Showing papers in "Journal of the Royal Army Medical Corps in 2019"

Case series of non-freezing cold injury: epidemiology and risk factors

Abstract: Background Non-freezing cold injury (NFCI) occurs when the peripheral tissue is cooled sufficiently that damage occurs, but not to the point of tissue freezing. Historically, the phenotype of the injuries studied was often severe, and it is unclear whether knowledge gained from these cases is entirely relevant to the frequently subtle injuries seen today. Methods We therefore sought to characterise a recent case series of 100 patients referred with suspected NFCI to a military UK NFCI clinic. Their demographics, medical history and situational risk factors leading to their injuries were analysed, and comparison was made between those subsequently diagnosed with NFCI (n=76) and those receiving alternate diagnoses (n=24). Results Statistically significant predisposing factors for NFCI in the UK service personnel (SP) were being of African-Caribbean ethnicity and having a short duration of service in the Armed Forces. Past or current smoking was not identified as a risk factor. Injuries were almost always suffered on training exercises (most commonly in the UK); being generally cold and being on static duties were statistically significant situational risk factors. Non-significant trends of risk were also found for having wet clothing, wet boots and immersion. Self-reported dehydration was not found to be a risk factor for NFCI. Conclusions Our demographic findings are in general agreement with those of previous studies. Our situational risk factor findings, however, highlight a pattern of NFCI risk factors to the modern UK SP: winter training exercises, when troops are generally cold and extremities often wet, with static duties frequently implicated in the disease mechanism.

Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield.

Abstract: Objectives Catastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents in the laboratory but few in a clinical setting. This study analyses the use of haemostatic dressings used in patients injured on the battlefield and their association with survival. Method A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry from 2003 to 2014, during combat operations in Iraq and Afghanistan. Data included patient demographics, the use of haemostatic dressings, New Injury Severity Score (NISS) and patient outcome. Results Of 3792 cases, a haemostatic dressing was applied in 317 (either Celox, Hemcon or Quickclot). When comparing patients who had a haemostatic dressing applied versus no haemostatic agent, there was a 7% improvement in survival. Celox was the only individual haemostatic dressing that was associated with a statistically significant improvement in survival, which was most apparent in the more severely injured (NISS 36–75). Conclusion We have shown an association between use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox. This supports the continued use of haemostatic agents as part of initial haemorrhage control for patients injured in conflict and suggests that civilian organisations that may need to deal with patients with similar injury patterns should consider their use and implementation.

Pathophysiology of primary blast injury.

Abstract: The majority of patients injured in the recent conflicts in Iraq and Afghanistan were as a result of explosion, and terrorist incidents have brought blast injuries to the front door of many civilian hospitals that had not previously encountered such devastation. This article reviews the physics and pathophysiology of blast injury with particular relevance to the presentation and management of primary blast injury, which is the mechanism least familiar to most clinicians and which may cause devastating injury without externals signs.

Experimental platforms to study blast injury

Abstract: Injuries sustained due to attacks from explosive weapons are multiple in number, complex in nature, and not well characterised. Blast may cause damage to the human body by the direct effect of overpressure, penetration by highly energised fragments, and blunt trauma by violent displacements of the body. The ability to reproduce the injuries of such insults in a well-controlled fashion is essential in order to understand fully the unique mechanism by which they occur, and design better treatment and protection strategies to alleviate the resulting poor long-term outcomes. This paper reports a range of experimental platforms that have been developed for different blast injury models, their working mechanism, and main applications. These platforms include the shock tube, split-Hopkinson bars, the gas gun, drop towers and bespoke underbody blast simulators.

