Procedure for assessing patients referred to the UK's military Heat Illness Clinic: a case series.

INTRODUCTION: The UK military operates a Heat Illness Clinic (HIC) to aid the return to exercise, training and occupational duty recommendations for individuals who have suffered exertional heat illness or heatstroke. This paper describes the process of assessment and reports representative data from n=22 patients referred to the HIC. METHOD: The assessment included clinical consultation, and measurement of maximal oxygen consumption (V̇O2max) and a heat tolerance test (HTT) conducted on a treadmill in an environmental chamber with an air temperature of 34°C and 44% relative humidity. Patients began the HTT wearing military clothing, carrying a rucksack (mass 15 kg) and walking at 60% V̇O2max, at 30 min the rucksack and jacket were removed and the T-shirt at 45 min, individuals continued walking for 60-90 min. Patients were considered heat tolerant if rectal temperature achieved a plateau. RESULTS: N=14 patients were heat tolerant on the first assessment and of the n=8 patients required to return for repeat assessment, five were heat tolerant on the second assessment and the remaining three on the third assessment. CONCLUSIONS: In conjunction with patient history and clinical evaluation, the HTT provides a physiological basis to assist with decisions concerning patient management and return to duty following an episode of heat illness.

Outcomes of UK military personnel treated with ice cold water immersion for exertional heat stroke.

INTRODUCTION: Despite mitigation efforts, exertional heat stroke (EHS) is known to occur in military personnel during training and operations. It has significant potential to cause preventable morbidity and mortality. International consensus from sports medicine organisations supports treating EHS with early rapid cooling by immersing the casualty in cold water. However, evidence remains sparse and the practice is not yet widespread in the UK. METHODS: Following changes to enable on-site ice cold water immersion (ICWI) at the Royal Marines Commando Training Centre, Lympstone, UK, we prospectively gathered data on 35 patients treated with ICWI over a 3-year period. These data included the incidence of adverse events (e.g. death, cardiac arrest or critical care admission) as the primary outcome. Basic anthropometric data, cooling rates achieved and biochemical and haematological test results on days 0-5 were also gathered and analysed. RESULTS: Despite being a cohort of patients in whom we might expect significant morbidity and mortality based on the severity of EHS at presentation, none experienced a serious adverse event. In this cohort with rapid initiation of effective cooling, biochemical derangement appeared less severe than that reported in previous studies. Higher body mass index (BMI) was associated with a lower cooling rate across a range of values previously reported as potentially of clinical significance. CONCLUSIONS: This case series supports recent updates to UK military guidance that ICWI should be more widely adopted for the treatment of EHS. Clinicians should be aware of likely patterns of blood test abnormalities in the days following EHS. Further work should seek to establish the impact of lower rates of cooling and develop strategies to optimise cooling in patients with higher BMI.

Neurological rehabilitation following heat illness in the UK Armed Forces.

Heat illness remains a significant threat to health in the UK Armed Forces despite recent improvements in the prevention of cases. A small number of heat illness survivors develop long-term neurological sequelae. Here we briefly review the background literature and present our experience of treating UK Armed Forces patients with neurological consequences of heat illness. In our cohort of patients, we observed significant improvements in subjective symptoms and objective assessments following a period of neurological rehabilitation at the Defence Medical Rehabilitation Centre. We conclude with recommendations for further research and for the incorporation of screening for neurological disability following heat illness into service policy.

Managing the risk of heat illness on board type 23 frigates deploying to the Arabian Gulf.

Temperature extremes are commonplace in the Middle East, varying between 30 degrees C and 50 degrees C. During the summer months, temperatures reach 50 degrees C consistently, with high humidity and sea temperatures rarely dropping below 33 degrees C. Sailing from the temperate climate of the U.K., Ship's crews are deploying to these extremes and working in spaces within the Ship where temperatures climb as high as 520C for at least 4 out of 6 months. Type 23 frigates (T23) were designed for anti-submarine warfare (anecdotally assumed to be North Sea based), yet now deploy continuously to hotter climates which subjects personnel to increased heat stress putting them at risk of heat injury. These risks can be minimised with simple measures such as maintaining hydration, rest periods outside of hot workspaces and finally cooling techniques such as inserting the arms up to the elbows in cool water for 10 minutes. During the 4 months spent in the Arabian Gulf of a 6 month tour, during the summer of 2010, personnel on board the T23 frigate HMS SOMERSET suffered no cases of heat illness despite the risks, due to employing these simple strategies.

