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.

Undifferentiated febrile illnesses in South Sudan: a case series from Operation TRENTON from June to August 2017.

Undifferentiated febrile illnesses present diagnostic and treatment challenges in the Firm Base, let alone in the deployed austere environment. We report a series of 14 cases from Operation TRENTON in South Sudan in 2017 that coincided with the rainy season, increased insect numbers and a Relief in Place. The majority of patients had headaches, myalgia, arthralgia and back pain, as well as leucopenia and thrombocytopenia. No diagnoses could be made in theatre, despite a sophisticated deployed laboratory being available, and further testing in the UK, including next-generation sequencing, was unable to establish an aetiology. Such illnesses are very likely to present in tropical environments, where increasing numbers of military personnel are being deployed, and clinicians must be aware of the non-specific presentation and treatment, as well as the availability of Military Infection Reachback services to assist in the management of these cases.

Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017.

INTRODUCTION: Diseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel. METHODS: A service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams. RESULTS: Over a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenic Escherichia coli (32%), other bacteria (6%) and protozoa (12%). CONCLUSION: Data collection on DNBIs during the initial phase of this deployment was clinically useful and integrated between different departments. However, a standardised, long-term solution that is embedded into deployed healthcare is required. The clinical activity recorded here should be used for planning, training, service development and targeted research.

Cheiroarthropathy and tendinopathy in diabetes.

Joint problems commonly occur in people with diabetes. Cheiroarthropathy affects the hands and results in painless limited finger joint extension, appearing to be associated with longer diabetes duration and the presence of microvascular complications. The prevalence of cheiroarthropathy seems to be falling, perhaps as a result of improvements in glycaemic management. Non-enzymatic glycation of collagen results in abnormally crosslinked protein resistant to degradation with subsequent increased build-up of collagen in joints. The management of cheiroarthropathy is predominantly conservative, with occupational and hand therapy at the forefront. Tendinopathy is more common in people with diabetes than those without, and is associated with obesity and insulin resistance. As with cheiroarthropathy, the exact causative mechanism of tendinopathy in diabetes is not known, but may be linked to inflammation, apoptosis and increased vascularity of affected tendons, driven by hyperinsulinaemia. Local fat pads have also been suggested to play a role in the pathogenesis of tendinopathy.

Dyslipidaemia and the military patient.

Dyslipidaemias refer to abnormal levels of circulating lipids and high cholesterol and is related to cardiovascular death. This paper examines the types and prevalence of dyslipidaemia with specific reference to a military population and describes who to target in screening strategies used to detect people with abnormal lipid profiles. The diagnostic limits for a diagnosis of dyslipidaemia are explored. Finally, medical management of hyperlipidaemia is discussed and how this may affect military medical grading.

The gonadotrophic response of Royal Marines during an operational deployment in Afghanistan.

Military training has been associated with changes in the hypothalamic-pituitary-gonadal axis consistent with central hypogonadism. Often such changes have been associated with body mass loss, though sleep deprivation and other psychological stress may also contribute. The effects of deployment in a combat zone on the hypothalamic-pituitary-gonadal axis in military personnel are not known. The objective was to investigate the hypothalamic-pituitary-gonadal axis in male military personnel deployed in Afghanistan. Eighty-nine Royal Marines were investigated pre-deployment, following 3 months in Afghanistan and following 2 weeks mid-tour leave. Testosterone, sex hormone-binding globulin (SHBG), follicle-stimulating hormone (FSH), luteinising hormone (LH), 17-hydroxyprogesterone, androstenedione (AD) and insulin were assayed and body mass recorded. The results showed that body mass (kg) dropped from 83.2 ± 9.2 to 79.2 ± 8.2 kg during the first 3 months of deployment (p < 0.001). Total testosterone did not change, but SHBG increased (30.7 ± 9.7 vs. 42.3 ± 14.1 nmol/L, p < 0.001), resulting in a significant (p < 0.001) fall in calculated free testosterone (435.2 ± 138 vs. 375.1 ± 98 pmol/L). Luteinising hormone and FSH increased by 14.3% (p < 0.001) and 4.9% (p = 0.003) respectively. Free testosterone, SHBG, LH and FSH returned to baseline following 2 weeks of mid-tour leave. Androstenedione (AD) decreased by 14.5% (p = 0.024), and insulin decreased by 26% (p = 0.039), over the course of deployment. In this study of lean Royal Marines, free testosterone decreased during operational deployment to Afghanistan. There was no evidence to suggest major stress-induced central hypogonadism. We postulate that reduced body mass, accompanied by a decrease in insulin and AD synthesis, may have contributed to an elevated SHBG, leading to a decrease in free testosterone.

