Defence Medical Services telemedicine now: a successful pilot of video consultations and instant messaging support to firm base training.

INTRODUCTION: Telemedicine was pioneered in the Defence Medical Services (DMS) in 1998, since then the capabilities within the DMS have not advanced in step with advances in technology. We present our findings of a pilot of remote video consultation via Skype for MODNET during an arduous course held in the UK. METHOD: Combat medical technician sick parades were live streamed via Skype to a Defence Primary Healthcare Medical Centre and medical officer (MO) support was delivered remotely. This process was augmented by the use of Pando for still images of wounds and infection sites in order to enhance decision making and situational awareness. RESULTS: Over a 3-week period, 34 consultations carried out during sick parade required the input from a remote MO, of those 34% required a prescription from an MO. None of the presentations required a face-to-face consultation, and all patients received MO-led care remotely. CONCLUSION: We have successfully demonstrated that video telemedicine consultations are safe, while simultaneously improving patient care, augmenting the distribution of medical assets and reducing costs.

Secure app-based secondary healthcare clinical decision support to deployed forces in the UK Defence Medical Services.

BACKGROUND: Modern instant messaging systems facilitate reach-back medical support for Defence Medical Services (DMS) by connecting deployed clinicians to remote specialists. The mobile app Pando (Forward Clinical, UK) has been used for this purpose by the DMS via the 'Ask Advice' function. We aimed to investigate the usage statistics for this technology in its first 1000 days to better understand its role in the DMS. METHODS: An observational study was undertaken using metadata extracted from the prospective database within the application server for clinical queries between June 2019 and February 2022. These data included details regarding number and name of specialties, timings, active users per day and the number of conversations. RESULTS: There were 29 specialties, with 298 specialist users and 553 requests for advice. The highest volume of requests were for trauma and orthopaedics (n=116; 21.0%), ear, nose and throat (n=67; 12.1%) and dermatology (n=50; 9.0%). There was a median of 164 (IQR 82-257) users logged in per day (range 2-697). The number of requests during each day correlated with the number of users on that day (r=0.221 (95% CI 0.159 to 0.281); p<0.001). There were more daily users on weekdays than weekends (215 (IQR 123-277) vs 88 (IQR 58-121), respectively; p<0.001). For the top 10 specialties, the median first response time was 9 (IQR 3-42) min and the median time to resolution was 105 (IQR 21-1086) min. CONCLUSION: In the first 1000 days of secure app-based reach-back by the DMS there have been over 500 conversations, responded to within minutes by multiple specialists. This represents a maturing reach-back capability that may enhance the force multiplying effect of defence healthcare while minimising the deployed 'medical footprint'. Further discussions should address how this technology can be used to provide appropriately responsive clinical advice within DMS consultant job-planned time.

The History of the Post-Graduate Medical and Nursing Officers (PGMNO) course in the British Army.

Military medicine has been evolving for over 5000 years of recorded civilisation and conflict. The Army Medical Services performed poorly during the Crimean War and the British Army introduced a professional training course for medical officers in 1860. The Army Medical School and the predecessor of today's Post-Graduate Medical and Nursing Officers (PGMNO) course have had to adapt to changes in British foreign policy and military requirements. The Army Medical School instigated a rigorous scientific medical training which led to major advances in the study of tropical diseases and trauma medicine. These advances were quickly included in the training of future cohorts. Although the Army Medical School has now closed, the PGMNO course thrives at its new location at the Defence Medical Academy, Whittington. Modern general duties medical officers (GDMOs) must be able to provide medical care in a range of austere environments, including humanitarian relief and conflict zones. New clinicians complete their basic military training before completing the PGMNO course and the Diploma in the Medical Care of Catastrophes. This programme ensures that GDMOs and military nurse practitioners gain a wide knowledge of the latest military and humanitarian medicine. The current era will require clinicians who are competent generalists, who can perform in small teams in dispersed locations. This article summarises the development of the British Army's PGMNO course and the evolution of its syllabus as part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Physiological and perceptual responses during walking at set and preferred pace in normal and overweight adults.

