Electronic Medication Record Accuracy in Haemodialysis Outpatient Settings.

Aims Irish haemodialysis (HD) units operate the electronic Kidney Disease Clinical Patient Management System (KDCPMS). KDCMPS is not always used as the primary electronic patient record. At this study setting, KDCPMS information accuracy has not been examined to date. This study aims to identify, characterise and quantify medication discrepancies within KDCPMS records of HD outpatients. Methods Prospective, observational study conducted on the HD unit of Tallaght University Hospital. Medicine reconciliation was conducted to identify KDCPMS discrepancies with medication review to document Drug Related Problems (DRPs). Clinical pharmacists issued recommendations to resolve DRPs. Results All KDCPMS records examined contained intentional and unintentional discrepancies (n=36). Unintentional discrepancies corresponding to 8.8 discrepancies per patient (5.13SD) was observed. One-hundred-and-forty-three DRPs were identified in 34 patients (94.4%). Sixty-five per cent (65%) of pharmacist recommendations were accepted (n=93), 22.4% rejected (n=32), 8.4% (n=12) referred to the renal multidisciplinary team (MDT) and 4.2% not actioned (n=6). Conclusion KDCPMS contains inaccuracies potentially leading to systemic error. Robust clinical governance supported by national policy is required to support KDCPMS as the primary platform for renal patients. Enhanced pharmaceutical care by specialist clinical pharmacists should be supported within national models of care for chronic disease management to improve patient outcomes.

Exploring trajectories in dietary adequacy of the B vitamins folate, riboflavin, vitamins B6 and B12, with advancing older age: a systematic review.

Maintaining nutritional adequacy contributes to successful ageing. B vitamins involved in one-carbon metabolism regulation (folate, riboflavin, vitamins B6 and B12) are critical nutrients contributing to homocysteine and epigenetic regulation. Although cross-sectional B vitamin intake in ageing populations is characterised, longitudinal changes are infrequently reported. This systematic review explores age-related changes in dietary adequacy of folate, riboflavin, vitamins B6 and B12 in community-dwelling older adults (≥65 years at follow-up). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (MEDLINE, Embase, BIOSIS, CINAHL) were systematically screened, yielding 1579 records; eight studies were included (n 3119 participants, 2­25 years of follow-up). Quality assessment (modified Newcastle­Ottawa quality scale) rated all of moderate­high quality. The estimated average requirement cut-point method estimated the baseline and follow-up population prevalence of dietary inadequacy. Riboflavin (seven studies, n 1953) inadequacy progressively increased with age; the prevalence of inadequacy increased from baseline by up to 22·6 and 9·3 % in males and females, respectively. Dietary folate adequacy (three studies, n 2321) improved in two studies (by up to 22·4 %), but the third showed increasing (8·1 %) inadequacy. Evidence was similarly limited (two studies, respectively) and inconsistent for vitamins B6 (n 559; −9·9 to 47·9 %) and B12 (n 1410; −4·6 to 7·2 %). This review emphasises the scarcity of evidence regarding micronutrient intake changes with age, highlighting the demand for improved reporting of longitudinal changes in nutrient intake that can better direct micronutrient recommendations for older adults. This review was registered with PROSPERO (CRD42018104364).

New Zealand women's experiences of managing gestational diabetes through diet: a qualitative study.