Post-Kidney-Transplant Diabetes: Evaluation of Risk Factors.

INTRODUCTION: Post-transplant diabetes mellitus is a complication of kidney transplantation with deleterious effects on graft and patient survival and is associated with higher mortality. The goal of this paper is to identify risk factors that contribute to its development so that it can be avoided. METHODS: We performed a retrospective analysis of 659 kidney transplants performed in adult patients between January 2013 and December 2017. We excluded patients with a previous diagnosis of diabetes mellitus and identified 61 patients with post-transplant diabetes mellitus (10.6%), then compared them to a control group of 61 patients who did not suffer from the disease, namely the kidney transplant pair or the patient submitted for transplant immediately after. DISCUSSION: A comparative analysis of the 2 groups revealed significant differences regarding the use of ß-blockers, fasting glucose on the fifth day post-transplant, kidney recipient age, and body mass index. Using multivariate logistic regression methods, 2 variables with an impact on post-transplant diabetes development were found: fasting glucose on the fifth day post-transplant (odds ratio 1.044, 95% confidence interval 1.010-1.079, P = .010) and body mass index (odds ratio 1.130, 95% confidence interval 1.009-1.264, P = .034). We did not find any differences for other potential risk factors. CONCLUSION: A high plasma glucose level on the fifth day after the transplant and a high body mass index in the setting of the transplant can potentially impact the transplant's outcomes, so it is important to identify these levels as soon as possible to take measures to prevent this disease.

Staphylococcus Infection-Associated Glomerulonephritis in a Kidney Transplant Patient: Case Report.

BACKGROUND: Staphylococcus infection-associated glomerulonephritis is a rare cause of graft dysfunction in kidney transplant. Suspicion should be high in the setting of elevation of serum creatinine, active urinary sediment, with or without hypocomplementemia, and simultaneous Staphylococcus aureus infection. A kidney biopsy is usually diagnostic. CASE REPORT: A 56-year-old man, who received a kidney transplant in 1998, with basal serum creatinine of 1.2 mg/dL and normal urinary sediment, was admitted to our kidney transplantation unit with graft dysfunction and a urinary tract infection caused by S aureus with septicemia, treated with antibiotics, in the context of recently intensified immunosuppression for a primary immune thrombocytopenia diagnosed 3 weeks earlier. After antibiotic treatment, the patient persisted with graft dysfunction, edema, and hypertension, with a S aureus isolation in the urine culture, active urinary sediment, and low C3. A kidney biopsy was performed, showing diffuse proliferative endocapillary and mesangial glomerulonephritis, with IgA(++) and C3(++) mesangial and endocapillary deposits in immunofluorescence. The patient was treated symptomatically and maintained his regular immunosuppression. At the last follow-up, his serum creatinine value was stable at 2.5 mg/dL. CONCLUSIONS: The onset of a nephritic syndrome with a simultaneous S aureus infection should lead to suspicion of this uncommon entity, confirmed histologically. Despite its association with poor graft survival, our patient's graft survival remained stable.

Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review.

OBJECTIVES: The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). METHODS: The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies. RESULTS: Fifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (sd) 7.02°), 41.45° (sd 10.5°) and 6.0° (sd 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively. CONCLUSION: In the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety.Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472-480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1.

An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice.

OBJECTIVES: Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making. MATERIALS AND METHODS: A 29-question electronic survey was distributed to the readership of an established orthopaedic journal with international readership. The survey aimed to analyse the influence of both extrinsic (journal quality, investigator profiles, etc.) and intrinsic characteristics (study design, sample size, etc.) of research studies in relation to their influence on practice patterns. RESULTS: A total of 353 surgeons completed the survey. Surgeons achieved consensus on the 'importance' of three key designs on their practices: randomised controlled trials (94%), meta-analyses (75%) and systematic reviews (66%). The vast majority of respondents support the use of current evidence over historical clinical training; however subjective factors such as journal reputation (72%) and investigator profile (68%) continue to influence clinical decision-making strongly. CONCLUSION: Although intrinsic factors such as study design and sample size have some influence on clinical decision-making, surgeon respondents are equally influenced by extrinsic factors such as investigator reputation and perceived journal quality.Cite this article: Dr M. Ghert. An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice. Bone Joint Res 2016;5:130-136. DOI: 10.1302/2046-3758.54.2000578.

