Coronary artery calcium scoring vs. coronary CT angiography for the assessment of occupationally significant coronary artery disease.

BACKGROUND: Existing pathways for investigating coronary artery disease (CAD) in individuals undertaking high-hazard employment are currently guided by coronary artery calcium scoring (CACS) or coronary CT angiography (CTA). The optimal pathway has not been established. AIM: To compare the diagnostic outcome and occupational recommendations from two differing investigative pathways for the investigation of CAD in a cohort of high-hazard employees. METHODS: We collected CACS and coronary CTA data from three clinics across two Hospitals on 200 consecutive individuals employed in high-hazard occupations to confirm/exclude occupationally significant CAD. High-hazard occupations were grouped into civil/military pilots and aircraft controllers (n â€‹= â€‹106); non-pilot aircrew (NPA) (n â€‹= â€‹26); and ground-based (military) personnel (GBP) (n â€‹= â€‹52). Demographics, referral indications and recommended occupational outcomes between pathways were compared between groups. RESULTS: The CACS pathway led to more than double the number of individuals being returned to partial or full employment, compared with the coronary CTA pathway (OR 2.10, [95%CI 1.54-2.85], P â€‹< â€‹0.001). This effect was seen in all sub-groups. Of the 177 subjects that would have been returned to full employment using CACS, 21 (11.9%) would have been occupationally restricted on the basis of significant non-calcified plaque disease using coronary CTA (11.4% pilots/controllers; 19.2% non-pilot aircrew, and 7.7% ground-based personnel). CONCLUSION: Using CACS to determine the presence of occupational CAD risks returning individuals to roles with occupationally significant CAD that may lead to an unacceptably high likelihood of an incapacitating/distracting acute coronary event. Coronary CTA appears to be a more reliable, non-invasive imaging modality for confirming or excluding occupationally significant CAD in high-hazard employees.

Aeromedical evacuation: experiences from the UK military level 2 hospital in Bentiu, South Sudan, during Op TRENTON.

INTRODUCTION: Aeromedical Evacuation (AE) is a vital role of the Defence Medical Services (DMS). With a far-reaching defence global footprint, an AE capability is crucial to enable movement of patients in the fastest, safest and least stressful way that meets or exceeds the level of care an injured or ill person may expect to receive in the UK. Operation (Op) TRENTON is a UK military humanitarian operation in support of the United Nations (UN) Mission in South Sudan. METHODS: A retrospective analysis was carried out of all patients who underwent AE from the UK level 2 hospital at Bentiu during Op TRENTON over a 17-month period from June 2017 to October 2018. RESULTS: 14 patients underwent AE. The median age was 36 (22-64) years and all patients were male. 21% of AEs were for UK personnel and 79% were for UN personnel. 29% of AEs were due to non-battle injury with the remainder due to disease. Musculoskeletal was the largest diagnostic group (n=4) followed by respiratory (n=3), cardiovascular (n=2), undifferentiated febrile illness (n=2), neurology (n=1), renal medicine (n=1) and psychiatry (n=1). CONCLUSIONS: Patients requiring AE from the level 2 hospital at Bentiu mostly had musculoskeletal and medical pathology, a stark contrast to the trauma patient cohort from operations in the past. The majority of patients had definitive care under the medical team highlighting the requirement for DMS physicians and the AE team, to be trained in acute, general and aviation medicine. The majority of AE moves were for UN personnel and on UN airframes, highlighting the importance of a sound understanding of the nations we are working with.

The great escape? The rise of the escape room in medical education.

Medical education has changed focus to a more learner-centred model, placing learners at the centre of innovations in training. The escape room is one such innovative learner-focused activity, in which a team of players cooperatively discover clues, solve puzzles and complete tasks in order to progress through the challenge to achieve a specific goal. Escape rooms can be used in medical education as a tool for team building, an entertaining way of delivering technical and non-technical skills, to read and acquire or refresh knowledge, as well as for educational research. Despite appearing to be a superficial form of entertainment, escape rooms can be grounded in sound educational theory and, when used effectively, act as a low-cost, high-impact resource for a variety of learners. While escape rooms may well be an example of yet another educational 'fad' demonstrating the rising influence of 'Millennial MedEd', it signals a promising shift to more learner-centred, team-based methods which are essential to the practice of safe modern healthcare during the current COVID-19 pandemic and beyond.