BACKGROUND: For women with gestational diabetes mellitus (GDM) poor dietary choices can have deleterious consequences for both themselves and their baby. Diet is a well-recognised primary strategy for the management of GDM. Women who develop GDM may receive dietary recommendations from a range of sources that may be inconsistent and are often faced with needing to make several dietary adaptations in a short period of time to achieve glycaemic control. The aim of this study was to explore how women diagnosed with GDM perceive dietary recommendations and how this information influences their dietary decisions during pregnancy and beyond. METHODS: Women diagnosed with GDM before 30 weeks' gestation were purposively recruited from two GDM clinics in Auckland, New Zealand. Data were generated using semi-structured interviews and thematic analysed to identify themes describing women's perceptions and experiences of dietary recommendations for the management of GDM. RESULTS: Eighteen women from a diverse range of sociodemographic backgrounds participated in the study. Three interconnected themes described women's perceptions of dietary recommendations and experiences in managing their GDM through diet: managing GDM is a balancing act; using the numbers as evidence, and the GDM timeframe. The primary objective of dietary advice was perceived to be to control blood glucose levels and this was central to each theme. Women faced a number of challenges in adhering to dietary recommendations. Their relationships with healthcare professionals played a significant role in their perception of advice and motivation to adhere to recommendations. Many women perceived the need to follow dietary recommendations to be temporary, with few planning to continue dietary adaptations long-term. CONCLUSIONS: The value of empathetic, individually tailored advice was highlighted in this study. A greater emphasis on establishing healthy dietary habits not just during pregnancy but for the long-term health of both mother and baby is needed.

Adherence to exclusive enteral nutrition by adults with active Crohn's disease is associated with conscientiousness personality trait: a sub-study.

BACKGROUND: It is probable that psychosocial factors predict adherence to exclusive enteral nutrition (EEN). Conscientiousness is an intrapersonal factor associated with greater medication adherence and healthy eating behaviours. This sub-study aimed to determine whether adherence to EEN was associated with conscientiousness. METHODS: Two groups of adults aged 16-40 years, were recruited to use EEN. Adults with active Crohn's disease used either EEN for 8 weeks or 2 weeks of EEN followed by 6 weeks of partial enteral nutrition (PEN). A control group of healthy adults used EEN for 2 weeks. Participants who reported eating food during EEN, ate more than one meal per day during PEN, or could not initiate or tolerate the oral nutritional supplements were defined as non-adherent. Conscientiousness was measured using the conscientiousness subset of the Big Five Inventory. RESULTS: Thirty-eight patients with active Crohn's disease (mean age 24.8 years) and 21 healthy adults (mean age 27.3 years) completed the conscientiousness questionnaire. In the Crohn's disease group, 23 (59%) completed and adhered to the treatments compared to 17 (81%) healthy adults; their conscientiousness scores were similar. Adherence and completion by the Crohn's disease group were associated with a greater mean conscientiousness score 35.57 (95% confidence interval = 32.88-38.25) compared to 30.13 (95% confidence interval = 26.53-33.73) in the non-adherent Crohn's disease group (P = 0.014). CONCLUSIONS: Conscientiousness was associated with treatment adherence. EEN can be a cognitively and emotionally demanding treatment for active adults with Crohn's disease; thus, considering personality traits may help determine suitable candidates.

The relationship between maternal 25-hydroxyvitamin D status in pregnancy and childhood adiposity and allergy: an observational study.

BACKGROUND: Vitamin D insufficiency (defined as <75 nmol l-1) is widespread among pregnant women around the world and has been proposed to influence offspring outcomes in childhood and into adult life, including adiposity and allergy. Disorders, including asthma and eczema, are on the rise among children. Our aim was to investigate the relationship between maternal 25-hydroxyvitamin D status in pregnancy and offspring adiposity, asthma and eczema in childhood. SUBJECTS AND METHODS: Maternal 25-hydroxyvitamin D concentrations were analysed in serum samples collected at 15 weeks' gestation from 1710 participants of the prospective Screening for Pregnancy Endpoints cohort study. The offspring of 1208 mothers were followed up at age 5-6 years. Data collected included height, weight, percentage body fat (PBF, measured by bioimpedance) and history of asthma and eczema. Multivariable analysis controlled for maternal body mass index (BMI), age and sex of the child and season of serum sampling. RESULTS: Complete data were available for 922 mother-child pairs. Each 10 nmol l-1 increase in maternal 25-hydroxyvitamin D concentration at 15 weeks' gestation was associated with a decrease in offspring PBF of 0.2% (95% confidence interval 0.04-0.36%, P=0.01) after adjustment for confounders but was not related to child BMI z-score. Maternal mean (±s.d.) 25-hydroxyvitamin D concentration was similar in children who did and did not have asthma (71.7±26.1 vs 73.3±27.1 nmol l-1, P=0.5), severe asthma (68.6±28.6 vs 73.3±26.8 nmol l-1, P=0.2) and eczema (71.9±27.0 vs 73.2±27.0 nmol l-1, P=0.5). CONCLUSIONS: The finding of a relationship between maternal vitamin D status and adiposity in childhood is important, particularly because vitamin D insufficiency in pregnancy is highly prevalent. The association between maternal vitamin D supplementation in pregnancy and adiposity in the offspring merits examination in randomised controlled trials.

