Management of children in the deployed intensive care unit at Camp Bastion, Afghanistan.

BACKGROUND: The deployed Intensive Therapy Unit (ITU) in the British military field hospital in Camp Bastion, Afghanistan, admits both adults and children. The purpose of this paper is to review the paediatric workload in the deployed ITU and to describe how the unit copes with the challenge of looking after critically injured and ill children. METHODS: Retrospective review of patients <16 years of age admitted to the ITU in the British military field hospital in Camp Bastion, Afghanistan, over a 1-year period from April 2011 to April 2012. RESULTS: 112/811 (14%) admissions to the ITU were paediatric (median age 8 years, IQR 6-12, range 1-16). 80/112 were trauma admissions, 13 were burns, four were non-trauma admissions and 15 were readmissions. Mechanism of injury in trauma was blunt in 12, blast (improvised explosive device) in 45, blast (indirect fire) in seven and gunshot wound in 16. Median length of stay was 0.92 days (IQR 0.45-2.65). 82/112 admissions (73%) were mechanically ventilated, 16/112 (14%) required inotropic support. 12/112 (11%) died before unit discharge. Trauma scoring was available in 65 of the 80 trauma admissions. Eight had Injury Severity Score or New Injury Severity Score >60, none of whom survived. However, of the 16 patients with predicted mortality >50% by Trauma Injury Severity Score, seven survived. Seven cases required specialist advice and were discussed with the Birmingham Children's Hospital paediatric intensive care retrieval service. The mechanisms by which the Defence Medical Services support children admitted to the deployed adult ITU are described, including staff training in clinical, ethical and child protection issues, equipment, guidelines and clinical governance and rapid access to specialist advice in the UK. CONCLUSIONS: With appropriate support, it is possible to provide intensive care to children in a deployed military ITU.

The pattern of paediatric trauma on operations.

OBJECTIVES: Recent military campaigns in Iraq and Afghanistan have resulted in the treatment of children in British Medical facilities. In order to determine how care for children may develop in the future, it is necessary to understand the current situation. The aim of this article is to examine the pattern of paediatric trauma on recent operations in Iraq and Afghanistan. METHODS: Data was requested from the Joint Theatre Trauma Registry, held at the Royal Centre for Defence Medicine in Birmingham, on all trauma calls for patients aged under 16 between the dates 21/3/03 and 31/8/09. Data included age, gender, theatre of operation, injury mechanism and type, trauma scores and destination of the child. RESULTS: 176 children were identified with 16.5% from Iraq and 83.5% from Afghanistan. The overall survival rate was 88.6% with survival rates in Iraq of 89.7% and in Afghanistan of 88.4%. Males accounted for 66.5% of admissions and the commonest age group was age 6-8 years. In 59.1% of total admissions the mechanism of injury was related to explosives. This differed between theatres with explosive injury causing 27.6% of admissions in Iraq and 63.5% in Afghanistan. Injury Severity Scores (ISS) showed equal numbers of minor and severe injuries with fewer moderately injured patients. The median ISS of all data was nine. The median ISS from Iraq was 16 and the median ISS from Afghanistan was nine. CONCLUSIONS: The treatment of children in British medical facilities whilst deployed on operations is likely to continue. An assessment of the injury patterns of paediatric patients on current deployments allows development of training and an understanding of logistic requirements. Data collection will also need to be adapted to meet the needs of paediatric patients. These remain issues that are being addressed by the Defence Medical Services.

Major military trauma: decision making in the ICU.

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.

Paediatric trauma management on deployment.

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.

The paediatric transfusion challenge on deployed operations.

This paper briefly touches on the problem of dealing with the severely injured child requiring massive transfusion and produces a guide on the management of this based on the current Surgeon General's Operational Policy Letter. There are no known UK guidelines on massive transfusion in trauma in the paediatric population although many specialist centres have guidance for dealing with cases in theatre during elective surgery. It is hoped that these guidelines will be used by deployed military anaesthetists to aid in their management of these difficult cases, not normally seen in the U.K.

Paediatric intensive care in the field hospital.

Our recent experience of paediatric critical care during UK military operations in Afghanistan is discussed alongside consideration of the background to the paediatric critical care service on deployment. We describe the intensive care unit's capabilities, details of recent paediatric critical care admissions during July to September 2008 and some of the ethical issues arising. Some desirable future developments will be suggested.

Overview of 12 months anaesthetic activity in a UK field hospital on enduring operations in Iraq.