Five-year publication rate of clinical presentations at the open and closed American shoulder and elbow surgeons annual meeting from 2005-2010.

BACKGROUND: The purpose of this study was to evaluate the five-year publication rate of papers presented at both the open and closed American Shoulder and Elbow Surgeons' (ASES) annual meetings from 2005 to 2010. METHODS: Online abstracts of the presentations at the open and closed ASES annual meetings were independently screened for clinical studies and graded for quality using level of evidence. The databases PubMed (MEDLINE), Ovid (MEDLINE), and EMBASE were comprehensively searched for full-text publications corresponding to these presentations and any paper published within five years of the presentation date was counted. RESULTS: Overall, 131/266 papers corresponding to the meeting presentations were identified for a five-year publication rate of 49.2 %. Sixty two (48 %) of the papers were published in The Journal of Shoulder and Elbow Surgeons, 23 (18 %) were published in The American Journal of Sports Medicine, and 20 (16 %) were published in The Journal of Bone and Joint Surgery. The mean patient sample size included in presentations with a subsequent full-text publication was higher (154; standard error =27) than the presentations not published (93; standard error = 13) (p = 0.039). There was no correlation (p = 0.248) between the publication rate and the level of evidence of the presentations. CONCLUSIONS: The publication rate of presentations at ASES meetings from 2005 to 2010 is similar to that reported from other orthopaedic meetings. Studies with large sample sizes should continue to be encouraged, and high quality presentations must consistently be followed up with full-text manuscript preparation in order to maximize the future clinical impact.

Ultrastructure of lung in pulmonary veno-occlusive disease.

A 17-year-old boy died of severe pulmonary hypertension due to pulmonary veno-occlusive disease. The condition was diagnosed in a lung biopsy specimen and confirmed at necropsy. The lung specimen was studied by electron microscopy and immunofluorescence microscopy. The occluded pulmonary veins were lined by intact endothelial cells, beneath which was a haphazard proliferation of collagen fibrils and smooth muscle cells. The alveolar capillaries showed thickening of the endothelial cell basement membrane with an increase in the number of cytoplasmic processes of pericytes. Electron-dense deposits were located within the thickened basement membrane. These deposits were considered to represent disintegrating extravasated erythrocytes rather than immune complexes because immunofluorescence microscopy showed no immunoglobulin or complement deposition within the lung.

Fatal malformations of the larynx and upper trachea.

Five infants with a spectrum of rare malformations of the larynx and trachea are presented. All infants died because of problems with intubation and ventilation. The series reflects the wide variety and complexity of malformations that may co-exist, and successful management may require open tracheotomy.

Fetal inflammatory response in second trimester candidal chorioamnionitis.

Candidal chorioamnionitis is an uncommon and apparently rather indolent intrauterine infection in which the fetus is able to marshal some of the immunological forces at its disposal against an easily visualized antigen impinging on lung mucosal surfaces. In a retrospective histological study of one of the largest reported series of these cases, we have encountered one each of 13, 16 and 22 weeks gestation, respectively. Of these, the youngest at 13 weeks showed no inflammatory response or positive cells on immunoperoxidase staining for immunoglobulins and proliferating Candida colonies were evident in the lungs. The 16 and 22 week cases revealed a unique giant cell response in the terminal airways and increasing numbers of cells staining positively for immunoglobulins, predominantly IgM, but with an increased proportion of IgA positive cells in the older case. Preliminary studies with a pan-T-cell antiserum on paraffin-embedded lung tissue from these cases have been encouraging with few positive cells seen in sections from the 13-week or control cases but abundant cells in the lungs of the two older infected cases. Some aspects of the relationship of these uncommonly encountered cases to the ontogeny of human immunity are discussed.

[Multiprofessional demand and clientele: influences and challenges for a Master's degree course in educational technology in the health sciences]. / Demanda e clientela multiprofissional: influências e desafios para um Mestrado em Tecnologia Educacional nas Ciências da Saúde.