The Perception of Art among Patients and Staff on a Renal Dialysis Unit.

This study investigated the purpose and effectiveness of giving outpatients an opportunity to engage in art activities while receiving dialysis treatment. A mixed method study was conducted. 21 semi-structured interviews were conducted with outpatients attending the dialysis unit and 13 surveys of clinicians were completed. The principle reasons to partake in the art activity programme included: to pass time, to relieve boredom, to be creative, to try something new, distraction from concerns, to stay positive and to achieve something new. Patients who did not participate in the programme pass their time primarily by watching TV or sleeping. All staff who partook in the survey were satisfied with the programme and wanted it to continue. Our findings indicate that the creative arts programme is viewed positively by staff and patients alike, and might be useful in other hospital departments. Further in depth qualitative research would be useful to interrogate the potential effect of engagement in art on positive mental health and quality of life for patients with chronic conditions.

Nutrition advice provided by general practice registrars: an investigation using patient scenarios.

BACKGROUND: Nutrition is recognized as a strong factor influencing the health outcomes of patients with chronic disease. General practitioners (GPs) require nutrition knowledge and skills to support patients to have healthy dietary behaviours. OBJECTIVE: To investigate New Zealand GP registrars' provision of nutrition advice using patient scenarios. STUDY DESIGN: A cross-sectional study design targeted GP registrars to investigate the nutrition care they provided to patients. METHODS: Fourty-seven GP registrars completed a survey at a training event. The survey included patient scenarios. Respondents were asked to provide nutrition advice for each scenario, in line with best practice guidelines. Responses to each scenario were scored based on a panel of nutrition experts. Regression analysis was used to compare the scores to participants' previously reported confidence to provide nutrition care. RESULTS: Seventeen male (36.2%) and thirty female (63.8%) GP registrars completed the survey, giving a response rate of 92.2%. GP registrars scored a mean of 7.9 ± 0.2 out of 15 for recall of dietary strategies with the scenarios. There was no association between GP registrars' scenario scores and their confidence to provide nutrition care. CONCLUSIONS: An evidence-practice gap exists for New Zealand GP registrars' confidence to provide nutrition care, and their knowledge of evidence-based nutritional guidelines to support patients to have healthy dietary behaviours. A better understanding of the determinants of this disparity is required in order to support optimal nutrition care by GPs.

Proceedings of the inaugural International Summit for Medical Nutrition Education and Research.

Medical Nutrition Education (MNE) has been identified as an area with potential public health impact. Despite countries having distinctive education systems, barriers and facilitators to effective MNE are consistent across borders, demanding a common platform to initiate global programmes. A shared approach to supporting greater MNE is ideal to support countries to work together. In an effort to initiate this process, the Need for Nutrition Education/Innovation Programme group, in association with their strategic partners, hosted the inaugural International Summit on Medical Nutrition Education and Research on August 8, 2015 in Cambridge, UK. Speakers from the UK, the USA, Canada, Australia, New Zealand, Italy, and India provided insights into their respective countries including their education systems, inherent challenges, and potential solutions across two main themes: (1) Medical Nutrition Education, focused on best practice examples in competencies and assessment; and (2) Medical Nutrition Research, discussing how to translate nutrition research into education opportunities. The Summit identified shared needs across regions, showcased examples of transferrable strategies and identified opportunities for collaboration in nutrition education for healthcare (including medical) professionals. These proceedings highlight the key messages presented at the Summit and showcase opportunities for working together towards a common goal of improvement in MNE to improve public health at large.

An Approach to Optimise Therapeutic Vancomycin Dosage in a Haemodialysis Population.