BACKGROUND: This study aimed to investigate the influence of body weight, exercise modality, and pace on physiological and perceptual responses to determine the relation between perceptual and physiological responses. METHODS: Aerobically untrained, normal weight, and overweight males and females participated. Participants were randomly assigned to one exercise condition for a 1-mile walk. RESULTS: Prescribed pace resulted in a greater physiological stress than self-selected pace (all p < 0.001) through blood lactate (1.3 ± 0.4 vs 1.7 ± 0.5 mmol), systolic blood pressure (128.9 ± 10.3 vs 139.2 ± 13.2 mmHg), heart rate recovery (2.1 ± 1.7 vs 4.5 ± 2.6 min), oxygen consumption (15.1 ± 2.6 vs 18.1 ± 3.6 ml/kg/min), heart rate (111.7 ± 16.6 vs 134.4 ± 8.3 bpm), and energy expenditure (5.5 ± 1.4 vs 6.8 ± 1.7 kcal/min). Overweight individuals exhibited higher values than normal weight for heart rate (113 ± 8.8 vs 125.5 ± 13.2 bpm, p < 0.001), percentage of max heart rate (60.7 vs 69.0%, p < 0.001), percent of VO2peak (42.2 vs 55.6%, p < 0.001), and total energy expenditure (100.9 ± 27.4 vs 114.1 ± 33.5 kcal, p = 0.022). Greater perceived effort was seen on a treadmill (6.3 ± 0.5 vs 12.5 ± 2.0 RPE, p < 0.001) and at prescribed pace (6.5 ± 1.1 vs 8.9 ± 1.9 RPE, p < 0.001). CONCLUSION: A novel finding of this study was the increased physiological stress and perception of effort on a treadmill and at a prescribed pace, while total energy expenditure showed no significant differences. This could indicate an unfavorable perception and less affective response to the treadmill modality. These results indicate exercise at self-selected pace in preferred environments promotes enjoyable experiences with similar health benefits as those during prescribed higher intensity exercise.

Procedural sedation at role 1: applicability to military clinicians and minimum monitoring criteria.

Procedural sedation is defined as producing a state of reduced consciousness, where the patient is still able to respond to verbal or physical stimulus and to continuously maintain a patent airway and adequate ventilation. This can be done to facilitate treatment that would not be otherwise possible. Recent evidence, guidelines and new equipment introductions have improved the safety of procedural sedation at UK role 1 medical treatment facilities (MTFs). A role 1 MTF is defined by the North Atlantic Treaty Organization as a medical facility focusing on the provision of primary healthcare, specialised first aid, triage, resuscitation and stabilisation, and is usually staffed by a general practitioner or a general duties medical officer. This paper aims to update role 1 clinicians on the current evidence base and guidance regarding monitoring of patients during procedural sedation.

Fellowship in Immediate Medical Care examination: applicability to the Defence Medical Services.

The Fellowship in Immediate Medical Care (FIMC) is the highest level of formal qualification available for pre-hospital practitioners, aiming to test the knowledge, technical and non-technical skills of those providing specialist Pre-Hospital Emergency Care (PHEC). The FIMC is a multiprofessional examination with the potential to support continuous quality improvement of the PHEC that the Defence Medical Services (DMS) can offer to our patients now and in the future. The aim of this article is to inform the readership about the evolution of the FIMC examination and its applicability to military clinicians (and their civilian counterparts). A secondary aim is to inform those who are preparing for the examination.

Perspectives of hematology oncology clinicians about integrating palliative care in oncology.

Patients with hematologic malignancies receive palliative care (pc) less frequently and later than patients with solid tumours. We compared survey responses of hematology oncology clinicians with other oncology clinicians to better understand their challenges with providing primary pc or using secondary pc. Patients' negative perceptions of pc and limited time or competing priorities were challenges for all clinicians. Compared with other oncology clinicians, more hematology oncology clinicians perceived pc referral criteria as too restrictive (40% vs. 22%, p = 0.021) and anticipated that integrating pc supports into their practice would require substantial change (53% vs. 28%, p = 0.014). This study highlights barriers that may need targeted interventions to better integrate pc into the care of patients with hematologic malignancies.

Demonstration of non-inferiority of a novel combination intramammary antimicrobial in the treatment of clinical mastitis.

