The Medical Reception Station: a new primary care capability for 3 Commando Brigade.

3 Commando Brigade's delivery of pre-hospital (Role 1) care has until now largely been based around junior doctors delivering trauma-based resuscitation and limited primary care from small self-contained Regimental Aid Posts (RAPs). With the drawdown of large scale operations in Iraq and Afghanistan, and the diversity of potential future military operations, the deficiency of General Practitioner(GP)-led care in the deployed setting has become more evident, and this has driven the requirement for a deployable primary care facility in the form of a Medical Reception Station (MRS). This paper describes the evolution of this project, the realities of deploying a new medical capability for the first time, some of the issues faced, and the potential utility of such a medical facility in future.

Winter Deployment 14 and 15: an audit of injury and illness rates in an Arctic environment.

INTRODUCTION: Arduous military training in a cold weather environment is likely to lead to a variety of injuries to the population at risk (PAR). This paper examines injury rates and medical presentations over the two years of Winter Deployments in 2014 and 2015 (WD14 and WD15) and proposes recommendations for future WDs. METHODS: Data on injury rates, number of aeromedical evacuations, and number of days of restricted duties allocated were collected prospectively for all patients presenting to Asegarden Medical Centre, Norway, during WD14 and WD15. The data were calculated as a percentage of the total PAR on each deployment to allow meaningful comparison. RESULTS: During WD14, 22.8% of the PAR presented to the Medical Centre compared to 26.9% during WD15. WD15 saw a reduction in the presentation of musculoskeletal (MSK) injuries, cold weather (CW) injuries and burns. Skin problems and diarrhoea and vomiting (D&V) remained similar in both years. An increase in dental and other presentations was seen in WD15. A reduction in the overall aeromedical evacuations and number of patients requiring a light duties (LD) chit was seen during WD15. CONCLUSION: WD15 has seen a decrease in injury rates, the number of aeromedical evacuations and LD chits issued. It is difficult to know whether these changes are a result of improved medical support, training or equipment. The liaison between the command, medical and training elements has led to improvements and should now concentrate on ways to further reduce injury rates whilst maximising arduous training benefits in an Arctic environment.

New Joiners Routine (NJR) - a novel screening tool in military primary care.

INTRODUCTION: This paper describes and audits a novel method of health care screening in a military setting and questions the validity of the current PULHHEEMS system. The system involves screening patients at entry into an establishment with the aim of making them fit for task. METHODS: A retrospective DMICP case note review was conducted over 3 months following the introduction of the NewJoiners Routine (NJR), to assess the level of positive screening findings, and the number of medical interventions that resulted from this screening. Key Performance Indicators (KPIs) were also assessed during the time frame of the audit. RESULTS: 131/194 (67.5%) had an unmet health need/ positive screening finding. This led to 66 medical interventions in 54 (25.7%) patients. KPIs during this period were markedly improved. DISCUSSION: Although not conclusive, this audit strongly suggests an improvement in culture in making personnel fit for task, and reflects the medical evidence of moving away from asymptomatic periodic health screening to targeted health screening.

Attendance at iron deficiency anaemia clinic: audit of outcomes 5 years on.

AIM: To determine the long-term outcomes of patients in whom no initial cause for their anaemia is established. METHOD: Six hundred and thirty-nine patients presenting to an iron deficiency anaemia pathway were prospectively entered onto a database. Initial assessment included haematological review, coeliac screen, oesophagogastroduodenoscopy and colonic imaging as per British Society of Gastroenterology guidelines. A 5-year audit of outcomes was undertaken using patient medical records and hospital laboratory databases. RESULTS: A diagnosis was found initially in 266 (42%) patients, with 124 (19%) having a gastrointestinal (GI) luminal neoplasm, 54 (8%) of which were malignant. Twelve patients had a nonluminal or non-GI malignancy. Eighty-eight (14%) had benign upper GI bleeding and 23 (4%) had coeliac disease. One hundred and forty-three (22%) did not have confirmed iron deficiency anaemia on review of haematinics. Complete records were available for 595 (93%) patients at 5 years. Of the 373 patients in whom a cause was not initially diagnosed, 6 (2%) were ultimately diagnosed with a GI luminal malignancy and 18 (5%) with a nonluminal or non-GI malignancy. There was no difference in the incidence of malignancies between those with or without confirmed iron deficiency. CONCLUSIONS: Most patients in whom no cause was found at initial investigation resolve on oral iron supplements. Patients with normal ferritin values had as high an incidence of GI malignancies as those with low values and should be investigated. In the over 50s if the anaemia remains after a course of iron further investigation is recommended as there is a significant incidence of both GI and non-GI pathology.

Sustained correction of OTC deficiency in spf( ash) mice using optimized self-complementary AAV2/8 vectors.