Vascular access training for REBOA placement: a feasibility study in a live tissue-simulator hybrid porcine model

Abstract: Background The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with severe haemorrhagic shock is increasing Obtaining vascular access is a necessary prerequisite for REBOA placement in these situations Methods During the EVTM workshop (September 2017, Orebro, Sweden), 21 individuals participated in this study, 16 participants and five instructors A formalised curriculum was constructed including basic anatomy of the femoral region and basic training in access materials for REBOA placement in zone 1 Key skills: (1) preparation of endovascular toolkit, (2) achieving vascular access in the model and (3) bleeding control with REBOA Scoring ranged from 0 to 5 for non-anatomical skills Identification of anatomical structures was either sufficient (score=1) or insufficient (score=0) Five consultants performed a second identical procedure as a post test Results Consultants had significantly better overall technical skills in comparison with residents (p=0005), while understanding of surgical anatomy showed no difference Procedure times differed significantly (p Conclusion This comprehensive training model using a live tissue-simulator hybrid porcine model can be used for femoral access and REBOA placement training in medical personnel with different prior training levels Higher levels of training are associated with faster procedure times Further research in open and percutaneous access training is necessary to simulate real-life situations This training method can be used in a multistep training programme, in combination with realistic moulage and perfused cadaver models

Guidelines for using animal models in blast injury research.

Abstract: Blast injury is a very complex phenomenon and frequently results in multiple injuries. One method to investigate the consequences of blast injuries is with the use of living systems (animal models). The use of animals allows the examination and evaluation of injury mechanisms in a more controlled manner, allowing variables such as primary or secondary blast injury for example, to be isolated and manipulated as required. To ensure a degree of standardisation across the blast research community a set of guidelines which helps researchers navigate challenges of modelling blast injuries in animals is required. This paper describes the guidelines for Using Animal Models in Blast Injury Research developed by the NATO Health Factors and Medicine (HFM) Research Task Group 234.

In-vitro study of species-specific coagulation differences in animals and humans using rotational thromboelastometry (ROTEM)

Abstract: Animal tests are conducted in all fields of trauma research, but transferability of these data to humans is limited. For example, it is still unclear which animal species is most similar to humans in terms of physiology of blood coagulation. To improve transferability and raise awareness of the existing differences, we compared human coagulation to coagulation of different animals. Rotational thromboelastometry was used to analyse the blood of pigs, sheep, rabbits and dogs. Animal data were compared with human coagulation based on the number of significant differences of the test parameters and on a descriptive comparison of the extent of relative deviation of the single values. All animal species showed significant differences in coagulation properties when compared with humans. Coagulation parameters of dogs and sheep were on average most similar to humans. However, there is no animal which is most similar to humans concerning all aspects of coagulation. Differences in coagulation between humans and animals are significant. This must be taken into account when transferring animal test data to humans.

From Northern Ireland to Afghanistan: half a century of blast injuries

Abstract: Introduction Throughout the last half century, blast injuries have been a common occurrence to UK military personnel during combat operations. This study investigates casualty data from three different military operations to determine whether survivability from blast injuries has improved over time and whether the tactics used could have influenced the injuries sustained. Methods Casualty data from operations in Northern Ireland, Iraq and Afghanistan were reviewed and found to contain a total of 2629 casualties injured by improvised explosive devices. The injury severities were examined and the suitability of comparison between conflicts was considered. Results The case fatality rate and mean severity score sustained remained consistent among the operations included in this study. Using the New Injury Severity Score, the probabilities of survival were calculated for each separate operation. The body regions injured were identified for both fatalities and survivors. Using this information, comparisons of injury severities sustained at an Abbreviated Injury Scale of 3 and above (identified as a threshold for fatal injury) were conducted between the different operations. Conclusions The data showed that as operations changed over time, survivability improved and the proportions of body regions injured also changed; however, this study also highlights how studying casualty data from different conflicts without taking account for the contextual differences may lead to misleading conclusions.

