Bmj Military Health最新文献

Introduction: Renal calculi are the predominant urological ailment in air force pilots. Flexible ureteroscopy (FURS) constitutes a valuable approach for renal calculi treatment. This study presents a decade-long exploration of using FURS for renal calculi treatment in air force pilots. Additionally, it investigates the safety and feasibility of granting waiver flights to pilots with renal parenchyma calcification.

Methods: From December 2009 to December 2019, a retrospective review was conducted on Chinese air force pilots undergoing treatment for renal calculi. Among the pilots assessed, a total of 71 individuals underwent FURS. Endoscopic methodology involved the insertion of a flexible ureteroscope into the ureter and renal pelvis, guided by a safety wire. Stone fragmentation was achieved using a holmium laser fibre, followed by extraction using a soft stone basket. Postoperative non-enhanced CT (NECT) scans was used to confirm stone clearance. Furthermore, clinical diagnoses were classified based on endoscopic findings and postoperative NECT results. All data were presented as mean (SD) or median (minimum-maximum) for continuous variables and frequency counts and percentages for categorical variables.

Results: FURS identified free kidney stones in 60 cases among all patients. The remaining 11 cases, without free stones detected during ureteroscopy, exhibited persistent high-density spots on postoperative NECT. Of the 60 cases with stones, renal calculi were successfully cleared in 30 pilots, while the remaining 30 exhibited persistent high-density spots on NECT postsurgery. Pilots with completely cleared free stones were deemed fit for flight. Pilots with diagnosed renal parenchyma calcification were granted permission to fly under waivers following a meticulous evaluation.

Conclusions: FURS could not only effectively eliminate renal calculi but also accurately diagnose renal parenchyma calcification, facilitating a prompt return to flight for pilots. A protocol for managing pilot renal calculi, informed by FURS and our experience, is proposed.

Introduction: Morbidity and mortality from pelvic ring injuries can be mitigated by early and effective external pelvic stabilisation. The field-expedient pelvic splint (FEPS) is a recently described technique to improvise an effective pelvic binder for an austere environment. This technique has not been biomechanically validated. We hypothesise that the FEPS will be biomechanically equivalent to a commercially available pelvic binder routinely used in the austere environment.

Methods: Compressive force generation of the FEPS was measured using a commercial load frame. A SAM Pelvic Sling was used as a control. The FEPS was tested for initial force generation, persistence of force generation over a 6-hour longitudinal test period and force generation after repeated assembly/disassembly.

Results: The FEPS generated 203N (±7N) with one windlass turn and 420N (±34N) with two windlass turns. The SAM Pelvic Sling generated 197N (±11N) of force. There was no significant difference between FEPS after one windlass crank and the SAM Pelvic Sling but the force generated by the FEPS with two windlass cranks was significantly higher than the SAM Pelvic Sling. Longitudinal testing showed that after 6 hours of continuous compression, the FEPS generated 189N (±19N) and the force generated at hour 6 was not significantly different from the initial force generated by SAM Pelvic Sling. Reusability testing showed no significant difference with force generation by the FEPS after repeated assembly/disassembly with one crank of the windlass but there was a significantly increased force generation by FEPS after repeated use trials with two cranks of the windlass.

Conclusion: The FEPS exerted equivalent pelvic compressive forces to its commercial equivalent and this force generation persists at effective levels over a 6-hour time course. The FEPS remained effective after repeated use. The FEPS is a viable alternative in the austere or resource-limited environment for temporary pelvic stabilisation.

Introduction: The Diamedica Draw-over Vaporiser 2 (DDV2) is the sevoflurane vaporiser used by the UK Defence Medical Services to provide deployed volatile general anaesthesia. The Defence Anaesthesia System employs the DDV2 with a turbine-driven ventilator as a 'push-over' vaporiser, a modification from the manufacturer's design. We investigated sevoflurane delivery at varying minute volumes (MVs), vaporiser settings and temperatures in this configuration.

Methods: A range of DDV2 settings (1%, 2%, 3%, 4% and induction) and MVs (2, 4, 6 and 8 L/min at 12 ventilations per minute) were tested at two ambient temperatures (20 and 30±3°C) over 30 min. A supplemental experiment, simulating anaesthesia during damage control surgery, was also completed, where he DDV2 was set to 2% with a 6 L/min MV for 90 min.

Results: In both experiments, two distinct phases of sevoflurane delivery were noted, a 'wash-in phase' followed by a 'maintenance period'. The wash-in phase normally lasted less than 5 min. During the maintenance period at low MVs and vaporiser settings the DDV2 delivered a constant output, while at higher MVs and settings vapour output fell predictably. At 20±3°C, using DDV2 settings likely to be encountered in clinical practice, sevoflurane delivery was within 20% of that set. Higher vaporiser settings, MVs and temperatures resulted in greater variation between vaporiser setting and agent delivery. This variation is explained by the incomplete temperature compensation of the DDV2.