Haemodialysis patients are at risk of gram-positive bacteraemia and commonly require intravenous vancomycin. Intravenously administered vancomycin is primarily excreted by the kidney and exhibits complex pharmacokinetics in haemodialysis patients; achieving therapeutic levels can be challenging. An audit in our unit showed current practises of vancomycin administration resulted in a high proportion of sub-therapeutic levels. A new protocol was developed with fixed weight-based loading and subsequent dosing guided by pre-dialysis levels, target levels were 10-20mg/L. Its effectiveness was prospectively evaluated between 24th September 2012, and 8th February 2013. During this period 25 patients commenced vancomycin, 15 were included. In total, 112 vancomycin levels were taken, 94 (84%) were therapeutic, this was a significant improvement compared to previous practise (odds ratio 5.4, CI 3.1-9.4, p<0.0001). In conclusion, our study shows this protocol can consistently and reliably achieve therapeutic vancomycin levels.

The impact of prostate cancer on men's everyday life.

Prostate cancer impacts on the daily lives of men, particularly their physical and emotional health, relationships and social life. This paper highlights how men cope with disease and treatment and the strategies they employ to manage their diagnosis alongside daily life. Twenty-seven men were interviewed at different stages in their disease pathway: nine men prior to radiotherapy, eight men at 6-8 months post radiotherapy and 10 men at 12-18 months post radiotherapy. A grounded theory approach was used to collect and analyse the data. Regardless of the point at which they were interviewed four areas emerged as important to the men: the pathway to diagnosis; the diagnosis; the impact of prostate cancer and its treatment on daily life; and living with prostate cancer. Prostate cancer was diagnosed using the prostate-specific antigen (PSA) test, rectal examination and biopsy. Many men did not understand the consequences of a high PSA reading before they undertook the test. Painful investigative biopsies were viewed as the worst part of the disease experience. Radiotherapy was considered less invasive than other treatments, although preparatory regimes were associated with stress and inconvenience. Men used various strategies to deal with treatment-induced threats to their masculinity in the long term.

Urea-N recycling in lactating dairy cows fed diets with 2 different levels of dietary crude protein and starch with or without monensin.

Rumensin (monensin; Elanco Animal Health, Greenfield, IN) has been shown to reduce ammonia production and microbial populations in vitro; thus, it would be assumed to reduce ruminal ammonia production and subsequent urea production and consequently affect urea recycling. The objective of this experiment was to determine the effects of 2 levels of dietary crude protein (CP) and 2 levels of starch, with and without Rumensin on urea-N recycling in lactating dairy cattle. Twelve lactating Holstein dairy cows (107 ± 21 d in milk, 647 kg ± 37 kg of body weight) were fed diets characterized as having high (16.7%) or low (15.3%) CP with or without Rumensin, while dietary starch levels (23 vs. 29%) were varied between 2 feeding periods with at least 7d of adaptation between measurements. Cows assigned to high or low protein and to Rumensin or no Rumensin remained on those treatments to avoid carryover effects. The diets consisted of approximately 40% corn silage, 20% alfalfa hay, and 40% concentrate mix specific to the treatment diets, with 0.5 kg of wheat straw added to the high starch diets to enhance effective fiber intake. The diets were formulated using Cornell Net Carbohydrate and Protein System (version 6.1), and the low-protein diets were formulated to be deficient for rumen ammonia to create conditions that should enhance the demand for urea recycling. The high-protein diets were formulated to be positive for both rumen ammonia and metabolizable protein. Rumen fluid, urine, feces, and milk samples were collected before and after a 72-h continuous jugular infusion of (15)N(15)N-urea. Total urine and feces were collected during the urea infusions for N balance measurements. Milk yield and dry matter intake were improved in cows fed the higher level of dietary CP and by Rumensin. Ruminal ammonia and milk and plasma urea nitrogen concentrations corresponded to dietary CP concentration. As has been shown in vitro, Rumensin reduced rumen ammonia concentration by approximately 23% but did not affect urea entry rate or gastrointestinal entry rate. Urea entry rate averaged approximately 57% of total N intake for cattle with and without Rumensin, and gastrointestinal rate was similar at 43 and 42% of N intake for cattle fed and not fed Rumensin, respectively. The cattle fed the high-protein diet had a 25% increase in urea entry rate and no effect of starch level was observed for any recycling parameters. Contrary to our hypothesis, Rumensin did not alter urea production and recycling.

