

Travel to high altitude and the incumbent exposure to hypobaric hypoxia leads to a prothrombotic state. This may increase the likelihood of thromboembolic events, including stroke, in otherwise healthy individuals. While there have been sporadic anecdotal reports of 'stroke-like' syndromes at high altitude for over 100 years, there are surprisingly few detailed reports supported by imaging.This report describes a case of posterior circulation infarct thought to be due to a paradoxical embolus through a patent foramen ovale. The relationship between high-altitude physiology, increased incidence of thromboembolism and the significance of patent foramen are discussed in the report.

Copeptin and arginine vasopressin at high altitude: relationship to plasma osmolality and perceived exertion.

PURPOSE: A diuresis is a key part of acclimatisation to high altitude (HA). Arginine vasopressin (AVP) is a hormone involved in salt and water balance and may potentially have a role in the development of altitude illness. ProAVP (copeptin) is more stable than AVP and is assayed by a straightforward, automated method. We investigated the relationship of AVP to copeptin and the copeptin response to exercise and altitude illness in a large cohort during a field study at HA. METHODS: 48 subjects took part in a 10-day trek at HA. Venous blood samples were taken at 3,833, 4,450 and 5,129 m post-trek (exercise) and the following day at rest. Daily recordings of symptoms of altitude illness, oxygen saturations and perceived exertion were carried out. RESULTS: AVP and copeptin levels increased with exercise and correlated closely (ρ 0.621 p < 0.001), this was strongest in the stressed state when AVP secretion was highest, at 5,129 m post-exercise (ρ 0.834 p < 0.001). On two-way ANOVA, both altitude (F = 3.5; p = 0.015) and exercise (F = 10.2; p = 0.002) influenced copeptin levels (interaction F = 2.2; p = 0.08). AVP levels were influenced by exercise (F = 14.4; p = 0.0002) but not altitude (F = 2.0; p = 0.12) with no overall group interactions (F = 1.92.6; p = 0.06). There was no association between copeptin or arginine vasopressin and altitude illness. Copeptin correlated with the Borg RPE score and was significantly higher in the group with a Borg score ≥15 (7.9 vs. 3.7 p < 0.001). CONCLUSION: We have shown that arginine vasopressin and copeptin levels correlate and are suppressed below 5,129 m. Furthermore, we have demonstrated that exertion, rather than altitude illness or increasing osmolality, is the stimulus for increases in copeptin.

Exercise HIMALAYAN SERPENT: feedback article.

Exercise HIMALAYAN SERPENT was open to junior doctors from the United Kingdom (UK) Armed Forces and aimed to educate potential expedition doctors on aspects of high altitude and wilderness medicine as well as conducting adventurous training (AT) and medical research. This was the first time such an exercise had been undertaken and this article explores the views of those junior doctors taking part to assess whether the exercise met the aims and objectives it set out.

Lessons learned while undertaking high altitude medical research in the Himalayas.

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.

Comparison of two methods of assessing total body water at sea level and increasing high altitude.

Fluid retention is a recognized feature of acute mountain sickness. However, accurate assessment of hydration, including the quantification of body water, has traditionally relied on expensive and non-portable equipment limiting its utility in the field setting. We compared the assessment of total body water (TBW) and their relationship to total body weight using two non-invasive methods using the NICas single-frequency bioimpedance analysis (SF-BIA) system and the BodyStat QuadScan 4000 multifrequency BIA system (MF-BIA). TBW measurements were performed at rest at sea level and at high altitude (HA) at 3833 m postexercise and at rest and thereafter at rest at 4450 m and 5129 m on 47 subjects. The average age was 34.5 ± 9.3 years with an age range of 21-54 years (70.2% male). There were strong correlations between TBW assessment with both methods at sea level (r = 0.90; 95% CI 0.78-0.95: P<0.0001) and at HA (r = 0.92; 0.89-0.94: P<0.0001), however, TBW readings were 0.2 l and 1.91 l lower, respectively, with the NICaS. There was a stronger correlation between TBW and body weight with the QuadScan (r = 0.91; P<0.0001) than with the NICaS (r = 0.83; P<0.0001). The overall agreement between the two TBW methods was good, but the 95% confidence intervals around these agreements were relatively wide. We conclude that there was reasonable agreement between the two methods of BIA for TBW, but this agreement was lower at HA.

Brain natriuretic peptide and NT-proBNP levels reflect pulmonary artery systolic pressure in trekkers at high altitude.

Our objective was to evaluate the utility of the natriuretic peptides BNP (brain natriuretic peptide) and NT-proBNP as markers of pulmonary artery systolic pressure (PASP) in trekkers ascending to high altitude (HA). 20 participants had BNP and NT-proBNP assayed and simultaneous echocardiographic assessment of PASP performed during a trek to 5150 m. PASP increased significantly (p=0.006) with ascent from 24+/-4 to 39+/-11 mm Hg at 5150 m. At 5150 m those with a PASP>/=40 mm Hg (n=8) (versus those with PASP<40 mm Hg) had higher post-exercise BNP (pg/ml): 54.5+/-36 vs. 13.4+/-17 (p=0.012). Their resting BNP at 5150 m was also higher: 57.3+/-43.4 vs. 12.6+/-13 (p=0.017). In those with a pathological (>/=400 pg/ml) rise in NT-proBNP at 5150 m (n=4) PASP was significantly higher: 45.9+/-7.5 vs. 32.2+/-6.2 mm Hg (p=0.015). BNP and NT-proBNP may reflect elevated PASP, a central feature of high altitude pulmonary oedema, at HA.

Can adventurous training have a role in improving clinical outcomes?

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

A comparison of performance between Teflon and polyurethane safety cannulae at extremes of operating temperatures.

OBJECTIVES: In the United Kingdom, approximately eight million peripheral cannulations are performed each year. Intravenous cannulae are made from either polytetrafluoroethylene (Teflon) or polyurethane. Polyurethane has a lower incidence of thrombophlebitis, however the physical characteristics of polyurethane may make the cannulae difficult to use at higher ambient temperatures. This effect maybe of importance to those involved in cannulation in extreme environments and especially for military doctors deployed in current theatres of operations. METHODS: In a randomised single blinded study we investigated the different characteristics of Teflon and polyurethane cannulae (Vasofix Safety Cannulae, B Braun) at three different temperatures (-10 degrees C, 21 degrees C and 40 degrees C). RESULTS: There is no statistically significant difference in the ease or speed of cannulation of either polyurethane or Teflon safety cannulae in extremes of temperature. CONCLUSIONS: This study provides evidence that performance of polyurethane safety cannulae are not impaired by temperature extremes.