Military Aid to the Civil Authorities: a Defence Medical Services perspective.

This paper describes the policy and principles for the provision of Military Aid to the Civil Authorities (MACA). It emphasises the importance of following the proscribed process in order to avoid possible political, legal, reputational and financial pitfalls. It outlines the broader military application of MACA before focusing on where the Defence Medical Services can contribute, drawn from recent experiences and identifying other capabilities that may be of utility. It draws heavily from Joint Doctrine Publication 02 and is quoted with the agreement of the Developments, Concepts and Doctrine Centre.

Rapid experimental evolution of reproductive isolation from a single natural population.

Ecological speciation occurs when local adaptation generates reproductive isolation as a by-product of natural selection. Although ecological speciation is a fundamental source of diversification, the mechanistic link between natural selection and reproductive isolation remains poorly understood, especially in natural populations. Here, we show that experimental evolution of parasite body size over 4 y (approximately 60 generations) leads to reproductive isolation in natural populations of feather lice on birds. When lice are transferred to pigeons of different sizes, they rapidly evolve differences in body size that are correlated with host size. These differences in size trigger mechanical mating isolation between lice that are locally adapted to the different sized hosts. Size differences among lice also influence the outcome of competition between males for access to females. Thus, body size directly mediates reproductive isolation through its influence on both intersexual compatibility and intrasexual competition. Our results confirm that divergent natural selection acting on a single phenotypic trait can cause reproductive isolation to emerge from a single natural population in real time.

Electronic health (eHealth) interventions for weight management among racial/ethnic minority adults: a systematic review.

Electronic health (eHealth) interventions have demonstrated efficacy for weight management. However, little is known about their efficacy among racial/ethnic minority populations, in whom there is a disproportionate prevalence of obesity. This systematic review evaluated the efficacy of eHealth weight management interventions among overweight and obese racial/ethnic minority adults. We required that trial samples be comprised of at least 50% racial/ethnic minorities or report outcomes by race/ethnicity. We searched five electronic databases for trials conducted through June 2012. Six papers met our eligibility criteria. These studies provide suggestive evidence that eHealth interventions can produce low magnitude, short-term weight loss among racial/ethnic minorities. Trials were methodologically sound, with high retention and participant engagement. There was no evidence detailing the efficacy of mobile health approaches, although this area is promising given high utilization rates of mobile devices among racial/ethnic minorities. More evidence, particularly from longer-term trials, is necessary to demonstrate that eHealth intervention approaches can produce clinically meaningful (≥ 5% of initial body weight) weight loss among racial/ethnic minority populations.

Student performance and course evaluations before and after use of the Classroom Performance System ™ in a third-year veterinary radiology course.

Effective teaching of veterinary radiology can be challenging in a traditional classroom environment. Audience response systems, colloquially known as "clickers," provide a means of encouraging student interaction. The purpose of this study was to compare student performance and course evaluations before and after using the Classroom Performance System™ in the third-year (fifth semester) didactic radiology course at the University of Tennessee College of Veterinary Medicine. Overall student performance was assessed by comparing median numeric final course grades (%) between years without and with use of the Classroom Performance System™. Grades of students were determined for individual instructors' sections. Student evaluations of the radiology course were compared for the years available (2007-2010). Student interactions were also evaluated subjectively by instructors who used the Classroom Performance System™. There was a significant difference (p = 0.009) between the median student grade before (2005 - 2008, median 82.2%; interquartile range 77.6-85.7%; range 61.9-95.5%) and after use of the classroom performance system (2009-2010, median 83.6%; interquartile range 79.9-87.9%; range 68.2-93.2%). There was no statistically significant difference in median student grades for individual instructors over the study period. The radiology course student evaluation scores were significantly higher in years where the Classroom Performance System™ was used in comparison to previous years (P = 0.019). Subjectively, students appeared more involved when using clickers. Findings indicated that the Classroom Performance System™ may be a useful tool for enhancing veterinary radiology education.

Preventing neural tube defects with folic acid: nearly 20 years on, the majority of women remain unprotected.