Nursing and medical contribution to Defence Healthcare Engagement: initial experiences of the UK Defence Medical Services

Abstract: Introduction The WHO Constitution enshrines ‘…the highest attainable standard of health as a fundamental right of every human being.’ Strengthening delivery of health services confers benefits to individuals, families and communities, and can improve national and regional stability and security. In attempting to build international healthcare capability, UK Defence Medical Services (DMS) assets can contribute to the development of healthcare within overseas nations in a process that is known as Defence Healthcare Engagement (DHE). Methods In the first bespoke DMS DHE tasking, a team of 12 DMS nurses and doctors deployed to a 1000-bedded urban hospital in a partner nation and worked alongside indigenous healthcare workers (doctors, nurses and paramedical staff) during April and May 2016. The DMS nurses focused on nursing hygiene skills by demonstrations of best practice and DMS care standards, clinical leadership and female empowerment. A Quality Improvement Programme was initiated that centred on hand hygiene (HH) compliance before and after patient contact, and the introduction of peripheral cannula care and surveillance. Results After a brief induction on the ward, it was apparent that compliance with HH was poor. Peripheral cannulas were secured with adhesive zinc oxide tape and no active surveillance process (such as venous infusion phlebitis (VIP) scoring) was in place. After intensive education and training, initial week-long audits were undertaken and repeated after a further 2 weeks of training and coworking. In the second audit cycle, HH compliance had increased to 69% and VIP scoring compliance to 99%. In the final audit cycle, it was noted that nursing compliance with HH (75/98: 77%) was significantly higher than the doctors’ HH compliance (76/200: 38%); p Conclusions DHE is a long-term collaborative process based on the establishment and development of comprehensive relationships that can help transform indigenous healthcare services towards patient-centred systems with a focus on safety and quality of care. Short deployments to allow clinical immersion of UK healthcare workers within indigenous teams can have an immediate impact. Coworking is a powerful method of demonstrating standards of care and empowering staff to institute transformative change. A multidisciplinary group of Quality Improvement Champions has been identified and a Hospital Oversight Committee established, which will offer the prospect of longer term sustainability and development.

Effect of hyperbaric oxygen therapy and corticosteroid therapy in military personnel with acute acoustic trauma.

Abstract: Introduction Acute acoustic trauma (AAT) is a sensorineural hearing impairment due to exposure to an intense impulse noise which causes cochlear hypoxia. Hyperbaric oxygen therapy (HBO) could provide an adequate oxygen supply. The aim was to investigate the effectiveness of early treatment with combined HBO and corticosteroid therapy in patients with AAT compared with corticosteroid monotherapy. Methods A retrospective study was performed on military personnel diagnosed with AAT between November 2012 and December 2017. Inclusion criteria for HBO therapy were hearing loss of 30 dB or greater on at least one, 25 dB or more on at least two, or 20 dB or more on three or more frequencies as compared with the contralateral ear. Results Absolute hearing improvements showed significant differences (independent t-test) between patients receiving HBO and the control group at 500 Hz (p=0.014), 3000 Hz (p=0.023), 4000 Hz (p=0.001) and 6000 Hz (p=0.01) and at the mean of all frequencies (p=0.002). Relative hearing improvements were significantly different (independent t-test) at 4000 Hz (p=0.046) and 6000 Hz (p=0.013) and at all frequencies combined (p=0.005). Furthermore, the percentage of patients with recovery to the functional level required by the Dutch Armed Forces (clinical outcome score) was higher in the HBO group. Conclusions Early-stage combination therapy for patients with AAT was associated with better audiometric results at higher frequencies and better clinical outcome score.

Military Prehospital Emergency Care: defining and professionalising the levels of care provided along the Operational Patient Care Pathway

Abstract: The Defence Medical Services aims to provide gold standard care to ill and injured personnel in the deployed environment and its prehospital emergency care (PHEC) systems have been proven to save lives. The authors have set out to demonstrate, using existing literature, consensus and doctrine that the NHS Skills for Health framework can be reflected in military prehospital care and provides an existing model for defining the levels of care our providers can offer. In addition, we have demonstrated how these levels of care support the Operational Patient Care Pathway and add to the body of evidence for the use of specialist PHEC teams to allow the right patient to be transported on the right platform, with the right medical team, to the right place. These formalised levels allow military planners to consider the scope of practice, amount of training and appropriate equipment required to support deployed operations.