Ornithine transcarbamylase deficiency (OTCD) is the most common inborn error of urea synthesis. Complete OTCD can result in hyperammonemic coma in the neonatal period, which can rapidly become fatal. Current acute therapy involves dialysis; chronic therapy involves the stimulation of alternate nitrogen clearance pathways; and the only curative approach is liver transplantation. Adeno-associated virus (AAV) vector-based gene therapy would add to current treatment options provided the vector delivers high level and stable transgene expression in liver without dose-limiting toxicity. In this study, we employed an AAV2/8-based self-complementary (sc) vector expressing the murine OTC (mOTC) gene under a liver-specific thyroxine-binding globulin promoter and examined the therapeutic effects in a mouse model of OTCD, the spf (ash) mouse. Seven days after a single intravenous injection of vector, treated mice showed complete normalization of urinary orotic acid, a measure of OTC activity. We further improved vector efficacy by incorporating a Kozak or Kozak-like sequence into mOTC complementary DNA, which increased the OTC activity by five or twofold and achieved sustained correction of orotic aciduria for up to 7 months. Our results demonstrate that vector optimizations can significantly improve the efficacy of gene therapy.

Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience.

INTRODUCTION: Perineal wound breakdown with delayed wound healing represents a significant cause of morbidity following surgery and radiotherapy to the perineum. The rectus abdominis myocutaneous (RAM) flap has been used increasingly to reconstruct the perineum with good effect. We describe our six-year experience of reconstruction of the perineum with the RAM flap and share some surgical adjuncts we believe are useful. METHODS: We conducted a retrospective case note review of all patients who underwent a reconstruction of the perineum using the RAM flap between August 2003 and October 2009. Indications for the flap, complication rates and outcomes were all observed. RESULTS: We conducted 16 RAM flap procedures, 15 of which (94%) were primary repairs and 1 (6%) a secondary repair. Three (19%) developed donor site hernias, two (12.5%) developed minor perineal wound infections, eight (50%) developed minor perineal wound breakdown and in one (6%) flap failure was observed. No perineal hernias were observed. There were no surgical mortalities. CONCLUSIONS: The RAM flap has a high success rate and an acceptable morbidity rate and is a useful tool in the reconstruction of complex perineal wounds. Modifications to the standard surgical technique may reduce complications and improve the versatility of this flap.

T1 hyperintense vertebral column melanoma metastases.

We report a case of T1 hyperintense vertebral column metastatic disease in a 24-year-old man with metastatic melanoma. Radiologic work-up revealed multiple lytic vertebral metastases on CT with corresponding T1 hyperintensity on MR imaging. Whereas T1 hyperintensity associated with melanoma has been well documented, to our knowledge, this is the first described case of widespread T1 hyperintense metastatic bone disease. T1 hyperintense bone lesions are virtually always benign. However, correlation with the lesion appearances on other MR imaging sequences and imaging modalities as well as with the clinical history may occasionally suggest otherwise.

Mesenteric panniculitis versus pancreatitis: a computed tomography diagnostic dilemma.

A case of mesenteric panniculitis is described in a patient with CT features mimicking pancreatitis. Emphasis is on the important CT features for accurate diagnosis.

A retrospective analysis of the effect of contrast-enhanced CT on the outcome of acute pancreatitis.

OBJECTIVES: Contrast CT is widely used to assess the severity of acute pancreatitis. Recently, studies in rats have shown that the administration of i.v. contrast material worsens the outcome of experimental acute pancreatitis. The aim of the current study was to determine if an effect of the administration of i.v. contrast could be identified in clinical acute pancreatitis. METHODS: Charts from the University of Kentucky Hospital from 1992 with an ICD-9 code of acute pancreatitis were reviewed. APACHE II scores at diagnosis of pancreatitis were calculated for all patients. The duration of clinical pancreatitis was determined from the date of onset of pain to the date of resolution of pain and resumption of oral nutrition. Contrast CT and noncontrast groups were compared using a Mann-Whitney rank sum test. RESULTS: There was no significant difference in the original APACHE II scores between the two groups. The contrast CT group had a mean duration of clinical pancreatitis of 10.8 days versus 6.2 days for the non-CT group (p = 0.004). CONCLUSIONS: This retrospective study supports the conclusions of recent animal studies that suggest that i.v. contrast might worsen or prolong attacks of acute pancreatitis.

Hypersea and the land ecosystem.