AIM: To test the non-inferiority of a novel combination intramammary product containing penicillin and cloxacillin to a reference intramammary product containing oxytetracycline, oleandomycin, neomycin and prednisolone with regard to bacteriological cure and clinical cure. METHODS: Clinical cases of mastitis were sourced from 30 spring-calving dairy farms in the Southland region of New Zealand. Affected quarters were infused three times at 24 hourly intervals with either the novel combination product containing 1 g penicillin and 200 mg cloxacillin, or a reference product containing 200 mg oxytetracycline, 100 mg oleandomycin, 100 mg neomycin and 5 mg prednisolone. Cows were enrolled when a farmer detected a case of clinical mastitis. Milk samples were collected for microbiological culture immediately before treatment (Day 0) and on Days 9, 16 and 23. Bacteriological cure was compared for 187 and 178 quarters treated with the reference and novel product, respectively, and clinical cure was compared for 235 and 223 quarters, respectively. Non-inferiority was assessed by calculating the difference in cure rates between the two products and constructing a 95% CI around the difference, using the variance inflation factor to account for herd level clustering. The non-inferiority margin was 20% for both bacteriological and clinical cure. Generalising estimating equation models were used to determine predictor variables. RESULTS: The bacteriological cure percentage, adjusted to account for herd-level clustering, was 8.5 (95% CI=-1.7-21.8)% higher for quarters treated with the novel than the reference product. The adjusted clinical cure percentage was 0.3 (95% CI=-11.2-12.0)% higher for clinical quarters treated with the novel than the reference product. Bacterial species was the only covariate for bacteriological cure (p=0.003), and quarter score at enrolment (indicating udder inflammation) was the only covariate for clinical cure (p=0.032) in the multivariable models. CONCLUSION: The novel combination product was demonstrated to be non-inferior to the reference product with regards to both bacteriological cure and clinical cure. CLINICAL RELEVANCE: Clinicians treating mastitis now have access to this novel combination intramammary product, and demonstration of its non-inferiority compared to the existing reference product will provide options for treatment approaches. The novel product contains fewer antimicrobials; which are of a narrower spectrum of activity.

Packers, pushers and stuffers--managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review.

Body packing, pushing and stuffing are methods by which illicit drugs may be carried within the human body. Patients involved in these practices may present UK emergency departments with complex medical, legal and ethical considerations. This review article examines not only the evidence behind the clinical management of these patients, but also the legal powers afforded to the authorities to authorise the use of intimate searches and diagnostic imaging for forensic purposes. Serious complications from concealed drug packets are now rare, and most asymptomatic patients may be safely discharged from hospital after assessment. Emergency surgery is indicated for body packers with cocaine poisoning and for some cases of heroin poisoning. Urgent surgery is indicated for obstruction, perforation, the passage of packet fragments and failure of conservative treatment. Guidance is given for doctors who are faced with requests from the authorities to perform intimate searches and diagnostic imaging for forensic purposes.

Do patients think that dry powder inhalers can be used interchangeably?

As recognised in management guidelines, patients are the most important group of people in any prescribing decision. Despite their importance, few studies have asked what patients think about being switched between different inhalers. This paper reports two such studies, one involving interviews of a sample of patients and the other consisting of a quantitative survey of patients across five countries. In the qualitative study, four of the five patients interviewed reported that they would be confused, worried and unhappy about a switch in their dry powder inhaler and would revisit their physician to be shown how to use the inhaler or to ask for a new prescription for their old inhaler. In the quantitative survey of 499 patients with asthma, more than half (51%) were opposed to their current dry powder inhaler being replaced by a substitute device, with 83% reporting concerns. There was considerable concern about training in use of the new device and confusion about the need for change. Almost a quarter of patients (23%) would want training, and 23% of patients thought they would need information about the new inhaler. From limited information, it appears that patients would be concerned about switching of their existing dry powder inhaler for another, with the potential for confusion, need for additional consultations and need for training in the new device.

Best practice in the use of spirometry.

This article examines spirometry as a method of detecting lung disease, particularly chronic obstructive pulmonary disease (COPD). Methods of producing an accurate assessment and identifying acceptable traces are outlined, and contraindications are discussed.

Heat illness--recent developments.

This paper reviews the literature concerning exertional heat illness in soldiers. It focuses on developments since Bricknell's two part paper "Heat Illness--A Review of Military Experience" published in this journal in 1996. Recent advances in the understanding of risk factors, pathophysiology and treatment are discussed with a view to reducing the already low incidence of heat illness within the Armed Forces.

The role of Ultrabithorax in the patterning of adult thoracic muscles in Drosophila melanogaster.