This article aims to identify the key characteristics of individuals pursuing a Master's degree in Health Education, discussing relevant issues concerning the objectives and content of their training. The analysis is based on data for Master's applicants selected during the four years since the program on Educational Technology in Health Sciences was created by the Unit of Educational Technology in Health, under the Health Sciences Center at the Federal University of Rio de Janeiro. The study showed that the applicants came from various professions and belonged to both teaching faculty and health care teams. The profile identified by the study has provided the material for discussing key aspects related to the Master's course characteristics and the challenges involved in achieving its social role and meeting the clientele's needs.

[Internal carotid bilateral occlusion, meningovascular syphilis and AIDS: case report]. / Oclusão bilateral das artérias carótidas internas, sífilis meningovascular e SIDA. Relato de caso.

We report a case of bilateral occlusion of internal carotid arteries, presenting with right hemiparesis and hypoesthesia, associated to meningovascular syphilis in a patient with AIDS. CT scan showed few small hypodense lesions, with a predominance on the left side, and the angiography showed bilateral occlusion of the carotid arteries. The association between syphilis and AIDS is not unusual, but the paucity of symptoms, probably due to a slow and gradual occlusion is not commonly reported.

[Mitral valve prolapse as a probable cause of cerebral ischemia. A case report]. / Prolapso da valva mitral como provável etiologia de isquemia cerebral. Relato de caso.

A 32 year old female patient, documented clinically and echocardiographically to have a competent prolapse of the mitral valve (MVP), developed a sudden ischemic cerebrovascular accident (CVA), suggestive of embolism. There were no predisposing factors to cerebrovascular disease, except for past use of contraceptive pills. Tomographic study disclosed an ischemic right-parietal "wedge-shaped" defect. The patients's recovery, with physiotherapy and AAS, was satisfactory. The authors discuss the association of MVP and CVA, considering physiopathogenic, prophylactic and therapeutic aspects, emphasizing the need to consider MVP as a cause of CVA in young adults.

Stress response and its relationship to cystic (pseudofollicular) change in the definitive cortex of the adrenal gland in stillborn infants.

The adrenal glands of 41 fresh stillbirths were studied and a 'stress response' pattern could be seen in 28. In these glands the stress response was characterised by compact cell change, lipid depletion, excess pyroninophilia, and dilatation of the very prominent granular endoplasmic reticulum. Scattered areas of cytolysis of cells, especially of the definitive cortex, gave rise to the commonly seen cystic (pseudofollicular) change and it was obvious that cells undergoing lysis were severely 'stressed'. In 2 infants there was a 'clear cell reversal' pattern. Histological and ultrastructural changes of the stress response were not identified in 11. Infants of low birthweight score were somewhat more commonly represented in the group that did not show a stress response. Cytolytic changes accompanying a stress response were commoner in immature infants. It is argued that cystic (pseudofollicular) change in the adrenal cortex of the newborn signifies a previous stress reaction.

Coronary arterial lesions and myocardial necrosis in stillbirths and infants.

In a detailed study of the coronary arterial tree and myocardium in 256 stillbirths and infants, abnormalities of the coronary arterial tree were noticed in 79 infants, and necrotic lesions of the myocardium in 111 infants. Of the 79 infants with arterial lesions, 70 had associated myocardial necrosis or scarring, or both; the group with coronary arterial lesions, therefore, accounted for the majority of cases with myocardial damage. The myocardial lesions varied from small zones of subendocardial damage, to larger 'geographical' zones of necrosis scattered haphazardly through the myocardium, and a small group where massive necrotic lesions of the papillary muscles were present. While the coronary arterial lesions were associated with all three patterns, they were particularly found in association with the 'geographical' and papillary muscle changes. The coronary arterial lesions varied from zones of acute focal, medial necrosis to severe proliferative intimal lesions and medial defects, with a distinct progression of changes from the acute to the more established lesions. The coronary arterial lesions were seen most commonly in association with conditions that could produce severe hypoxia, and it is argued that they result from hypoxia. It is suggested further that the myocardial damage, so commonly associated with the coronary arterial lesions, could compromise the ability of the hypoxic infant to respond to such an insult. The coronary arterial lesions seen in this group of young infants could offer one explanation for the later development of a variety of other pathological conditions seen in adolescents and young adults.