Conclusions: The DDV2 functions predictably at a range of settings, MVs and temperatures. Anaesthetic delivery in the defence anaesthesia configuration is like that previously described in the draw-over configuration. The equipment was found to be reliable and robust. This experimental work supports the continued use of the Defence Anaesthesia System for the delivery of and training in deployed general anaesthesia.

Introduction: Military personnel must manage a multitude of competing physiological and cognitive stressors while maintaining high levels of performance. Quantifying the external workload and cognitive demands of tactical military field exercises closely simulating operational environments, will provide a better understanding of stressors placed on personnel to inform evidence-based interventions.

Methods: Thirty-one soldiers completing a dismounted 48 hours tactical field exercise, participated in the study. External workload was quantified using a wrist-worn triaxial accelerometer, with cognitive function (Go-/No-Go, N-back, psychomotor vigilance task and subjective workload ratings (NASA-TLX) assessed pre-exercise, mid-exercise and postexercise. Physical activity was described using Euclidian Norm Minus One (mg), with moderate vigorous physical activity (MVPA) and sedentary light physical activity (SLPA) as ≥ or <113 mg, respectively. Changes in general cognitive performance (total accuracy-speed trade-off (ASTO) % change) and function outcome variables (overall mean reaction time, ASTO and number of correct and missed responses) were calculated for each assessment from pre-exercise, to mid-exercise and postexercise.

Results: For the exercise duration (50:12±02:06 hh:mm) participants spent more time completing SLPA compared with MVPA (1932±234 vs 1074±194 min; p<0.001), equating to 33% of the time spent completing MVPA. Overall cognitive performance decreased over the exercise (pre-to-post: -249). However, the largest decrement was observed pre-to-mid (-168). Perceived mental demand associated with the cognitive assessments significantly increased over the duration of the exercise (pre-: 33; mid-: 38 and post-: 51; χ² _F(2) = 26.7, p = <0.001, W=0.477) which could suggest that participants were able to attenuate a further decline in cognitive performance by investing more effort/mental resources when completing assessments.

Conclusion: The study successfully quantified the physical activity, and subsequent impact on cognitive function, in soldiers completing a 48 hours tactical field exercise. Further research is needed to better understand how physiological stressors interact with cognitive function during military operations.

Introduction: Musculoskeletal injury is one of the leading causes of medical discharge in the UK Armed Forces. Residential rehabilitation (RR) courses are part of Defence rehabilitation, for service personnel (SP) who do not respond to treatment at primary care. Historically, it was delivered as a 3-week block model. As a quality improvement project, rolling admissions were introduced aiming to improve access to RR and deliver outcomes that met the requirements of primary care referrers.

Method: Clinical outcomes were assessed for SP with either spinal or lower limb pathology using the Musculoskeletal Health Questionnaire (MSK-HQ) on course admission and discharge and the Medical Deployment Standard (MDS) on admission and 6 months post course. Wait times were also recorded. Outcomes were compared with the block admission using retrospective audit data. Referrer feedback was gathered using a questionnaire pre introduction and post introduction of rolling admissions.

Results: Rolling admissions reduced course wait times from an average of 55 days to 19 days. Of SP who attended a rolling admission course with spinal pathology (n=23), 58% showed an increase in MDS, 65% showed an increase of the minimally important change in MSK-HQ. With lower limb pathology (n=35) 57% increased MDS, 49% increased MSK-HQ. For the block model, of those with spinal pathology (n=30) 43% increased MDS, 67% increased MSK-HQ, with lower limb pathology (n=30) 60% increased MDS, 33% increased MSK-HQ. Referrer feedback improved with rolling admissions with feedback most positive in relation to the model's responsiveness for admitting SP onto the course.

Conclusion: Rolling admission provided similar clinical outcomes as the previous block model in a shorter time frame with lower wait times and better met the needs of referrers. Future study recommendations include longer term follow-up and looking at alternative ways to measure the success of RR within the care pathway.

While there are women represented in some notable positions within the UK Defence Medical Services (DMS), the challenges and barriers to successful female progression have not disappeared. The DMS needs highly talented, motivated doctors working to support operations, yet we struggle to recruit and retain female personnel. This is in clear contrast to the increased proportion of female personnel working within the civilian medical workforce.This article seeks to communicate this problem, illustrated by the lived experiences of DMS female doctors, by exploring the six gender bias barriers ('Glass Walls') that hold women back in the workplace.Cultural change requires a determined effort, driven persistently from the top and at every level of leadership and management. The first step requires recognition and acceptance of the problem. Progress is likely to be slow, or fail, if driven by the female minority alone. While the DMS remains a majority-male organisation, male allies are pivotal in advocating for their female colleagues, to promote change, in an effort to recruit and retain talented individuals.