Energy availability and nutrition during a Special Force Qualification Course (Q-Course)

Abstract: Introduction The Special Forces (SF) are an elite military group usually engaged in physically demanding field operations, resulting among others in high daily energy requirements. Optimising energy supply and nutritional requirements is therefore mandatory for success. The aim of this study was to estimate energy availability and nutrition during a Qualification Course (Q-Course) for Belgian SF. Methods 21 participants recorded all foods and beverages consumed during four days in a structured food diary. Energy expenditure was measured with an accelerometer and fat mass measured with quadripolar impedance. Energy availability was calculated by the following formula: (energy intake by foods and beverages − energy expenditure for physical activity)/kg FFM/day (FFM, fat-free mass). Results The mean (SD) total energy expenditure was 4926 kcal/day (238), with a minimum of 4645 kcal/day and a maximum of 5472 kcal/day. The mean (SD) total energy consumption was 4186 kcal/day (842), giving an energy balance ranging from −2005 kcal/day to 1113 kcal/day. The mean (SD) energy availability was 17 kcal/kg FFM/day, with a minimum of 1 kcal/kg FFM/day and a maximum of 44 kcal/kg FFM/day. The mean (SD) intake of carbohydrates was 6.8 g/kg body weight/day (1.5). Conclusions During this studied Q-Course, energy intake was not optimal as demonstrated by an overall negative energy balance and low energy availability. High interindividual variations in energy intake were found, highlighting the importance of providing SF members nutritional education.

Guidelines for reproducing blast exposures in the laboratory

Abstract: Discussions at a NATO Health Factors and Medicine Symposium 207 (HFM-SYM-207) revealed the importance of a systematic approach to understanding blast injuries much like the well-established approach used to solve the classical toxicology problem where the aetiology of the injury requires an

Phosgene use in World War 1 and early evaluations of pathophysiology

Abstract: World War 1 ended 100 years ago. The aftermath included the consolidation of significant advances in medical care of casualties. Some of these advances were made in the care of chemical casualties, in particular the mechanisms of toxicity and treatment of phosgene exposure. Phosgene, or carbonyl chloride, is an extremely poisonous vapour that was used to devastating effect during World War 1. Observations made of acutely poisoned casualties formed the basis of much research in the early post-World War 1 era. Some extremely elegant experiments, some at the nascent Porton Down research facility, further evaluated the toxin and defences against it. Researchers drew on knowledge that was later forgotten and has since been relearnt later in the 20th century and made many correct assumptions. Their work is the bedrock of our understanding of phosgene toxicity that survives to this day. The horrors of chemical warfare prompted the Geneva Protocol of 1925, prohibiting the use of chemical agents in warfare, and chemical warfare on this scale has not been repeated. The ease with which phosgene can be synthesised requires healthcare providers to be familiar with its effects.

Passive-dynamic ankle-foot orthosis improves medium-term clinical outcomes after severe lower extremity trauma

Abstract: Introduction Individuals with delayed below-knee amputation have previously reported superior clinical outcomes compared with lower limb reconstruction. The UK military have since introduced a passive-dynamic ankle-foot orthosis (PDAFO) into its rehabilitation care pathway to improve limb salvage outcomes. The aims were to determine if wearing a PDAFO improves medium-term clinical outcomes and what influence does multidisciplinary team (MDT) rehabilitation have after PDAFO fitting? Also, what longitudinal changes in clinical outcomes occur with MDT rehabilitation and how do these results compare with patients with previous lower extremity trauma discharged prior to PDAFO availability? Methods We retrospectively evaluated levels of mobility, activities of daily living, anxiety, depression and pain in a heterogeneous group of 23 injured UK servicemen 34±11 months after PDAFO provision. We also retrospectively analysed 16 patients across four time points (pre-PDAFO provision, first, second and final inpatient admissions post-PDAFO provision) using identical outcome measures, plus the 6 min walk test. Results Outcomes were compared with previous below-knee limb salvage and amputees. Before PDAFO, 74% were able to walk and 4% were able to run independently. At follow-up, this increased to 91% and 57%, respectively. Mean depression and anxiety scores remained stable over time (p>0.05). After 3 weeks, all patients could walk independently (pre-PDAFO=31%). Mean 6 min walk distance significantly increased from 440±75 m (pre-PDAFO) to 533±68 m at last admission (p=0.003). The ability to run increased from 6% to 44% after one admission. Conclusions All functional and most psychosocial outcomes in PDAFO users were superior to previous limb salvage and comparable to previous below-knee amputees. The PDAFO facilitated favourable short-term and medium-term changes in all clinical outcome measurements.