Getting to the heart of the matter: investigating the idiopathic sudden cardiac death of a previous well soldier.

A 25-year-old infantry soldier, who was previously fit and well, had a cardiac arrest while undertaking an advanced fitness test. Despite early cardiopulmonary resuscitation by colleagues and the emergency services, he was later pronounced dead. A postmortem performed by an expert pathologist and a toxicology screen were normal and the death was attributed to sudden arrhythmic death syndrome (SADS). Screening of his family in our Inherited Cardiac Conditions clinic identified Brugada syndrome (BrS) in two first-degree relatives. This case generates discussion on sudden cardiac death, family screening in SADS, BrS and the limitations of recruit screening with an ECG.

Apical hypertrophic cardiomyopathy: what are the risks in our diverse military population?

We present the case of a 50-year-old, fit, asymptomatic gurkha officer. At a routine medical, an ECG showed T-wave inversion in the chest leads V3-6. Transthoracic echo showed left ventricular apical hypertrophy and cavity obliteration consistent with apical hypertrophic cardiomyopathy (ApHCM). Cardiac magnetic resonance imaging showed apical and inferior wall hypertrophy in the left ventricle with no aneurysm or scarring. A 24-hour monitor showed normal sinus rhythm with no evidence of non-sustained ventricular tachycardia. Eighteen-panel genetic testing revealed no specific mutations. Cardiopulmonary exercise testing demonstrated a V̇O2 max, anaerobic threshold and peak V̇O2 consistent with above average cardiopulmonary capacity. There was no family history of either ApHCM or sudden cardiac death (SCD). Risk of SCD by the European Society of Cardiology's HCM calculator was low. This case generates discussion on the prognosis of ApHCM, factors that worsen prognosis, occupational limitation considerations and appropriate monitoring in this patient group.

Role of bispectral index monitoring and burst suppression in prognostication following out-of-hospital cardiac arrest: a systematic review protocol.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is associated with significant mortality or may have a poor neurological outcome. Various community-training programmes have improved practices like bystander cardiopulmonary resuscitation (CPR) and early defibrillation using automated external defibrillator (AED). Post-resuscitation care has also changed significantly in the millennium. Interventions like targeted temperature management (TTM), avoidance of hyperoxia and emergency cardiac catheterisation have given patients a chance of a better neurological outcome. Despite these timely interventions, it is still very difficult to predict neurological outcome. The European Resuscitation Council and European Society of Intensive Care Medicine (ERC-ESICM) published guidance in 2015 with a strong recommendation to delay prognostication for at least 72 h and with an emphasis to adapt a multimodal approach, which includes neurological examination, biomarkers, electroencephalogram (EEG) and radiological tests. These interventions not only have cost attached to them, but the unpredictability has a significant emotional impact on family members. Bispectral index (BIS) monitoring device acts on the principle of EEG and converts the waveform into an absolute number and also measures the burst suppression. We hypothesize that patients who have a low BIS value and high burst suppression within 24 h of presentation will have a poor neurological outcome. The primary objective of this review is to look at BIS monitor as a tool, which could help bring forward the timing of prognostication. METHODS: Electronic databases will be systematically searched for randomised controlled trials and prospective or retrospective cohort studies with no language restrictions. The search will be supplemented with grey literature searches of thesis, dissertations and hand searching of relevant journals. Two independent reviewers will screen, select and perform analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) method. The selected studies will be analysed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system. Meta-analysis will be performed if suitable. DISCUSSION: This review will synthesize the evidence on the use of BIS monitors within 24 h of achieving return of spontaneous circulation (ROSC) and may help in early prognostication. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD 42016050224 .