Defining sepsis on the wards: results of a multi-centre point-prevalence study comparing two sepsis definitions.

Our aim was to prospectively determine the predictive capabilities of SEPSIS-1 and SEPSIS-3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24-h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS-1 definition, 212 patients had sepsis. When using the SEPSIS-3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quickSOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS-1 criteria had a sensitivity (95%CI) of 65% (54-75%) and specificity of 47% (41-53%); SEPSIS-3 criteria had a sensitivity of 86% (76-92%) and specificity of 32% (27-38%). SEPSIS-3 and SEPSIS-1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5-5.6) and 1.6 (1.3-2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63-0.76)), followed by NEWS (0.58 (0.51-0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49-0.61)) and quickSOFA score (0.56 (0.49-0.64)) could not predict outcome. The SEPSIS-3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis-induced organ dysfunction.

Steerable THz pulses from thin emitters via optical pulse-front tilt.

A new method of steering THz pulses radiated from a thin emitter excited by tilted optical pulse-fronts has been developed theoretically and validated in a proof-of-concept experiment. This steering technique is potentially efficient and rapid, and it should benefit from a THz-pulse energy that can scale with optical-beam size and magnitude. Conversely, the method employed for measuring the steered THz pulses is also capable of characterizing the pulse-front tilt of an optical beam.

Multinational, pilot audit of a Velcro adjustable compression wrap system for venous and lymphatic conditions.

OBJECTIVE: The aim of this small pilot audit was to record the performance of an adjustable Velcro compression wrap, ReadyWrap, and the experiences of patients and health-care professionals using the system as a self-care option for the management of venous and lymphatic leg conditions in both the treatment and maintenance phases. METHOD: This audit was held within a 4-week review period. Participants included venous leg ulcer (VLU) patients with and without oedema, and patients with lymphoedema. Where open wounds were present they were managed with debridement, skin care and dressings according to clinical need. Lymphoedema patients received manual lymphatic drainage and skin care regimens as per standard practice. The Velcro system evaluated formed part of a treatment pathway with compression bandages and/or compression hosiery as clinically indicated. Patients, carers and health-care professionals applied the garments following assessment and training. Objective data recorded included change in circumferential measurements and improvement in wound status. Observation of health-care professionals, patients and carers with regard to the comfort and ease of application/removal of the device were recorded. RESULTS: There were 17 patients included in the audit. Within the 4-week period a reduction in limb circumference was recorded in all cases. Improvements in open wounds were recorded in most cases. Following the 4-week audit period 94% of the application of the device was performed by either the patient (59%) or the carer (35%) thereby reducing the health-care professional contact that was required for application. CONCLUSION: Early results in this small audit demonstrate that this adjustable Velcro compression wrap may provide a simple, clinically effective and patient-acceptable solution for self-care with compression. Use of this type of device could have the potential to reduce overall health-care burden by reducing necessary skilled treatment visits and/or cost while still achieving good clinical outcomes. Further studies are required to confirm this pilot study and provide additional data.

Clinical audit of a lymphoedema bandaging system: a foam roll and cohesive short stretch bandages.

OBJECTIVE: Late-stage lymphoedema is characterised by chronic swelling, shape distortion, inflammatory processes and tissue fibrosis. Our aim was to perform a clinical audit of a lymphoedema compression bandaging system (Rosidal Soft foam roll layer and figure-of-eight application of Actico cohesive inelastic bandages) specifically designed for patients with late stage lower limb lymphoedema. METHOD: The audit explored suitability of the bandaging system, benchmarking limb volume changes with research evidence, and reporting patient and practitioner evaluations. RESULTS: A mean reduction (33%) in excess limb volume was reported for the 11 patients with unilateral lymphoedema who completed a course of bandaging over 12 days. Mean percentage reduction of absolute limb volume after treatment was 8%. Patient and practitioner evaluations indicated the suitability of this bandage system for patients with late stage lymphoedema in terms of comfort and effectiveness. CONCLUSION: The bandaging system is suitable for patients with late stage chronic swelling. Two parameters for calculating change in limb volume are not interchangeable. Future evaluation of the bandaging system, using validated outcome measures within a comprehensive research study is required. DECLARATION OF INTEREST: Activa Healthcare provided financial support to the project and supplied the materials.

One Health: opportunities for Defence Engagement (Health).