Many countries, including the USA and Canada, have implemented fortification of foods with folic acid, however the British Government only issues advice that supplements should be taken before and after conceiving. In this study, information was collected from women attending antenatal clinics to understand current levels of compliance with health advice and to investigate what is driving womens' behaviour. Eighty-nine percent of women consumed supplements but only 31% took folic acid prior to conceiving. Hence, the vast majority are starting too late to prevent neural tube defects (NTDs). Educational achievement, income and marital status emerged as the most significant factors influencing non-compliance. GPs and midwives were the main catalyst for women starting folic acid, however, 81% of these women started post-conception. When asked why they took folic acid, the majority of women did not mention the association with NTDs. Forty-one percent of women who did not take the supplements at all were unaware that it was recommended that they should. Fortification of UK food products offers a major public health opportunity. In the absence of fortification, gaps in the public health message need to be addressed. GPs and midwives cannot be relied upon alone to educate these women.

An RCT pilot study to test the effects of intravenous midazolam as a conscious sedation technique for anxious children requiring dental treatment--an alternative to general anaesthesia.

AIM: To add to the evidence base for acceptable and effective paediatric conscious sedation techniques in dental primary care. OBJECTIVES: To compare three conscious sedation techniques for primary care as an alternative to dental general anaesthesia (DGA) in children. To assess the feasibility and practicality of running the trial in general dental practice. To form the basis for sample size calculations and assess scales of measurement. DESIGN: Single centre, randomised control trial (RCT). SETTING: Queensway Anxiety Management Clinic (QAMC). A primary care based general and referral dental practice for the management of anxious patients. SUBJECTS, MATERIALS AND METHODS: Sixty five children too anxious for management with relative analgesia, requiring invasive dental procedure for which dental general anaesthesia (DGA) will be required if an alternative cannot be found. INTERVENTIONS: Group 1 (n = 20) - A combination of inhaled medical air and titrated intravenous midazolam. Group 2 (n = 22) - A combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam. Group 3 (n = 23) - A combination of an inhaled mixture of 0.3% sevoflurane and 40% nitrous oxide in oxygen with titrated intravenous midazolam. MAIN OUTCOME MEASURES: Successful completion of the intended dental treatment with a child who is co-operative and responsive to verbal commands. RESULTS: Fifty per cent (ten children) successfully completed treatment in Group 1, 73% (16 children) in Group 2 and 83% (19 children) in Group 3. This difference was not significant at a 5% level (chi(2) = 5.53, df = 2, P = 0.07) Of the total of 20 failures, eight children in Group 1 and one child in Group 2 were successfully treated with the addition of sevoflurane and nitrous oxide in oxygen. Only two children required referral to a hospital setting for DGA and the remaining nine children were managed with an alternative conscious sedation technique. CONCLUSION: This pilot shows that intravenous midazolam especially in combination with the addition of inhaled nitrous oxide or sevoflurane and nitrous oxide were promising safe and effective techniques, sufficient to justify progression to a definitive RCT with appropriate methods.

The cancer recognition (CARE) antibody test.

The cancer recognition (CARE) antibody (Ab) test is a serologic assay for a specific IgM that is elevated in cancer patients. All tests are measured using an indirect enzyme-linked immunosorbent assay (ELISA) of human serum. The target polypeptide in the CARE Ab test is the IgM binding epitope (LT-11) of the CARE antigen (Ag) consisting of a 16 mer structure that has been produced synthetically. The mean relative concentration (MRC) is determined relative to standard, normalized human plasma. Non-parametric analysis showed median MRC values of healthy volunteers (HVs) with no history of cancer (n =47), family history of cancer (n = 126) and a previous cancer history (n = 24) to be 26, 34 and 46, respectively. It was determined that there was no significance found among the medians of the three HV groups (P = 0.53). The specificity of the HV types was between 87 and 98%. Benign/non-cancer surgical patients (n = 27) had a median value of 20 with a specificity of 96%. The cancer patients (n = 61) had a median value of 246 with a sensitivity of 89%. There was a significant difference between the HV and cancer patients (P < 0.0001) as well as between the benign/surgical non-cancerous group and cancer patients (P < 0.0001). The IgM antibody is heat stable at room temperature for two days versus being frozen at -80 degrees C (r2 = 0.97). Either serum or plasma samples may be used in the CARE Ab test (r2 = 0.92). The CARE Ab was almost exclusively IgM with no serum conversion to IgG in sequential measurements of patients with cancer over a six-month period. Preliminary data from patients undergoing post-operative cancer treatment showed that decreasing Ab levels revealed patients negative for residual cancer or undergoing remission, while relapsing patients show an increase in Ab levels. A return to a positive Ab level shortly after treatment is a poor prognostic sign while in advanced cancers the Ab levels may be depressed significantly.

Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited?

PURPOSE: The United Kingdom Small Aneurysm study has demonstrated the low risk of rupture in aneurysms less than 5.5 cm in diameter. With the advent of endoluminal techniques, patients considered unfit to undergo laparotomy are now considered for endovascular repair. However, the natural history of aneurysms larger than 5.5 cm remains uncertain, especially when severe comorbidity is present. In our center, we prospectively maintain records of all patients for whom elective aneurysm surgery was refused. This study documented the outcome of all patients referred with abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter who were turned down for elective open repair and determined the cause of death and risk of rupture in all patients. METHODS: Details of all patients with AAAs from January 5, 1989, to January 5, 1999, were recorded, and demographic details on all patients with AAAs larger than 5.5 cm were collected. Copies of death certificates were obtained from the Office of National Statistics, local in-hospital patient records, and general practitioner records. Results of postmortem examinations were also obtained. Aneurysms were stratified according to their size at presentation (5.5-5.9 cm, 6.0-7.0 cm, and > 7.0 cm), and the reasons no intervention was made were documented. RESULTS: A total of 106 patients were turned down for elective aneurysm surgery in the 10-year period (10.6 per year). The mean age of the patients was 78.4 years (SD, 7.4), and 70 were men and 36 were women. At the end of the study, 76 patients (71.7%) had died. Overall, the 3-year survival rate was 17%. Patients with AAAs larger than 7.0 cm lived a median of 9 months. A ruptured aneurysm was certified as a cause of death in 36% of the patients with an AAA of 5.5 to 5.9 cm, in 50% of the patients with an AAA of 6 to 7.0 cm, and 55% of the patients with an AAA larger than 7.0 cm. Reasons given for not intervening were patient refusal (31 cases), the patient being "unfit for surgery" (18 cases), the "advanced age" of the patient (18 cases), cardiac disease (9 cases), cancer (9 cases), respiratory disease (6 cases), and other (15 cases). CONCLUSION: Although we recognize the problems with death certification, we found that rupture was a significant cause of death in patients with an untreated AAA that was larger than 5.5 cm. Although little difference in outcome was observed in aneurysms in the 5.5 to 7.0 cm size range, patients with an AAA that was larger than 7.0 cm seemed to have a much poorer prognosis.

Quantitative urinalysis in healthy Beagle puppies from 9 to 27 weeks of age.

UNLABELLED: To evaluate indices of renal function in healthy, growing Beagle puppies from 9 to 27 weeks of age and to determine whether indices change with age during this period. Animals-6 healthy Beagle puppies. PROCEDURE: Urine collections were performed at 2-week intervals in puppies 9 to 27 weeks old. Daily excretion of urinary creatinine, protein, sodium, potassium, chloride, phosphorus, and calcium were determined, as were quantitative urinalyses including endogenous creatinine clearance, urine protein-to-creatinine ratios (UPr/C), and fractional clearances of sodium (FNa), potassium (FK), chloride (FCI), calcium (FCa), and phosphorus (FP). RESULTS: Significant differences among age groups were detected for endogenous creatinine clearance, and daily urinary protein, potassium, calcium, and phosphorus excretion. Significant differences also existed among age groups for UPr/C, FNa, FK, FCI and FP. Age-related effects fit a linear regression model for FNa, UPr/C, daily phosphorus excretion, and daily protein excretion. Quadratic regression models were judged most appropriate for endogenous creatinine clearance, FK, daily chloride excretion, and daily potassium excretion. Endogenous creatinine clearance measurements higher than adult reference ranges were observed from 9 to 21 weeks of age. The FNa, FK, FCI, FCa, and FP were slightly higher than those reported for adult dogs. CONCLUSIONS AND CLINICAL RELEVANCE: Selected results of quantitative urinalyses in healthy 9- to 27-week-old Beagle puppies differ with age and differ from those measured in adult dogs. Diagnostic measurements performed in puppies of this age range should be compared with age-matched results when possible.