Temporal and spatial mapping of red grouper Epinephelus morio sound production.

The goals of this project were to determine the daily, seasonal and spatial patterns of red grouper Epinephelus morio sound production on the West Florida Shelf (WFS) using passive acoustics. An 11 month time series of acoustic data from fixed recorders deployed at a known E. morio aggregation site showed that E. morio produce sounds throughout the day and during all months of the year. Increased calling (number of files containing E. morio sound) was correlated to sunrise and sunset, and peaked in late summer (July and August) and early winter (November and December). Due to the ubiquitous production of sound, large-scale spatial mapping across the WFS of E. morio sound production was feasible using recordings from shorter duration-fixed location recorders and autonomous underwater vehicles (AUVs). Epinephelus morio were primarily recorded in waters 15-93 m deep, with increased sound production detected in hard bottom areas and within the Steamboat Lumps Marine Protected Area (Steamboat Lumps). AUV tracks through Steamboat Lumps, an offshore marine reserve where E. morio hole excavations have been previously mapped, showed that hydrophone-integrated AUVs could accurately map the location of soniferous fish over spatial scales of <1 km. The results show that passive acoustics is an effective, non-invasive tool to map the distribution of this species over large spatial scales.

Impact of screening mammography on mortality from breast cancer before age 60 in women 40 to 49 years of age.

BACKGROUND: Whether screening mammography programs should include women in their 40s is controversial. In Canada, screening of women aged 40-49 years has not been shown to reduce mortality from breast cancer. Given that screening mammography reduces mean tumour size and that tumour size is inversely associated with survival, the lack of benefit seen with screening is puzzling and suggests a possible adverse effect on mortality of mammography or subsequent treatment (or both) that counterbalances the expected benefit derived from downstaging. METHODS: We followed 50,436 women 40-49 years of age until age 60 for mortality from breast cancer. Of those women, one half had been randomly assigned to annual mammography and one half to no mammography. The impact of mammography on breast cancer mortality was estimated using a left-censored Cox proportional hazards model. RESULTS: Of 256 deaths from breast cancer recorded in the study cohort, 134 occurred in women allocated to mammography, and 122 occurred in those receiving usual care and not allocated to mammography. The cumulative risk of death from breast cancer to age 60 was 0.53% for women assigned to mammography and 0.48% for women not so assigned. The hazard ratio for breast cancer-specific death associated with 1 or more screening mammograms before age 50 was 1.10 (95% confidence interval: 0.86 to 1.40). CONCLUSIONS: Mammography in women 40-49 years of age is associated with a small but nonsignificant increase in the risk of dying of breast cancer before age 60. Caution should be exercised when recommending mammographic screening to women before age 50.

A pilot study of an enhanced mental health assessment during routine and discharge medicals in the British Armed Forces.

OBJECTIVES: A pilot study to assess the practicality of introducing an enhanced mental health assessment (EMHA) into all routine and discharge medicals of the UK Armed Forces in order to facilitate treatment prior to and on return to civilian life. METHODS: A pilot study was conducted using an EMHA questionnaire with questions about depression, anxiety, post-traumatic stress disorder, alcohol use, sleep and anger/irritability. At pilot sites, the EMHA was completed during all routine and discharge medicals between May 2011 and July 2011. At the end of the study period, qualitative data were collected from participating medical officers and practice managers regarding their opinions about the pilot study. RESULTS: The quantitative data revealed an average pick-up rate for mental health (MH) problems. Out of the four military medical centres who participated and the 325 questionnaires collected, one referral to a Department of Community Mental Health was made. 26 (8%) patients were categorised as 'some concern and patient offered advice and/or reassurance'. The vast majority of patients were found to have no evidence of MH problems. However, using a validated alcohol screening tool, 64% of service personnel were found to have a score indicating 'higher risk drinking'. Analysis of the qualitative data suggests that the EMHA is an easy tool to implement with minimal additional time and resources needed. The interviewees pointed out a number of limitations and suggestions for possible further studies. CONCLUSIONS: The pilot study successfully demonstrated that the EMHA questionnaire is easy to administer, does not take up a large amount of additional resources or manpower and provides a useful check of MH status. The study picked up an average number of MH cases and the questions on alcohol consumption highlighted that military personnel may be at a 'higher risk of drinking'.