The One Health concept continues to gain traction as a necessary approach to tackle emerging threats to human, animal and environmental health but has not yet been adopted within Defence Engagement (Health). The health of humans, animals and ecosystems are closely interlinked. The One Health concept recognises this interdependence and seeks to balance and optimise the health of all three through an integrated and unifying approach. With a focus on zoonoses, vectorborne disease, antimicrobial resistance and food safety it encourages collaboration, communication, coordination and capacity building. The UK has made commitments to the One Health approach in the Global Health and Security Agenda, and the Integrated Review. This article explores how the One Health approach could and should be adopted within Defence Engagement (Health) activity to offer the potential for high-impact, low-risk activity while facilitating long-term relationship building.

Using Defence Engagement (Health) to progress the Women Peace and Security agenda.

Since the unanimous passing of United Nations Security Council Resolution 1325, which calls on member states to address gender inequality, many countries and the wider North Atlantic Treaty Organisation community have championed the Women Peace and Security agenda to empower women and reduce violence within fragile states. When women are empowered and actively involved in decision-making, there is less violence, and more peace and stability in that society, which benefits all members.Defence Medical Services are uniquely positioned to progress this agenda, particularly through its Defence Engagement activities. The UK's military medical community has more women in leadership than the wider military community. Our personnel can and should be used to model and empower military healthcare workers in partner nations. This paper forms part of a special issue of BMJ Military Health dedicated to Defence Engagement.

Using nominal group technique to identify the planning considerations for UK Armed Forces medical personnel delivering defence engagement first aid training activities.

INTRODUCTION: Defence Medical Services personnel regularly deploy overseas to deliver training activities as part of defence engagement (DE) to positively influence partners and others. There remains scope for medical planners to enhance our understanding of how to optimally use medical staff and assets for DE. We aimed to develop a tool to improve planning for DE activities delivering first aid training. METHODS: We used nominal group technique to conduct a focus group with UK experts in planning first aid training DE activities to identify and prioritise important planning considerations within a conceptual framework based on the Defence Lines of Development. We validated and refined this framework with international experts from partner nation militaries to help strengthen the final planning tool. RESULTS: We developed a detailed tool covering training curriculum and logistical and infrastructure requirements to deliver safe and effective DE training activities. First aid training engagement priorities include being tailored to the training audience and in harmony with the national or military healthcare services of that country. Messaging around the women, peace and security agenda should be integrated into training packages at conception to be effective. CONCLUSIONS: We propose a planning tool to aid in designing first aid training that considers the necessary components to support meaningful education and effective engagement in support of UK's strategic goals. We welcome the use of and feedback on this tool and its impact to those planning first aid training activities as part of DE operations.

Framework for the evaluation of military health systems.

The organisation of a military health system (MHS) differs from the civilian system due to the role of the armed forces, the unique nature of the supported population and their occupational health requirements. A previously published review of the Military Medical Corps Worldwide Almanac demonstrated the value of a standardised framework for evaluation and comparison of MHSs. This paper proposes such a framework which highlights the unique features of MHSs not covered by health services research of national health systems. These include: national context and summary; organisational structure; firm base facilities, healthcare beneficiaries and medical research; operational capabilities, overseas deployments, collaborations and alliances; personnel including recruitment, training and education; and history and culture. This common framework can help facilitate international collaboration between military medical services including capability development, training exercises and mutual support during military operations. It can also inform national contributions to future editions of the Almanac.

The effectiveness and safety of heat/cold therapy in adults with lymphoedema: systematic review.

PURPOSE: The aim of this review is to assess the efficacy and safety of using heat and cold therapy for adults with lymphoedema. METHODS: A multi-database search was undertaken. Only studies which included adults with lymphoedema who were treated with heat or cold therapy reporting any outcome were included. Screening, data extraction, and assessment of bias were undertaken by a single reviewer and verified by a second. Due to the substantial heterogeneity, a descriptive synthesis was undertaken. RESULTS: Eighteen studies were included. All nine studies which assessed the effects of heat-therapy on changes in limb circumference reported a point estimate indicating some reduction from baseline to end of study. Similarly, the five studies evaluating the use of heat-therapy on limb volume demonstrated a reduction in limb volume from baseline to end-of-study. Only four studies reported adverse events of which all were deemed to be minor. Only two studies explored the effects of cold therapy on lymphoedema. CONCLUSIONS: Tentative evidence suggests heat-therapy may have some benefit in treating lymphoedema with minimal side effects. However, further high-quality randomised controlled trials are required, with a particular focus on moderating factors and assessment of adverse events.Implications for rehabilitationThis review highlights the potential benefit that heat therapy may have on reducing limb circumference and volume for adults with lymphoedema.There was no evidence that controlled localised heat therapy was unsafe.The current evidence-base is at a point where no specific clinical recommendations can be made.The use of heat therapy should only be applied as part of a methodologically robust study to treat lymphoedema.