Understanding the needs of veterans seeking support for mental health difficulties.

Abstract: Since the late 1990s, studies have been conducted in the UK to monitor the health and well-being of military personnel. The bulk of this work has been conducted by researchers at King’s College London, first after the 1991 Gulf War and then later by setting up a cohort study in the wake of the

Environment at the time of injury determines injury patterns in pelvic blast.

Abstract: The use of explosives by terrorists, or during armed conflict, remains a major global threat. Increasingly, these events occur in the civilian domain, and can potentially lead to injury and loss of life, on a very large scale. The environment at the time of detonation is known to result in different injury patterns in casualties exposed to blast, which is highly relevant to injury mitigation analyses. We describe differences in pelvic injury patterns in relation to different environments, from casualties that presented to the deployed UK military hospitals in Iraq and Afghanistan. A casualty on foot when injured typically sustains an unstable pelvic fracture pattern, which is commonly the cause of death. These casualties die from blood loss, meaning treatment in these should focus on early pelvic haemorrhage control. In contrast, casualties injured in vehicle present a different pattern, possibly caused by direct loading via the seat, which does not result in pelvic instability. Fatalities in this cohort are from injuries to other body regions, in particular the head and the torso and who may require urgent neurosurgery or thoracotomy as life-saving interventions. A different strategy is therefore required for mounted and dismounted casualties in order to increase survivors.

Do UK military General Practitioners feel adequately skilled in the provision of care to the acutely unwell or injured patient

Abstract: Background General Practice training in the civilian and military environments follows a common training pathway, yet the scope of practice of a military General Practitioner (GP) varies significantly. A level of care for the acutely unwell and traumatically injured patients is frequently provided in austere environments remotely located from definitive medical care. This qualitative service needs evaluation scopes current level of trauma and acute care training and requirement for further training within military GPs and GP trainees. The transition to contingency operations increases the likelihood of medical officers being deployed to remote, austere locations, and it remains important to be fully skilled to manage any acute medical or trauma situation. Aims and objectives The aim of this project is to identify how to maintain skills in prehospital and acute care within the military general practice. The specific objectives are (1) to assess the current level of training and experience across military GPs and military GP trainees in the domain of prehospital and acute competencies; (2) to assess satisfaction with the current level of training in these domains; (3) to assess the current deficiencies in training in this domain; and (4) to suggest possible changes or enhancements to the current military GP training pathway. Methods Qualitative data was collected using a combination of focus groups and semistructured interviews. An initial focus group gathered codes and concepts. A topic guide generated from the initial focus group informed six semistructured interviews. A final focus group was used for validation purposes. Data were analysed using the constructivist grounded theory approach. Concurrent observational data were also collected from military and civilian courses pertinent to the research topic. Results Focus groups (n=2, total participants=14) and semistructured interviews (n=6) suggest that military GPs and trainees feel their level of trauma and acute care training generally diminishes over time, with significant interservice variation, and is of generally a lower level than desired. Qualified GPs suggest that maintaining clinical currency in prehospital emergency care (PHEC) for short-notice deployments is difficult. Modification to the current military GP training programme and easier access to training courses are suggested as potential solutions to the perceived shortfall in training in these areas. Conclusions Prehospital care and care of the acutely unwell patient remain an area of significant anxiety within military primary care doctors. While most military GPs may not want or choose to spend much of their time exclusively managing trauma and acute care, it is accepted that there is a professional requirement to provide this level of care on a frequent basis. The study suggests that there is an appetite for a higher level of training, both within the military GP specialist training pathway and postqualification. Suggested solutions to this challenge include (1) modification of the current military general practice specialty trainee residential course and (2) modification of military GPs’ terms of reference to include PHEC experience during the working week.