The British Field Hospital facility in Southern Iraq has seen a continuous turnover of patient admissions since the start of offensive operations during the 2003 Gulf conflict (Operation TELIC). During the war a number of procedures were carried out and these have been well described to date. On May 1st 2003 President Bush declared an end to high intensity operations with a subsequent reduction in medical activity. However, the facility has continued to provide medical care to large numbers of service and civilian patients from the end of hostilities to the present day. The purpose of this review is to present anaesthetic and demographic data relating to procedures carried out at the Field Hospital over a 12-month period from the end of the war-fighting phase of the conflict.

Children's representations of pets in their social networks.

OBJECTIVES: To develop a child-friendly methodology to study children's representations of social support available from their personal relationships; and to examine children's representations of support from their pets compared to support from human relationships. DESIGN: Participants were 22 year-3 primary school children aged 7-8 years. They were asked to list all the people and animals important to them and then to select a 'top 10' of most special relationships. Using a story-based methodology, children were asked who from their 'top 10' they would turn to if they were the child in the story. RESULTS: Consistency in the data indicated that the children could reliably discriminate between different relationships in terms of the support functions they serve. Pets were often ranked higher than certain kinds of human relationship, and they featured prominently as providers of comfort, esteem support and confidants for a secret. Confidence in these findings is gained through pets not being nominated for functions they could not realistically perform.

Dogs as catalysts for social interactions: robustness of the effect.

It is known that pet dogs can act as catalysts for human social interactions, and it has been suggested that this may enhance feelings of well-being. Two studies were carried out to establish the robustness of this effect. In Study 1, a highly trained dog was used to ensure that the dog itself did not solicit attention from passers-by, and data were collected across a range of normal daily activities in which a dog could be included, not confined to conventional dog walking areas as in previous studies. Being accompanied by a dog increased the frequency of social interactions, especially interactions with strangers. In Study 2, also using a trained dog, a different (male) participant observer was dressed either smartly or scruffily. Although there were significantly more interactions when he was smartly dressed, the greatest effect was between the Dog present and No Dog conditions irrespective of the handler's dress. It is concluded that the social catalysis effect is very robust, which opens the way for investigating possible consequences of the effect for well-being and health.

Sebaceous carcinoma arising within an ovarian cystic mature teratoma.

A 77-year-old woman presented with an abdominal swelling and underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy for a left ovarian tumor. This was an ovarian mature cystic teratoma in which had developed a sebaceous cell carcinoma. This is a rare form of ovarian malignancy whose behavior is poorly documented. The treatment and follow-up of this case are discussed.

Organization and polymorphism of rabbit immunoglobulin heavy chain genes.

Germline genes encoding C mu, C gamma, C alpha, and C epsilon heavy chains of rabbit immunoglobulins have been isolated from recombinant phage and cosmid libraries. The JH, C mu, C gamma, and C epsilon are found in a 5'-JH-C mu-C gamma-C epsilon-3' orientation on a 90kb stretch of DNA. Four C alpha genes have been cloned and presumably reside 3' to the other CH genes. Southern blot analysis of rabbit sperm DNA indicates that the rabbit genome contains a single C gamma gene, one C mu gene, and as many as 10 C alpha genes. Restriction site polymorphism is found for C mu, C gamma, and C alpha genes of rabbits of various heavy chain haplotypes. The organization of the rabbit CH genes differs from that of mouse and human CH genes in that the rabbit has multiple C alpha genes, whereas mouse and human have one or two C alpha genes, respectively. In addition, mouse and human have four C gamma genes, whereas rabbit has only one C gamma gene. The presence of a single C gamma gene indicates that at least in the rabbits examined, no germline gene encoding latent or unexpected, C gamma allotypes is present. The genetic control of the expression of latent C gamma allotypes is discussed.

Characterization of functionally distinct subpopulations of rabbit T lymphocytes.

Two subpopulations of rabbit spleen and mesenteric lymph node T cells were identified by a monoclonal antibody, 8AC8. These subpopulations were separated on the flow cytometer and were analysed for their response to T cell mitogens and antigens, their responsiveness in mixed lymphocyte cultures, and their ability to function as cytotoxic effector cells. The 8AC8+ T cell subpopulation contained cells highly responsive to T cell mitogens, to antigen, and to allogeneic or autologous stimuli in a mixed lymphocyte reaction. In contrast, the 8AC8- T cell subpopulation was non-responsive to T cell mitogens, and responded, poorly to antigen, and to allogeneic and autologous stimuli in an MLR. Both the 8AC8+ and 8AC8- subpopulations exhibited xenogenic cytotoxic effector function. Thus, the 8AC8 MAb identified a subpopulation of mature differentiated rabbit T cells; these 8AC8+ cells share many of the characteristics of the human OKT4 helper/inducer T cell subpopulation.

Molecular characterization of the recombination region of six murine major histocompatibility complex (MHC) I-region recombinants.