Energy at high altitude.

For the military doctor, an understanding of the metabolic effects of high altitude (HA) exposure is highly relevant. This review examines the acute metabolic challenge and subsequent changes in nutritional homeostasis that occur when troops deploy rapidly to HA. Key factors that impact on metabolism include the hypoxic-hypobaric environment, physical exercise and diet. Expected metabolic changes include augmentation of basal metabolic rate (BMR), decreased availability of oxygen in peripheral metabolic tissues, reduction in VO2 max, increased glucose dependency and lactate accumulation during exercise. The metabolic demands of exercise at HA are crucial. Equivalent activity requires greater effort and more energy than it does at sea level. Soldiers working at HA show high energy expenditure and this may exceed energy intake significantly. Energy intake at HA is affected adversely by reduced availability, reduced appetite and changes in endocrine parameters. Energy imbalance and loss of body water result in weight loss, which is extremely common at HA. Loss of fat predominates over loss of fat-free mass. This state resembles starvation and the preferential primary fuel source shifts from carbohydrate towards fat, reducing performance efficiency. However, these adverse effects can be mitigated by increasing energy intake in association with a high carbohydrate ration. Commanders must ensure that individuals are motivated, educated, strongly encouraged and empowered to meet their energy needs in order to maximise mission-effectiveness.

Importance of accounting for the variability of electrocardiographic data among diagnostically similar patients with inferior wall healed myocardial infarction.

The authors describe a method to account for patient-to-patient variability in electrocardiographic data. The method yielded criteria for healed inferior myocardial infarction with diagnostic performances better than those of traditional electrocardiographic parameters.

A mediational model of the impact of interparental conflict on child adjustment in a multiethnic, low-income sample.

Path analysis was used to determine whether the effects of interparental conflict on children's depression and conduct disorder are mediated by 3 dimensions of parenting: acceptance, inconsistent discipline, and hostile control. The study extends the literature by testing this mediational model with a low-income, predominantly ethnic minority sample of preadolescent children and by examining the effects of multiple dimensions of interparental conflict from the child's perspective. Results supported the mediational model when analyses were based on child's reports of all variables but not when mother's reports were used to assess child depression and conduct problems. Exploratory analyses revealed unique mediational paths associated with conflict frequency and resolution, which were examined along with intensity as distinct dimensions of interparental conflict.

Using digital versus analog ECG data in clinical trials.

In 54 patients, we measured 3 different electrocardiogram (ECG) parameters required in the Symphony 1 trial and compared various combinations of pairs of measurements from 4 different sets of analog data and 1 set of digital data. Particularly for measurements of the durations of R waves in lead aVF, we found poor intraobserver and interobserver reliability and poor agreement between analog and digital data. There was much better agreement in measurements of the amplitudes of S waves in lead V3. The poorer agreement involving durations appears to be due to difficulties in accurately identifying the offsets of portions of the QRS complex, especially in lead AVF. We conclude that, particularly in measurements of duration, digital and analog data are not equivalent.

Hormonal response to orthostasis in elderly people with systemic systolic hypertension.

