What do environment-related illnesses tell us about the character of military medicine and future clinical requirements?

Extreme environments present medical and occupational challenges that extend beyond generic resuscitation, to formulating bespoke diagnoses and prognoses and embarking on management pathways rarely encountered in civilian practice. Pathophysiological complexity and clinical uncertainty call for military physicians of all kinds to balance intuition with pragmatism, adapting according to the predominant patterns of care required. In an era of smaller operational footprints and less concentrated clinical experience, proposals aimed at improving the systematic care of Service Personnel incapacitated at environmental extremes must not be lost to corporate memory. These general issues are explored in the particular context of thermal stress and metabolic disruption. Specific focus is given to the accounts of military physicians who served on large-scale deployments into the heat of Iraq and Kuwait (Operation TELIC) and Oman (Exercise SAIF SAREEA). Generalisable insights into the enduring character of military medicine and future clinical requirements result.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

BACKGROUND: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. METHODS: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. RESULTS: A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients. CONCLUSIONS: EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Group O low titre only emergency donor panels for small combat teams.

INTRODUCTION: Military elements increasingly operate in small teams in remote areas with no immediate blood product support. Planners and operators may endorse collection of fresh whole blood from pretested donors in emergency situations. The biggest risk of transfusion is the accidental use of ABO incompatible blood which can be fatal. The risk may be mitigated by using only group O LOw (OLO) titre donors with plasma containing low levels of the naturally occurring antibody to group A and B red cells. This paper reviews the ABO blood group distribution in potential blood donors from a high readiness UK medical regiment and explores the feasibility of using only group OLO donors in small teams. METHODS: A retrospective review of routine volunteer blood donor samples was undertaken at 6 monthly intervals during a 2-year period. Personnel were tested in groups when available during training to create multiple donor panels to simulate small teams. RESULTS: 206 donation samples were collected from 157 potential donors. All donors were acceptable based on the lifestyle questionnaire, serology and microbiology screen. Of the 206 samples reviewed, 85 (41%) were group O (D pos and D neg). 14 group O (16.5%) were shown to have high titre of anti-A or B. Therefore, 71, that is, 34% overall were suitable as OLO donors. The donor panel size varied from 15 to 44. The absolute number of OLO donors in each panel ranged from 4 to 17 and the number of O neg donors was 0-3. CONCLUSION: A third of samples were suitable as OLO donors; however, there were insufficient 'universal' donors within smaller subgroups (<10). In this situation, we recommend the careful use of both group O and group A donors or the use of a buddy-buddy blood group matrix.

The relation of religious belief and practices, depression, and hopelessness in persons with clinical depression.

Religious belief and practices have been associated with lower levels of depression in persons dealing with stressful situations. In this study, researchers examined this relationship in 271 persons diagnosed with clinical depression. It was hypothesized that religious belief and practices would be associated with lower depression and that this relationship would be mediated by hopelessness. Religious belief, but not religious behavior, was a significant predictor of lower levels of hopelessness and depression beyond demographic variables. Through the relation of religious belief to lower levels of hopelessness, religious belief was indirectly related to less depression. There was also a small direct positive association of belief with depression, pointing to the complexity of the role belief plays for religious persons. Further study is needed for a better understanding of different ways religion affects depressed persons.

A case for including spirituality in quality of life measurement in oncology.

Most of the commonly used quality of life (QOL) instruments in oncology do not include spirituality as a core domain. However, previous research suggests that spirituality might be an important aspect of QOL for cancer patients and that it may, in fact, be especially salient in the context of life-threatening illness. This study used a large (n=1610) and ethnically diverse sample to address three questions relevant to including spirituality in QOL measurement: (1) Does spirituality demonstrate a positive association with QOL?; (2) Is this association unique?; and (3) Is there clinical utility in including spirituality in QOL measurement? Spirituality, as measured by the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp), was found to be associated with QOL to the same degree as physical well-being, a domain unquestioned in its importance to QOL. The significant association between spirituality and QOL was unique, remaining after controlling for core QOL domains as well as other possible confounding variables. Furthermore, spiritual well-being was found to be related to the ability to enjoy life even in the midst of symptoms, making this domain a potentially important clinical target. It is concluded that these results support the move to the biopsychosocialspiritual model for QOL measurement in oncology.

The religious needs and resources of psychiatric inpatients.

A recent survey of psychiatric research indicates religion has been given little attention, and when it has been considered, the measures have been simplistic. The present study was designed to describe the religious needs and resources of psychiatric inpatients. With the use of a multidimensional conception of religion and two established instruments, 51 adult psychiatric inpatients were surveyed about their religious needs and resources. For comparison, 50 general medical/surgical patients, matched for age and gender, were also surveyed. Eighty-eight percent of the psychiatric patients reported three or more current religious needs. Although there were no differences in religious needs between the two patient groups, there were significant differences in religious resources. Psychiatric patients had lower spiritual well-being scores and were less likely to have talked with their clergy. Religion is important for the psychiatric patients, but they may need assistance to find resources to address their religious needs.

Hospitalized psychiatric and medical patients and the clergy.

Earlier research suggested that persons in a community with significant psychiatric disorders seek relief from their clergy as often as from trained mental-health professionals. In this research, contacts with clergy about current hospitalization by matched samples of inpatient psychiatric (N=51) and medical/surgical (N=50) patients were compared, as were responses to structured interviews about the importance of religion, religious affiliation, and participation, spiritual needs, and spiritual well-being. The findings suggest that the two groups were similar in demographics, the degree to which religion was a source of strength and comfort in their lives, and percentages reporting as having a clergy person; the group of hospitalized psychiatric patients was significantly less likely, however, than the sample of medical/surgical patients to have discussed their current hospitalization with their clergy persons. Possible causes for this difference as well as areas of further research are discussed.

The medical captivity of religion and health.

Uses actual hospital-based experiences to draw attention to and illustrate how modern chaplaincy may fall into forms of paternalism and iatrogenesis. Notes particularly how high tech iatrogenesis and high touch chaplaincy may interact in counterproductive ways. Opines that the church once again needs a revisioning of health which is based on theological notions of the church as sustaining community and as a school for empowerment.

Development of a model for spiritual assessment and intervention.

A multidisciplinary model for making spiritual assessments and interventions is described. The practitioner bases these assessments and interventions upon knowledge gained from philosophy, theology, physiology, psychology, and sociology. Specific assessments are made in the areas of spiritual development and seven practical dimensions of spiritual care. The patient's life experiences, events, and questions shape the nature of spiritual care as the practitioner works toward assisting the patient to maintain or expand the level of spiritual functioning.

Wisdom and folly in death and dying.

This author presents the argument, in the context of homiletic reflections on Psalm 90∶12, that psychosocial care for the terminally ill continues to be compromised by the anxiety and denial of the staff who provide such care. An illustrative case example is offered. An explanation is provided in terms of the support for such denial in the instrumental values of our technological culture. The work of Kübler-Ross is presented as an example of the religious function of science in modern culture. A paradoxical prescription, based on Psalm 90∶12, is proposed as a solution to the problem. A postscript by a colleague of the author illustrates the subjective attitude of the staff advocated in the paradoxical prescription.