Using Southern DNA hybridization techniques, restriction enzyme site polymorphisms have been used to correlate the molecular maps of the murine major histocompatibility complex (MHC) I region with the genetic map derived from analyses of recombinant mouse strains. The data indicated that the DNA that maps between the I-A and I-E subregions is limited to 3.4 kilobases (kb) and includes the 3' end of the E beta gene. According to classical genetic mapping by recombinational analysis of serological markers, this region should encode the I-B and I-J subregions. These observations are surprising in two respects. First, 3.4 kb is a small amount of DNA to encode even one complete murine gene. Second, this region, which putatively encodes the I-J gene, appears to reside at least partially within the E beta gene. To analyze these apparent paradoxes, further, we cloned the 3.4-kb region in question from six I-region combinant strains [B10.A(3R), B10.a(5R), B10.A(4R), B10.GD, B10.HTT, and B10.S(9R)] and four strains used in the derivation of the recombinants (B10.D2, B10.A, C57BL/10, and ASW) into a lambda phage vector. By direct restriction enzyme mapping of polymorphic sites, we have confirmed the previously identified boundaries of the I-A and I-E subregions and have narrowed the estimate of the distance between these subregions to approximately 2.0 kb of DNA. This 2.0-kb region encompasses part of the intron between the first- (beta 1) and second-domain (beta 2) exons and the second-domain exon (beta 2) of the E beta gene.(ABSTRACT TRUNCATED AT 250 WORDS)

DNA sequence of the gene encoding the E alpha Ia polypeptide of the BALB/c mouse.

A 3.4-kilobase DNA fragment containing the gene coding for the E alpha chain of an Ia (I region-associated) antigen from the BALB/c mouse has been sequenced. It contains at least three exons, which correlate with the major structural domains of the E alpha chain-the two external domains alpha 1 and alpha 2, and the transmembrane-cytoplasmic domain. The coding sequence of the mouse E alpha gene shows striking homology to its counterpart at the DNA and protein levels. The translated alpha 2 exon demonstrates significant similarity to beta 2-microglobulin, to immunoglobulin constant region domains, and to certain domains of transplantation antigens. These observations and those of others suggest that the Ia antigen, transplantation antigen, and immunoglobulin gene families share a common ancestor.

A molecular map of the immune response region from the major histocompatibility complex of the mouse.

A stretch of 200 kilobases (kb) of DNA from the I region of the mouse major histocompatibility complex has been cloned and characterized. It contains the genes for the biochemically defined class II proteins E alpha, E beta and A beta. DNA blot analyses suggest that the I region may contain only 6-8 class II genes. Correlation of our molecular map with the genetic map of the I region confines two of the five I subregions, I-J and I-B, to less than 3.4 kb of DNA at the 3' end of the E beta gene where a hotspot for recombination has been observed. Indeed, the I-A and I-E subregions may be contiguous. If so, the I-B and I-J subregions are not encoded in the I region between the I-A and I-E subregions.

Immune response gene function correlates with the expression of an Ia antigen. I. Preferential association of certain Ae and E alpha chains results in a quantitative deficiency in expression of an Ae:E alpha complex.

These studies were stimulated by the observation, reported in the accompanying paper (19), that IEu failed to interact with I-Ak or I-As in F1 mice to allow a response to the antigen, pigeon cytochrome c, unlike I-E subregions derived from other Ia.7+ haplotypes. Serological and biochemical analyses were performed to determine whether or not cells from these F1 mice express the Ak,se:E alpha complexes that should function as restriction elements for T cell recognition of pigeon cytochrome c on antigen-presenting cells. Using the Y-17 monoclonal antibody, which recognizes the combinatorial or conformational determinant Ia.m44 on certain Ae:E alpha complexes, we were able to distinguish between Aue:Eu alpha and Ab,k,se:Eu alpha complexes on cell surfaces. Although complement-dependent microcytotoxicity with Y-17 failed to detect Ab,k,se:Eu alpha complexes on cells from appropriate F1 mice, these molecules were detected by both quantitative absorption and quantitative immunofluorescence studies. However, Ab,k,se:Eu alpha complexes were found to be present at levels only one-seventh to one-eighth the levels expressed by homozygous I-Ab, I-Ek; I-Ak, I-Ek; and I-As, I-Ek cells. The results of two-dimensional polyacrylamide gel electrophoresis analyses suggest that the low levels of expression of Ab,k,se:Eu alpha complexes are a consequence of the preferential association of Aue and Eu alpha chains with each other in the F1 cells. As will be shown in the following paper (19), the quantitative deficiency in the expression of Ake:Eu alpha and Ase:Eu alpha complexes results in a corresponding defect in antigen-presenting cell function, thus providing strong evidence that Ia antigens represent products of Ir genes.