BACKGROUND: Orthostatic hypotension is a common phenomenon in the elderly. Hormonal changes during orthostatic stress have been described in elderly normotensive people and in those with essential hypertension. However, the hormonal response in elderly people who have systolic hypertension during orthostasis has not yet been quantified. METHODS: In this study we investigated 14 non-diabetic men, aged 60 to 75 years, with untreated systolic hypertension who were subjected to 45 degrees passive head-up incline on a tilt table for 15 min. Their hormonal profile and hemodynamic changes were analyzed before and after the stress. RESULTS: In the supine position, plasma levels of norepinephrine, atrial natriuretic peptide and aldosterone were in the normal range, while the plasma renin activity was low. Immediately upon tilt the systolic blood pressure fell but it reverted to baseline values after 15 min of orthostasis. At that time the cardiac output decreased while the systemic vascular resistance and the plasma norepinephrine concentration rose. The atrial natriuretic peptide appeared to fall, and the renin-aldosterone level did not change. CONCLUSION: The physiologic response to orthostatic stress in elderly people with systolic hypertension is comparable to that of elderly normotensive people and those with essential hypertension, i.e. a decrease in cardiac output and an increase in plasma norepinephrine levels. The atrial natriuretic peptide appeared to fall appropriately. The response of the renin-aldosterone system mimicked that in elderly patients with low renin essential isolated hypertension. These observations may have a bearing on the management of elderly people with systolic hypertension who also have orthostatic symptoms; they may not require a different approach from that needed for others of the same age group.

Does parenting differ based on social class?: African American women's perceived socialization for achievement.

Research has provided some evidence of ethnic group, gender, and class differences in the socialization for achievement. However, there is little research on African American women with the exception of the studies of low-income, single mothers. To understand the similarities and differences in socialization for achievement based on social class, middle-class African American women from working- and middle-class backgrounds were studied using qualitative and quantitative methods to compare them on issues related to achievement socialization. Women from middle-class backgrounds reported that their parents had higher expectations for them and were more involved in their education than did women from working-class backgrounds. More middle-class parents expected their daughters to be successful in careers than did working-class parents. Women from working-class families did receive support from their parents but they did not have as much support as did the women from middle-class backgrounds. Women from working-class families perhaps made use of other sources to support their desire to succeed. There were no differences in perceived race-related socialization based on social class. Implications of these findings for future research are discussed.

Baroreflex function during 45-degree passive head-up tilt before and after long-term thiazide therapy in the elderly with systolic systemic hypertension.

The ratio of the 30th to the 15th cardiac cycle duration on an electrocardiogram (30:15 ratio) immediately after active standing from the supine position has been used as one of the markers of baroreflex function. A ratio of < or = 1.0 has been suggested to indicate baroreflex dysfunction. Blood pressure (BP) changes were measured and the 30:15 ratio was calculated after standing and during 45-degree passive head-up tilt from the supine position in 10 nondiabetic men (mean age +/- SE 70.1 +/- 1.05 years, and BP < 150/90 mm Hg). After tilt the decrease in systolic BP (from 132 +/- 4.8 to 117 +/- 6.3 mm Hg; p < 0.001) appeared to be larger than that after standing (from 132 +/- 4.6 to 123 +/- 5.8 mm Hg; p < 0.01), whereas the 30:15 ratios were 0.965 +/- 0.006 and 0.970 +/- 0.014, respectively, which suggested baroreflex dysfunction. Although the mean of the 2 ratios did not differ, the variance appeared to be less during tilting than after standing. Thus, the 45-degree passive head-up tilt appeared to be a better and more uniform inducer of orthostatic stress than active standing. Therefore, 45-degree head-up tilt was used in a group of 10 nondiabetic male patients (aged 70 +/- 1.46 years) with isolated systolic hypertension (systolic BP > 160 mm Hg, diastolic BP of < 90 mm Hg) to assess their baroreflex function. Upon tilting, their systolic BP decreased from 190 +/- 5.5 to 179 +/- 5.8 mm Hg (p < 0.05) and their 30:15 ratio was 0.985 +/- 0.011.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic response to orthostatic stress in the elderly with systolic systemic hypertension before and after long-term thiazide therapy.