Mutations in the homeotic gene, Ultrabithorax (Ubx), result in the transformation of the third thoracic (T3) segment into the second thoracic (T2) segment. Although it has been well established that these mutations have striking effects on adult epidermal structures in T3, the effect of these mutations on the adult musculature has been controversial. In this study, a series of Ubx regulatory mutations, anterobithorax, bithorax, postbithorax, and bithoraxoid, as well as combinations of these alleles were used to reevaluate the role of Ubx in the patterning of the T3 musculature. Homeotic indirect and direct flight muscles (IFMs and DFMs) were identified in the transformed T3 segment of all alleles and allelic combinations with the exception of postbithorax. We critically evaluated the pattern and amount of these muscles and found that while the amount and/or quality of homeotic IFMs increased, the amount of homeotic DFMs did not vary significantly as the severity of the ectodermal transformation increased. Because Ubx is not expressed in the adult mesoderm of T3, these results suggest that inductive cues play a major role in the patterning of adult thoracic muscles. We provide a model that illustrates the central role of inductive cues in generating the final adult muscle pattern in the thorax.

Host recognition by the tobacco hornworm is mediated by a host plant compound.

It is generally believed that animals make decisions about the selection of mates, kin or food on the basis of pre-constructed recognition templates. These templates can be innate or acquired through experience. An example of an acquired template is the feeding preference exhibited by larvae of the moth, Manduca sexta. Naive hatchlings will feed and grow successfully on many different plants or artificial diets, but once they have fed on a natural host they become specialist feeders. Here we show that the induced feeding preference of M. sexta involves the formation of a template to a steroidal glycoside, indioside D, that is present in solanaceous foliage. This compound is both necessary and sufficient to maintain the induced feeding preference. The induction of host plant specificity is at least partly due to a tuning of taste receptors to indioside D. The taste receptors of larvae fed on host plants show an enhanced response to indioside D as compared with other plant compounds tested.

Imaginal pioneers prefigure the formation of adult thoracic muscles in Drosophila melanogaster.

In insects, specialized mesodermal cells serve as templates to organize myoblasts into distinct muscle fibers during embryogenesis. In the grasshopper embryo, large mesodermal cells called muscle pioneers extend between the epidermal attachment points of future muscle fibers and serve as foci for myoblast fusion. In the Drosophila embryo, muscle founder cells serve a similar function, organizing large numbers of myoblasts into larval muscles. During the metamorphosis of Drosophila, nearly all larval muscles degenerate and are replaced by a set of de novo adult muscles. The extent to which specialized mesodermal cells homologous to the founders and pioneers of the insect embryo are involved in the development of adult-specific muscles has yet to be established. In the larval thorax, the majority of imaginal myoblasts are associated with the imaginal discs. We report here the identification of a morphologically distinct class of disc-associated myoblasts, which we call imaginal pioneers, that prefigures the formation of at least three adult-specific muscles, the tergal depressor of the trochanter and dorsoventral muscles I and II. Like the muscle pioneers of the grasshopper, the imaginal pioneers attach to the epidermis at sites where the future muscle insertions will arise and erect a scaffold for developing adult muscles. These findings suggest that a prior segregation of imaginal myoblasts into at least two populations, one of which may act as pioneers or founders, must occur during development.

Octopamine mimics the effects of parasitism on the foregut of the tobacco hornworm Manduca sexta.

The parasitic braconid wasp Cotesia congregata lays its eggs inside the body of the larval stage of its host, the moth Manduca sexta. The Cotesia congregata larvae develop within the hemocoel of their host until their third instar, when they emerge and spin cocoons and pupate on the outer surface of the caterpillar. From this time until their death approximately 2 weeks later, the Manduca sexta larvae show striking behavioral changes that include dramatic declines in spontaneous activity and in the time spent feeding. Coincident with these behavioral changes, it is known that octopamine titers in the hemolymph of the host become elevated by approximately 6.5-fold. Octopamine is an important modulator of neural function and behavior in insects, so we examined hosts for neural correlates to the behavioral changes that occur at parasite emergence. We found that, in addition to the changes reported earlier, after parasite emergence (post-emergence), Manduca sexta larvae also showed marked deficits in their ability to ingest food because of a disruption in the function of the frontal ganglion that results in a significant slowing or the absence of peristaltic activity in the foregut. This effect could be produced in unparasitized fifth-instar larvae by application of blood from post-emergence parasitized larvae or of 10(-6)mol l(-1)d,l-octopamine (approximately the level in the hemolymph of post-emergence larvae). In contrast, blood from parasitized larvae before their parasites emerge or from unparasitized fifth-instar larvae typically had no effect on foregut activity. The effects of either post-emergence parasitized blood or 10(-6)mol l(-1) octopamine could be blocked by the octopamine antagonists phentolamine (at 10(-5)mol l(-1)) or mianserin (at 10(-7)mol l(-1)).