Phenotyping established chronic lung allograft dysfunction predicts extracorporeal photopheresis response in lung transplant patients.

Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality in lung transplant recipients after the first year. Treatment remains limited and unpredictable. Existing data suggests extracorporeal photopheresis (ECP) may be beneficial. This study aimed to identify factors predicting treatment response and the prognostic implications. A single center retrospective analysis of all patients commencing ECP for CLAD between November 1, 2007 and September 1, 2011 was performed. In total 65 patients were included, 64 of whom had deteriorated under azithromycin. Median follow-up after commencing ECP was 503 days. Upon commencing ECP, all patients were classified using proposed criteria for emerging clinical phenotypes, including "restrictive allograft syndrome (RAS)", "neutrophilic CLAD (nCLAD)" and "rapid decliners". At follow-up, 8 patients demonstrated ≥10% improvement in FEV1 , 27 patients had stabilized and 30 patients exhibited ≥10% decline in FEV1 . Patients fulfilling criteria for "rapid decliners" (n=21, p=0.005), RAS (n=22, p=0.002) and those not exhibiting neutrophilia in bronchoalveolar lavage (n=44, p=0.01) exhibited poorer outcomes. ECP appears an effective second line treatment in CLAD patients progressing under azithromycin. ECP responders demonstrated improved progression-free survival (median 401 vs. 133 days). Proposed CLAD phenotypes require refinement, but appear to predict the likelihood of ECP response.

Mortality in Barrett's esophagus: three decades of experience at a single center.

BACKGROUND AND STUDY AIMS: There is a view that the majority of deaths in patients with Barrett's esophagus are from causes other than esophageal adenocarcinoma (EAC). The aim of this analysis was to establish the pattern of mortality for a number of causes in patients with Barrett's esophagus. PATIENTS AND METHODS: This was a single-center prospective cohort study of patients from Rotherham District General Hospital, which is a secondary referral center. The cohort consisted of 1239 patients who were diagnosed with Barrett's esophagus between April 1978 and March 2009.  Follow-up for mortality was undertaken by "flagging" the patients with the NHS Information Center. Causes of death were compared with UK Office of National Statistics age- and sex-specific mortality data for 1999, the median year of diagnosis. Analysis was by a "person - years at risk" calculation from date of diagnosis. RESULTS: The ratio of observed deaths from EAC compared with those expected in this cohort was 25.02 - a very large excess. There was no difference in mortality from colorectal cancer or circulatory disease and there were fewer deaths from cancers other than esophageal adenocarcinoma and colon cancer compared with national statistics. There was a small statistically significant difference in mortality from all causes but this disappeared completely when deaths from esophageal adenocarcinoma were excluded. CONCLUSIONS: Overall, mortality in Barrett's esophagus is increased significantly but only as a result of the large excess of deaths from EAC. This strengthens the case for endoscopic surveillance if successful interventions can be undertaken in patients with Barrett's esophagus to prevent development of esophageal adenocarcinoma.

The role of a Royal Navy General Duties Medical Officer in helicopter assault force operations: a reflective article.

Royal Navy General Duties Medical Officers (RN GDMOs) are employed in land operations in Afghanistan in much the same way as British Army GDMOs. In this article the author explores how time with a Royal Marine Commando unit and completion of Commando training in parallel to thorough medical training are beneficial for the roles a RN GDMO is expected to undertake in Helicopter Assault Force Operations.

An audit of the quality of deployed DMICP records on Operation HERRICK 14.