Beware the BATUS Cactus--cactus dermatitis in exercising soldiers on the Albertan prairie.

Species of the Opuntia or prickly pear genus of cacti are endemic to the British Army Training Unit Suffield (BATUS) training area in Alberta, Canada. They are known to provoke a dermatitis reaction in harvesters of the cacti fruit. It's spines are frequently an uncomfortable nuisance to unwary soldiers exercising in BATUS. We report two cases of particularly debilitating adverse skin reactions to the cacti spines that occurred during the 2010 Exercise Prairie Thunder season.

Cold injuries in contemporary conflict.

OBJECTIVES: To describe the cases of cold injury sustained during the most recent winter operational tour of Afghanistan, Op HERRICK 15. METHODS: Retrospective review of all notified British military cases of cold injury sustained between 1 Oct 11 and 30 Mar 12 recorded by UK Medical Group Environmental Health Team. RESULTS: 14 patients with 13 Non-freezing Cold Injuries (NFCI) and two hypothermic injuries were identified. Five patients were of African ethnic decent. Eight out of 13 NFCI patients had probably suffered a previous injury, injuries were sustained from December until February and 9/13 NFCI patients had periods of static duties implicated in the injury mechanism. Eight patients were able to remain in operational theatre on restricted duties whilst 6/14 were evacuated home after sustaining their injuries. CONCLUSIONS: Although awareness and equipment have improved, cold injuries remain an important cause of Disease and Non Battle Injury on current operations within the British Military. Cases of cold injury are probably under reported and often stem from situations where risk would seem predicable. It is hoped this article will assist in enabling greater understanding of contemporary operational cold injuries and continuing the development of preventative strategies.

Novel drug OMS103HP reduces pain and improves joint motion and function for 90 days after arthroscopic meniscectomy.

PURPOSE: This phase 2 study compared OMS103HP (Omeros, Seattle, WA) with control (lactated Ringer's) irrigation solution in patients undergoing arthroscopic partial meniscectomy. METHODS: This was a prospective, multicenter, double-blind, randomized, vehicle-controlled, parallel-group study. Safety and postoperative pain, range of motion, and self-reported function were evaluated for 90 days. Statistical results were based on univariate analysis of variance and repeated-measures analyses. RESULTS: Mean visual analog scale (VAS) pain scores within 24 hours after discharge from the recovery room showed more pain in the control group beginning at 2 hours and peaking at 8 hours. Univariate analysis of variance of mean VAS scores over the 24-hour period did not meet statistical significance. Repeated-measures analysis yielded a statistically significant difference (P = .004) for time-by-treatment interaction, showing a clear drug benefit over time based on VAS scores. There were statistically significant differences at day 7 between the groups in passive flexion without pain (P = .022). The proportion of patients achieving flexion of 95° or greater, 110°, and 125° was greater for the OMS103HP group. The Knee Injury and Osteoarthritis Outcome Score (KOOS) showed statistically significant differences (P ≤ .05) between the OMS103HP and control groups for 4 of 5 outcomes (symptoms, pain, sport and recreation, and knee-based quality of life but not activities of daily living). All scores showed a treatment effect through day 90. The overall incidence of adverse events and abnormal laboratory values for the OMS103HP and control groups was similar. Serious adverse events occurred in 1 control patient. CONCLUSIONS: In this study of patients with meniscal tears who underwent simple debridement, the use of OMS103HP resulted in reduced acute postoperative pain (measured by VAS over the first 24 hours postoperatively), reduced pain during recovery (measured by the KOOS pain subscale, which measures both background levels of pain and exacerbations caused by movements or activities), improved postoperative knee motion, and improved functional outcomes as assessed with the KOOS Knee Survey. Clinical benefits of OMS103HP were consistent and sustained throughout 90 days of postoperative follow-up. LEVEL OF EVIDENCE: Level I, prospective, randomized, controlled trial.

Hibernoma in a 16-year-old boy.

A hibernoma is a rare benign tumour of brown adipose tissue. We report a hibernoma overlying the scapula of a 16-year-old boy.

Challenges faced by British Military Ophthalmic Services during the First World War.

The First World War was a time of great change for many areas of military medicine. This article reviews some of the particular challenges faced by British Ophthalmic Services during 1914-18.

Molecular internalization of a region of myelin basic protein.