Diagnosis and management of urinary retention.

Failure to empty the urinary bladder completely can be attributed to failure of detrusor contractile function, inappropriate outlet resistance, or both. For each of these mechanisms, anatomic, neurogenic, and end-organ (myogenic or idiopathic) abnormalities are possible. The approach to urinary retention involves systematic consideration of neurogenic, obstructive, and functional causes and requires understanding of the neurophysiology and pharmacology of micturation.

Functional urethral obstruction in 3 dogs: clinical and urethral pressure profile findings.

Three dogs with dysuria and urine retention caused by excessive functional urethral resistance are described. All dogs had clinical histories and urologic signs that previously would have been classified as detrusor-urethral dyssynergia. Diagnosis of functional urinary obstruction was established by exclusion of anatomic urinary obstruction and confirmed by urethral pressure profilometry. In 2 cases, multiple pressure deflections recorded in the urethral pressure profile suggested spasm of urethral musculature, whereas in a 3rd dog, abnormally high pressures were recorded along a portion of the proximal urethra. Functional urinary obstruction was associated with prostatitis in 1 dog and with a history of urethral calculi in 1 dog, and no underlying disorder could be identified in the remaining dog. All 3 dogs improved with medical treatments that included alpha adrenergic antagonists. The etiology, diagnosis, and pharmacologic management of functional urinary obstruction are discussed.

Is there carotid artery aneurysm formation following saphenous vein patch endarterectomy?

The use of saphenous vein patching following carotid endarterectomy is reported to produce aneurysmal dilatation with the risk of thrombosis and possible rupture. The authors have studied patients who have had saphenous vein patch angioplasty following carotid endarterectomy to assess whether there is any progressive arterial dilatation. Thirty-five patients who had undergone saphenous vein patch carotid endarterectomy were age- and sex-matched with 31 subjects that had direct closure endarterectomy. All participants underwent carotid duplex scanning. The external diameters of the mid common carotid artery, the bulb and the proximal internal carotid artery were measured bilaterally. The diameters of the endarterectomized carotid were compared with the contralateral side using a paired t-test. Using an unpaired t-test, the saphenous vein angioplasty group was compared with the directly closed group. A graph was plotted of the ratio of internal carotid artery diameter of the saphenous vein angioplasty group (endarterectomized artery to the contralateral artery) against the length of follow-up, and the Pearson correlation coefficient was calculated. When the saphenous vein angioplasty group was compared with the directly closed group there was a significant difference between the carotid bulb (11.6 versus 9.7mm, P < 0.001) and internal carotid artery diameters (9.0 versus 7.0mm, P < 0.001). Longitudinal analysis of the saphenous vein angioplasty group showed that the increased diameter of the endarterectomized internal carotid artery progressed with time after surgery (r = 0.51, P < 0.005, and r = 0.56, P < 0.001). Vein patching increases the diameter of the internal carotid artery, and this may further increase with time possibly predisposing to aneurysm formation. Further longitudinal studies of paired data are required.

Parenteral nutrition in the management of a dog with lymphocytic-plasmacytic enteritis and severe protein-losing enteropathy.

Management of lymphocytic-plasmacytic enteritis in a dog with whipworm infestation, hypoproteinemia, and ascites is described. Short-term parenteral nutrition hastened normalization of serum proteins, resolution of diarrhea, and weight gain. A description of the potential benefits, limitations, and possible complications of parenteral nutrition in refractory inflammatory bowel disease is given.

Profound postanesthetic hypoglycemia attributable to glucocorticoid deficiency in 2 dogs.

Glucocorticoid deficiency was diagnosed as the cause of severe postanesthetic hypoglycemia in 2 dogs. Prior signs of systemic illness were not described in either dog; however, preoperative hematologic findings were consistent with glucocorticoid deficiency. Fasting hypoglycemia is a possible complication of chronic adrenal insufficiency primarily because of impaired gluconeogenesis.