BACKGROUND: Troops deploying to remote and hostile environments are exposed to numerous threats to their health and wellbeing. Medical care is provided by dedicated but often inexperienced young doctors, nurses and medics. This audit looks at the quality of medical records that are available to these deployed clinicians and the quality of their record keeping against nationally set guidance for the Summary Care Record (SCR) and Out of Hours record keeping. METHODS: The data was collected from consecutive GP and nurse medical consultations at Camp Bastion Primary Health Care Centre during Op HERRICK 14. RESULTS: Only 21.7% of personnel had an imported medical record from the UK and only 1% had a summary fitting the guidance for the SCR. Additionally the quality of record keeping for consultations did not conform to standards set by the Royal College of General Practitioners 'Out of Hours Clinical Audit Tool'. CONCLUSIONS: The low numbers and poor quality of imported medical records into Op HERRICK 14 alongwith the inexperience of clinicians in keeping medical records compliant with relevant standards is of primary importance in the context of patient safety on operations. This audit highlights a number of areas of potential concern for the Defence Medical Services and areas for enhancement of pre-deployment training.

Op HERRICK primary care casualties: the forgotten many.

OBJECTIVE: The number of battle casualties generated during war is far outnumbered by non-battle casualties. Each year the current conflict in Afghanistan sees hundreds of service personnel medically evacuated direct from the front line to the care of their home units' primary care facility. To date these casualties remain undiscovered by medical research. This is the first study to look at the care pathway of primary care casualties from Operation HERRICK using information from the Defence Patient Tracking System (DPTS). METHODS: Information relating to all casualties from Afghanistan discharged at the airhead between 1 January 2009 and 31 December 2010 was collected from the DPTS. Common conditions were identified and information relating to the follow up care extracted to provide an overview of the care pathway. RESULTS: 387 aeromedical evacuations were identified as primary care casualties. The three commonest conditions were musculoskeletal (183 cases), mental health (29) and noise-induced hearing loss (26). 205 (53%) were not seen outside of primary care for the tracked condition. 166 (81%) of those that remained under primary care had two or less consultations during the time period of the study. The mean time frame between the 1st and 2nd consultation was 5.4 weeks. CONCLUSIONS: A significant number of aeromedical evacuations from Afghanistan are for primary care casualties. The DPTS can be used to provide a basic overview of the care pathway of repatriated personnel. Little contact with the medical services would appear to occur for these types of casualties. There is a significant gap in military medical research looking at primary care casualties repatriated from operations.

Factors affecting front line casualty care in Afghanistan.

OBJECTIVE: Limited research has been undertaken to assess the effectiveness of pre-hospital care given at the point of wounding, nor how battlefield conditions affect the implementation of Battlefield Advanced Trauma Life Support (BATLS). This study examines the quality of care given at Role 1 and the psychological impact on clinical personnel of the application of current pre-hospital trauma management guidelines. METHOD: Data was collected through 17 digitally recorded semi-structured interviews with healthcare clinicians deployed in Role 1 medical facilities on OP HERRICK 14 following major medical incidents. Interview transcripts were subjected to content analysis based on a modified grounded theory approach. RESULTS: Triage was found to be done poorly with individuals treating patients as they were found rather than by identifying clinical priorities. Pain management was not always achieved. Fluid replacement was hampered with difficulty in obtaining parenteral access. Subsequently fluids were sometimes given in excess of protocols. Clinical documentation was not always completed even after a patient had been evacuated. Some interesting elements were noted, such as post incident reports being used as a reflective process which may be self-developmental and help clinicians deal psychologically with the incident. Clinical personnel carry out their duties, irrespective of personal injury or threats to their safety. However their performance may be tapered under such stress. Human factors training prior to deployment may help to ensure adherence to BATLS protocols despite the complexities of the battle space. CONCLUSIONS: The data identified a number of factors that affected clinicians ability to provide a high standard of casualty care. The general perception of this research cohort was that despite all the obstacles, the level of trauma care was of a high nature. However, the study provides pointers to a number of areas for future exploration where patient care was not BATLS protocol compliant.