The conformation of myelin encephalitogenic or basic protein (BP) was investigated with a double-antibody radioimmunoassay by studying the reaction of BP or its fragments with antibodies produced in two rabbits against peptide 43-88 linked to rabbit serum albumin. Both antisera reacted well with peptide 43-88 but showed little or no reaction with BP. Absorption of these antisera with a BP-immunoadsorbent did not remove the antibody activity against peptide 43-88. Within the region of peptide 43- 88 it was shown that peptides 68-88 and 79-88 gave an equivalent or better reaction than peptide 43-88, whereas peptides 43-67 and 64-73 had very little reactivity. In the BP fragments containing region 43-88, peptide 1-88 showed the best reactivity, peptide 20-166 showed minimal reactivity, while peptide 1-115 showed none. These data document the internal position of at least a portion of peptide 43-88 and all of residues 79-88 in the BP molecule. The much greater reactivity of peptide 1-88 as compared to peptide 1-115 suggests that the region or a portion of the region of BP containing residues 89- 115 participates in the conformational alignment of BP restricting access to peptide 79-88. After absorption with BP, neither of the antisera prepared to peptide 43-88 reacted with PNS myelin in fixed tissue sections but continued to react with CNS myelin in similarly treated sections. The present findings demonstrate the need to consider the role of shielded antigenic determinants in the investigation of antigens or of immune responses.

Assessing barriers to quality trauma care in low and middle-income countries: A Delphi study.

BACKGROUND: Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system. METHODS: A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement. RESULTS: There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus. CONCLUSION: 11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.

Paediatric population pharmacokinetic modelling to assess hydrocortisone replacement dosing regimens in young children.

CONTEXT: Accurate hydrocortisone dosing in children with adrenal insufficiency is important to avoid the risks of over and under treatment including iatrogenic Cushing's syndrome and adrenal crisis. OBJECTIVE: To establish a population pharmacokinetic model of hydrocortisone in children and use this to refine hydrocortisone replacement regimens. DESIGN AND METHODS: Pharmacokinetic study of hydrocortisone granules, available in 0.5, 1, 2 and 5 mg dose strengths, in 24 children with adrenal insufficiency aged 2 weeks to 6 years. Cortisol concentrations quantified by LC-MS/MS were used to refine an adult pharmacokinetic model to a paediatric population model which was then used to simulate seven different hydrocortisone treatment regimens. RESULTS: Pre-dose cortisol levels were undetectable in 54% of the 24 children. The developed pharmacokinetic model had good predictive performance. Simulations for the seven treatment regimens using either three- or four-times daily dosing showed treatment regimens delivered an AUC0-24h within the 90% reference range for healthy children except in neonates where two regimens had an AUC below the 5th percentile. Cortisol concentrations at individual time points in the 24 h were outside the 90% reference range for healthy individuals in 50%, 55-65% and 70-75% for children, infants and neonates, respectively, with low cortisol levels being most prevalent. CONCLUSIONS: Current paediatric hydrocortisone treatment regimens based on either three- or four-times daily administration replicate cortisol exposure based on AUC0-24h, but the majority of cortisol levels are above or below physiological cortisol levels with low levels very common before the next dose.

Immunocytochemical localization studies of myelin basic protein.

The location of myelin encephalitogenic or basic protein (BP) in peripheral nervous system (PNS) and central nervous system (CNS) was investigated by immunofluorescence and horseradish peroxidase (HRP) immunocytochemistry. BP or cross-reacting material could be clearly localized to myelin by immunofluorescence and light microscope HRP immunocytochemistry. Fine structural studies proved to be much more difficult, especially in the CNS, due to problems in tissue fixation and penetration of reagents. Sequential fixation in aldehyde followed by ethanol or methanol provided the best conditions for ultrastructural indirect immunocytochemical studies. In PNS tissue, anti-BP was localized exclusively to the intraperiod line of myelin. Because of limitations in technique, the localization of BP in CNS myelin could not be unequivocally determined. In both PNS and CNS tissue, no anti-BP binding to nonmyelin cellular or membranous elements was detected.

Immunocytochemical localization of calmodulin and a heat-labile calmodulin-binding protein (CaM-BP80) in basal ganglia of mouse brain.

Antisera to calmodulin, a Ca2%-dependent modulator protein, and a heat-labile calmodulin-binding protein have been used to localize these proteins in mouse caudate-putamen. The two proteins appear to be located at identical sites in this brain area. At the light microscopic level, calmodulin and calmodulin-binding protein are found within the cytoplasm and processes of large cells. At the electron microscopic level the proteins are associated with neuronal elements only, primarily at postsynaptic sites within neuronal somata and dendrites. Within the dendrites the immunocytochemical label is associated predominantly with the postsynaptic density and dendritic microtubules. These results are in accord with recent biochemical and immunihistochemical studies of calmodulin in brain and in dividing cells. Thus, calmodulin and the heat-labile calmodulin-binding protein may play a role in the nervous system at the site of neurotransmitter action and at the level of microtubular function.