The hemodynamic effects of orthostatic stress in elderly subjects with systolic hypertension were studied before and after long-term hydrochlorothiazide therapy (50 mg daily). Sixteen nondiabetic men aged 70 +/- 1 (SE) years participated in the study initially, and 12 completed 1 year of therapy. Patients underwent 45 degrees head-up incline on a tilt table before, after 1 month and after 1 year of therapy. Hemodynamic variables were measured in the following situations: (1) the supine position, (2) immediately after completion of passive 45 degrees head-up position at 0 minute, (3) at 15 minutes in the tilted state while patients performed intermittent foot movements to minimize gravitational pooling and simulate the standing position outside the laboratory, and (4) after returning to the supine position. Systolic and diastolic blood pressure (BP) decreased significantly after 1 month of therapy, and this reduction was maintained up to 1 year in all aforementioned body positions, with the exception of diastolic BP at 0 minute of tilt, which was significant at 1 year only. Before therapy was begun, there was a significant reduction in systolic BP immediately after completion of tilting; however, this was statistically insignificant both at 1 month and 1 year of therapy. Thus, the data may help dispel the concern of exacerbating the hypotensive response to orthostatic stress in patients with systolic hypertension after long-term thiazide diuretic therapy.

Mitral valve prolapse and neuroticism in chest pain patients with normal and diseased coronary arteries.

Patients with chest pain and normal coronary arteries (NCA) score higher on measures of neuroticism than patients with coronary artery disease (CAD). This relationship, coupled with findings linking mitral valve prolapse (MVP) and anxiety disorders, led us to examine prospectively the possibility that a greater incidence of MVP among NCA patients accounts for their elevated neuroticism scores. One-hundred-forty-four patients completed psychological tests and a structured interview prior to cardiac catheterization. Forty-one of the 144 patients (28%) had normal coronary arteries. Within the NCA group 29 percent had MVP; within the CAD group only 13 percent had MVP. Despite the significant difference between NCA and CAD groups on measures of neuroticism, there were no differences as a function of MVP status, nor was there an interaction of MVP and coronary arterial status. These findings support the case for an association between NCA and neuroticism independent of the presence or absence of MVP.

One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries.

As many as 30% of patients with chest pain symptoms who are referred for arteriography are found to have normal coronary arteries. Research has shown that patients with anginal symptoms and normal coronary arteries score higher on neuroticism measurements (anxiety, depression and somatic concerns) at the time of catheterization than patients with anginal symptoms who have coronary artery disease. Research examining the cardiac course of chest pain patients with normal coronary arteries indicates that this is a nonprogressive disorder. Although follow-up studies of these patients report continued chest pain and diminished physical activity, these studies have ignored the psychologic status of the patients. Thus, it is not known whether their higher neuroticism scores at the time of catheterization persist following angiography or whether such elevated indexes of neuroticism are transient phenomena associated with precatheterization anticipatory stress. The present study examined 48 Veterans Administration Medical Center patients: 24 with anginal symptoms and normal coronary arteries and 24 with documented coronary artery disease. The patients completed a structured clinical interview and a set of psychologic inventories on the day before catheterization and 1 year later. The findings established continued high neuroticism scores among patients with anginal symptoms only and supported the findings of other investigators regarding continuing chest pain and restricted physical activity. The knowledge alone of benign coronary artery status resulted in virtually no change in the psychosocial status of these patients. Alternative treatment methods are discussed.

Relationship between Doppler left ventricular diastolic filling indexes and the electrocardiographic criteria for left atrial enlargement.

Traditional electrocardiographic (ECG) criteria for left atrial enlargement (LAE) emphasize the increased amplitude and width of the corresponding component of the hypertrophied atrium. Although a correlation exists between LAE and ECG criteria, a cause-and-effect relationship has not been conclusively demonstrated. Because the diastolic properties of the left ventricle directly influence left atrial emptying, these properties might also influence the ECG diagnosis of LAE. Therefore, the authors hypothesized that the ECG criteria for LAE are influenced by diastolic properties of the left ventricle as defined by Doppler-derived parameters.