Mental resilience training

Abstract: This paper will explain the concept behind mental resilience training (MRT) and how the training package was developed and implemented within the British ArmyInfantry Training Centre (ITC) Catterick between 2014 and 2016. MRT is a mindfulness-based psychological skills training package that integrates cognitive behavioural and mindfulness based principles and techniques, which have been proven to improve stress regulation, emotional and cognitive control and self-confidence in military personnel. MRT is based on an extensive evidence base that has demonstrated that psychological skills training delivers tangible improvements in performance in elite sport and in healthcare, business and military contexts. The initial trials at the ITC Catterick have delivered tangible improvements in infantry recruits’ use of psychological skills within real-life training contexts.

Fatal head and neck injuries in military underbody blast casualties.

Abstract: Introduction Death as a consequence of underbody blast (UBB) can most commonly be attributed to central nervous system injury. UBB may be considered a form of tertiary blast injury but is at a higher rate and somewhat more predictable than injury caused by more classical forms of tertiary injury. Recent studies have focused on the transmission of axial load through the cervical spine with clinically relevant injury caused by resultant compression and flexion. This paper seeks to clarify the pattern of head and neck injuries in fatal UBB incidents using a pragmatic anatomical classification. Methods This retrospective study investigated fatal UBB incidents in UK triservice members during recent operations in Afghanistan and Iraq. Head and neck injuries were classified by anatomical site into: skull vault fractures, parenchymal brain injuries, base of skull fractures, brain stem injuries and cervical spine fractures. Incidence of all injuries and of each injury type in isolation was compared. Results 129 fatalities as a consequence of UBB were identified of whom 94 sustained head or neck injuries. 87 casualties had injuries amenable to analysis. Parenchymal brain injuries (75%) occurred most commonly followed by skull vault (55%) and base of skull fractures (32%). Cervical spine fractures occurred in only 18% of casualties. 62% of casualties had multiple sites of injury with only one casualty sustaining an isolated cervical spine fracture. Conclusion Improvement of UBB survivability requires the understanding of fatal injury mechanisms. Although previous biomechanical studies have concentrated on the effect of axial load transmission and resultant injury to the cervical spine, our work demonstrates that cervical spine injuries are of limited clinical relevance for UBB survivability and that research should focus on severe brain injury secondary to direct head impact.

Deskilling and return to practice on low-tempo contingency operations.

Abstract: Recent UK Defence Medical Services operations involving large numbers of secondary care clinicians have included the United Nations Mission in South Sudan, support to the Global Ebola Response, and prolonged hospital deployment for medical cover of large exercises such as SAIF SAREEA and KHANJAR

Medical immunity, international law and just war theory.

Abstract: Under customary international law, the First Geneva Convention and Additional Protocol I, medical personnel are protected against intentional attack. In § 1 of this paper, we survey these legal norms and situate them within the broader international humanitarian law framework. In § 2, we explore the historical and philosophical basis of medical immunity, both of which have been underexplored in the academic literature. In § 3, we analyse these norms as applied to an attack in Afghanistan (2015) by the United States; the United States was attempting to target a Taliban command-and-control centre but inadvertently destroyed a Medecins Sans Frontieres hospital instead, killing 42 people. In § 4, we consider forfeiture of medical immunity and, more sceptically, whether supreme emergency could justify infringement of non-forfeited protected status.