Hypercalcemia and parathyroid hormone-related protein in a dog with undifferentiated nasal carcinoma.

Hypercalcemia was discovered in a 7-year-old, castrated male basset hound with a suspected nasal tumor. The dog died the day after admission and nasal carcinoma and disseminated intravascular coagulation were diagnosed on postmortem. Detectable levels of serum PTHrP support a diagnosis of hypercalcemia of malignancy.

Movement-related variation in forces under compression stockings.

OBJECTIVES: Compression therapy is widely used in the treatment of venous leg ulcers, but the efficacy of this treatment is variable. Assessment of variation in compression forces associated with movement may help to elucidate the mechanism of action of compression therapy. The aim of this study was to develop and apply a system to investigate forces under compression stockings during movement. METHOD: Three sensors were placed on the medial aspect of the left leg on six healthy volunteers to monitor forces under class 2 (Continental European classification) compression stockings. Data were recorded during dorsiflexion and plantar flexion of the left foot and also during short periods of walking. RESULTS: Changes in pressure were observed, associated with dorsiflexion and plantar flexion of the foot. These changes were dependent on sensor position. Changes in pressure during walking were also position-dependent and of variable duration. CONCLUSIONS: The system enables forces associated with compression therapy to be examined during movement and may thus be of value in further understanding its mechanism of action. Foot movement can be associated with clear changes in pressure under compression stockings and rapid changes in pressure may occur during walking.

Leucocyte filterability: comparing diluted with undiluted blood.

Red blood cells and about 95% of white blood cells have an immediate and constant effect on the flow of undiluted or diluted blood through 5 microm filters. The remaining 5% of all leucocytes exert an increasing influence on flow such that the rate of flow of diluted and undiluted blood through these filters is continually declining over a period of 150 s. Analysis of this declining flow rate enables these cells to be counted and their rheological properties to be deduced. Approximately 50% of these slow leucocytes pass through the filters with a transit time of about 30 s and the remaining cells act as pore blockers for 150 s. The numbers and flow properties of slow leucocytes was approximately the same in blood from young women (25 years) and older men (65 years). However, the number of slow leucocytes was increased in a group of men (65 years) suffering from peripheral arterial occlusive disease. Dilution of the blood with phosphate-buffered saline increased the numbers of slow leucocytes in both of the older, but not the younger, group of volunteers. This effect was particularly noticeable in the patient group. It is recommended that filtration studies of the rheological profile of leucocytes can, and must, be performed with undiluted blood. The properties after dilution may sometimes, but not invariably, reflect changes ex vivo as well as inherent differences in the cells themselves.

Methods for studying leukocyte filterability in undiluted blood from intermittent claudicants.

Leukocytes are characterised from their influence on the filterability of undiluted blood from patients with PAOD (intermittent claudicants - Fontaine Stage II) and a group of sex and age-matched controls. Undiluted blood was filtered through 5 microm Nuclepore (Hemafil) filters for 300 s, at 711 Pa and room temperature, using a custom-made constant pressure filtrometer. Four populations of leukocytes are identified in both groups. In the control group, 94.4% of the leukocytes are identified as fast leukocytes with a transit time of 1.8 s. The remaining white cells are recognised as slow flowing leukocytes and subdivided into three further sub-populations. The first of these (SL1; 2.8% of total leukocyte count) is characterised by a transit time of 31.7 s, a second population (SL2; 1.5% of total leukocyte count) by a transit time of 145.8 s while the remaining cells are identified as pore blockers (PB) under these conditions. A similar rheological classification is valid in the patients but the sum of the three minor populations is elevated compared to controls (p = 0.001) although there is no overall leukocytosis. The only significant difference in flow properties of any blood cells, between the two groups of volunteers, is seen in the major population of leukocytes with an elevated transit time of 2.4 s. Stepwise regression analysis identifies the concentration of fast leukocytes, SL2 and PB as the major variables affecting blood flow through the filter. It is argued that the higher concentration of SL2 and PB probably reflect the increased sensitivity of neutrophils to physical stimuli.