The land ecosystem, in spite of its relative youth, outstrips the marine ecosystem in terms of greater primary productivity and species diversity per unit area. This occurs because land eukaryotes actively direct the flow of nutrient-rich fluids. The body fluids of land eukaryotes have had a significant evolutionary and geochemical impact, and we here refer to these fluids, and the organisms through which they flow, as 'Hypersea'. Hypersea is a previously unrecognized biogeophysical entity formed by eukaryotic life and its symbionts, parasites and hyperparasites on land. The oldest convincing evidence for Hypersea consists of fossil tracheophytes, mycorrhizal fungi, and protoctists displaying intimate ecological interactions in the Lower Devonian Rhynie Chert (approx. 400 million years old), just older than the first major coal deposits. We use the concept of hypermarine upwelling to help explain both (a) the genesis of coal and (b) why the average species diversity per unit area and biomass production of the land biota has exceeded that of the marine biota for hundreds of millions of years.

Production of immunoreactive chorionic gonadotropin during mixed lymphocyte reactions: a possible selective mechanism for genetic diversity.

Maternal immunologic recognition of the blastocyst as well as the hormone chorionic gonadotropin (CG) has been shown to be a requirement for successful implantation of the blastocyst and maintenance of the fetal graft. On the basis of these observations, we tested whether lymphocytes could produce chorionic gonadotropic-like hormones during a mixed lymphocyte reaction (MLR). Here we described the production of immunoreactive chorionic gonadotropin (ir-CG) as a result of an allogeneic stimulus but not other mitogenic stimuli. The kinetics of production, as monitored by immunofluorescence with antibody specific to the beta chain of the human CG (hCG) molecule, paralleled the blastogenic response. Gel filtration of the de novo-synthesized ir-CG showed the molecular weight of the intact molecule to be approximately 58,000. This molecule bound to a concanavalin A affinity column and also dissociated into two subunits of approximate molecular weights 32,000 and 18,000. These molecular weights are consistent with reported molecular weights for glycosylated intact hCG, as well as the beta and alpha chains of hCG, respectively. The material from the MLR but not the control cultures elicited significant testosterone production from Leydig cells, and this activity could be blocked by antiserum to hCG. The results described here, together with the fact that the blastocyst is implanted in a lymphocyte infiltrate, lend support to our postulate that lymphocyte-derived CG enhances successful implantation of the allogeneic fetus, thus providing a mechanism for selection of genetic diversity.

Lymphocyte production of endorphins and endorphin-mediated immunoregulatory activity.

The immune and neuroendocrine systems appear able to communicate with each other by virtue of signal molecules (hormones) and receptors common to both systems. This review summarizes our data concerning the production of one type of neuroendocrine hormone, endorphins (END), by stimulated lymphocytes. The induction by various agents and structural characterization are described, as well as the lymphocyte-derived END's potential role as a mediator of endotoxic shock. Also discussed is the ability of pituitary-derived END and the related enkephalins to inhibit a primary in vitro antibody response. These activities are discussed in the context of a complete regulatory circuit between the immune and neuroendocrine systems.

Peptide hormones shared by the neuroendocrine and immunologic systems.

While numerous studies have demonstrated that the neuroendocrine system can control immune functions, it is only now becoming apparent that the control is reciprocal in that the immune system can control neuroendocrine functions. In this paper, recent studies which seem to provide a molecular basis for this bidirectional communication are reviewed. These studies suggest that the immune and neuroendocrine systems represent a totally integrated circuit by virtue of sharing a common set of hormones, such as corticotropin, thyrotropin, and endorphins, and their receptors. Possible hypothalamic and immunologic controls of this circuitry are discussed.

Bacterial lipopolysaccharide induction of leukocyte-derived corticotropin and endorphins.

Previous reports have shown that there is an endogenous opioid component associated with pathophysiological responses to endotoxin. It has been shown that these responses are alleviated by naloxone, a specific opiate antagonist. Results of another study have indicated that leukocytes may mediate some of those responses since leukocyte depletion alleviated the effects of lipopolysaccharide. In view of the above reports as well as the finding that leukocytes produce immunoreactive (ir-) endorphins and corticotropin (ACTH) when stimulated with Newcastle disease virus or ACTH-releasing factor, we postulated that leukocytes may serve as an extrapituitary source of endorphins produced in response to bacterial endotoxin. To test this hypothesis, human peripheral blood leukocytes as well as mouse spleen cells were cultured in vitro with Escherichia coli lipopolysaccharide for 48 h. The lipopolysaccharide (i.e., endotoxin) was shown to induce de novo synthesis of ir-ACTH and ir-endorphins. The leukocyte-derived ir-ACTH had a molecular weight of approximately 2,900 and demonstrated a bioactivity similar to that of pituitary-derived ACTH. The lymphocyte-derived ir-endorphin comigrated with alpha- and gamma-endorphin at approximately 1,800 daltons and was shown to bind to brain opiate receptors. These findings imply that leukocyte-derived endorphins may be involved in the pathophysiological response to endotoxin.