Use of Web 2.0 tools and social media for continuous professional development among primary healthcare practitioners within the Defence Primary Healthcare: a qualitative review

Abstract: Introduction Alongside traditional attendance at learning, general practitioners use social media and Web 2.0 tools in the UK for continuous professional development (CPD). Research has demonstrated, however, barriers to their uptake and use, as well as a requirement for training. Primary care doctors working for the Defence Primary Healthcare (DPHC) use similar technologies, but it is not known what factors affect the uptake. This qualitative research aimed to explore the knowledge and attitudes of this demographic further. Methods An online questionnaire was distributed to DPHC doctors via email and a social networking service (SNS) tool. Questions included demographic and open free-text response boxes. These were subjected to thematic analysis to identify initial concepts subsequently grouped into categories. Results DPHC doctors are already using Web 2.0 and social media for education. The benefits of convenience are recognised, but protected time is required to maximise impact. They also identified attendance at learning events, better quality information technology (IT) and further training as important enablers for their CPD. Conclusions The results reaffirmed previous findings that while there is engagement with online learning and Web 2.0 technologies, training in Web 2.0 use and substandard IT infrastructure were barriers to greater uptake. Attended learning events are also popular due to the peer-to-peer networking that takes place, but also as they allow protected time out of the office. The use of Web 2.0 for CPD and of SNS should be given equal status to allow the development of a DPHC doctors’ ‘communityof practice’.

Military spouses with deployed partners are at greater risk of poor perinatal mental health: a scoping review

Abstract: Background Poor mental health in the perinatal period is associated with a number of adverse outcomes for the individual and the wider family. The unique circumstances in which military spouses/partners live may leave them particularly vulnerable to developing perinatal mental health (PMH) problems. Methods A scoping review was carried out to review the literature pertaining to PMH in military spouses/partners using the methodology outlined by Arksey and O’Malley (2005). Databases searched included EBSCO, Gale Cengage Academic OneFile, ProQuest and SAGE. Results Thirteen papers fulfilled the inclusion criteria, all from the USA, which looked a PMH or well-being in military spouses. There was a strong focus on spousal deployment as a risk factor for depressive symptoms and psychological stress during the perinatal period. Other risk factors included a lack of social/emotional support and increased family-related stressors. Interventions for pregnant military spouses included those that help them develop internal coping strategies and external social support. Conclusions US literature suggests that military spouses are particularly at risk of PMH problems during deployment of their serving partner and highlights the protective nature of social support during this time. Further consideration needs to be made to apply the findings to UK military spouses/partners due to differences in the structure and nature of the UK and US military and healthcare models. Further UK research is needed, which would provide military and healthcare providers with an understanding of the needs of this population allowing effective planning and strategies to be commissioned and implemented.

History of military psychology.

Abstract: Military psychology is a specialist discipline within applied psychology. It entails the application of psychological science to military operations, systems and personnel. The specialty was formally founded during World War I in the UK and the USA, and it was integral to many early concepts and interventions for psychological and neuropsychological trauma. It also established a fundamental basis for the psychological assessment and selection of military personnel. During and after World War II, military psychology continued to make significant contributions to aviation psychology, cognitive testing, rehabilitation psychology and many models of psychotherapy. Military psychology now consists of several subspecialties, including clinical, research and occupational psychology, with the latter often referred to in the USA as industrial/organisational psychology. This article will provide an overview of the origins, history and current composition of military psychology in the UK, with select international illustrations also being offered.

Psychology, risk, health and deployed military operations.

Abstract: This article will focus on a study by the UK Defence Science and Technology Laboratory (Dstl) which investigated the risk propensity and health behaviours of UK army personnel deployed to Iraq in 2007 as part of Op TELIC. The study addressed the concept of impulsive sensation seeking and how this interacted with health behaviours associated with alcohol, smoking, driving and sex at predeployment, during deployment and postdeployment, as well as perceptions of risk and psychological well-being. There is also a description of other deployment-related risk and health research and analysis undertaken by Dstl as part of a wider discussion on the nature of both risk and health on deployed operations.

Artificial intelligence and the radiologist: the future in the Armed Forces Medical Services

Abstract: Artificial intelligence (AI) involves computational networks (neural networks) that simulate human intelligence. The incorporation of AI in radiology will help in dealing with the tedious, repetitive, time-consuming job of detecting relevant findings in diagnostic imaging and segmenting the detected images into smaller data. It would also help in identifying details that are oblivious to the human eye. AI will have an immense impact in populations with deficiency of radiologists and in screening programmes. By correlating imaging data from millions of patients and their clinico-demographic-therapy-morbidity-mortality profiles, AI could lead to identification of new imaging biomarkers. This would change therapy and direct new research. However, issues of standardisation, transparency, ethics, regulations, training, accreditation and safety are the challenges ahead. The Armed Forces Medical Services has widely dispersed units, medical echelons and roles ranging from small field units to large static tertiary care centres. They can incorporate AI-enabled radiological services to subserve small remotely located hospitals and detachments without posted radiologists and ease the load of radiologists in larger hospitals. Early widespread incorporation of information technology and enabled services in our hospitals, adequate funding, regular upgradation of software and hardware, dedicated trained manpower to manage the information technology services and train staff, and cyber security are issues that need to be addressed.

Global health diplomacy and humanitarian assistance: understanding the intentional divide between military and non-military actors

Abstract: Often known as ‘globalhealth diplomacy’, the provision of medical care to accomplish strategic objectives, advance public diplomacy goals and enhance soft power is increasingly emphasised in international affairs and military policies. Despite this emergent trend, there has been little critical analysis and examination of the ethics of military actors engaging in this type of work. This type of mission represents the most common form of military medical deployment within the International Security Assistance Force in Afghanistan and is now explicitly emphasised in many militaries’ defence doctrine. The growth of these programmes has occurred with little analysis, examination or critique. This paper examines the history of global health diplomacy as directly related to humanitarian assistance, focusing on the difference in intention to highlight ethical dilemmas related to military involvement in the humanitarian sphere. The relationship between non-military humanitarian actors and military actors will be a focal point of discussion, as this relationship has been historically complicated and continues to shift. Relevant differences between these two groups of actors, their motivations and work will be highlighted. In order to examine the morally important differences between these groups, analysis will draw on relevant international doctrine and codes that attempt to provide ethical guidance within the humanitarian sphere.

Influenza syndromic surveillance and vaccine efficacy in the UK Armed Forces, 2017-2018.

Abstract: Introduction This paper describes the first ever analysis of health data to report influenza vaccine uptake and the effectiveness of the vaccine in preventing general practice presentations for influenza-like illness (ILI) in the UK Armed Forces (UK AF). This was undertaken during the 2017–2018 influenza season. Methods Clinical Read codes for ILI and influenza vaccinations were used to generate reports for the period from September 2017 to April 2018. Using a methodology adapted from Public Health England9s (PHE) in hours syndromic surveillance, the ILI rate for the UK AF was calculated. Subsequent analysis explored vaccination uptake in target groups and compared the relative risk (RR) of ILI in vaccinated versus unvaccinated Service Personnel (SP). Results 4234 SPs had a record of ILI between September 2017 and April 2018, with a peak rate of 216 cases per 100 000 PAR. The absolute risk reduction for reporting ILI in vaccinated versus unvaccinated SP was 0.4% (p=0.0031), and the RR was statistically significant at 15% (95% CI 5% to 23 %) lower than in the non-vaccinated PAR. The number needed to vaccinate (NNV) to prevent one presentation of ILI was 241 (95% CI 145 to 714). The 8153 vaccinations recorded for the untrained strength equate to approximately 38% of overall training throughput and 65% of all Army SP recorded as being in phase 1 training at some point during this period. Conclusions The relative risk reduction (RRR) for vaccinated personnel was modest and lower than reported elsewhere, but closely compares with ILI rates included in a 2018 Cochrane review. The small RRR and large NNV do not support widening the population of UK AF eligible to receive influenza vaccine. Regimental Medical Officers (RMOs) seeking advice on whether to vaccinate other groups of SP should be aware that this approach offers questionable clinical benefit. The ILI surveillance methodology used in this work could be adapted for syndromic surveillance of other infectious diseases.

Primary blast lung injury simulator: a new computerised model

Abstract: Mathematical modelling and computational simulation are becoming increasingly important tools in many fields of medicine where in vivo studies are expensive, difficult or impractical. This is particularly the case with primary blast lung injury, and in this paper, we give a brief overview of mathematical models before describing how we generated our blast lung injury simulator and describe some early results of its use.