IntroductionDespite mitigation efforts, exertional heat stroke (EHS) is known to occur in military personnel during training and operations. It has significant potential to cause preventable morbidity and mortality. International consensus from sports medicine organisations supports treating EHS with early rapid cooling by immersing the casualty in cold water. However, evidence remains sparse and the practice is not yet widespread in the UK.MethodsFollowing changes to enable on-site ice cold water immersion (ICWI) at the Royal Marines Commando Training Centre, Lympstone, UK, we prospectively gathered data on 35 patients treated with ICWI over a 3-year period. These data included the incidence of adverse events (e.g. death, cardiac arrest or critical care admission) as the primary outcome. Basic anthropometric data, cooling rates achieved and biochemical and haematological test results on days 0–5 were also gathered and analysed.ResultsDespite being a cohort of patients in whom we might expect significant morbidity and mortality based on the severity of EHS at presentation, none experienced a serious adverse event. In this cohort with rapid initiation of effective cooling, biochemical derangement appeared less severe than that reported in previous studies. Higher body mass index (BMI) was associated with a lower cooling rate across a range of values previously reported as potentially of clinical significance.ConclusionsThis case series supports recent updates to UK military guidance that ICWI should be more widely adopted for the treatment of EHS. Clinicians should be aware of likely patterns of blood test abnormalities in the days following EHS. Further work should seek to establish the impact of lower rates of cooling and develop strategies to optimise cooling in patients with higher BMI.

With three-quarters of the 80 million people in need of humanitarian assistance being women or children in 2014, maternal care makes up a significant burden of medical care in humanitarian assistance and disaster relief operations. Due to lack of infrastructure and up to 80% of these displaced people being located in developing countries, mothers are often extremely vulnerable to disease, abuse and malnutrition. This can lead to late presentations of severe disease and birthing complications that would usually be easily manageable, but are far more complex due to the physical condition of the mother and lack of available resources. The British Armed Forces are often involved in humanitarian assistance and disaster relief either intentionally or due to the nature of the operations they carry out. However, it is not always possible to predict the requirement of maternal care. This humanitarian special edition article focuses on the factors impacting the maternal patient in a humanitarian environment, also looking at common pathologies and ways of managing these in a Role 1 facility. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

To investigate the associations between internalizing problems, metacognition problems, and mindfulness levels in university students during the COVID-19 pandemic. Depression, anxiety, and stress levels were compared between university students quarantined in dormitories and their homes under curfew conditions. The direct and indirect associations between internalizing problems, metacognition problems, and mindfulness levels of students under quarantine were evaluated. Metacognition problems and low mindfulness levels were associated with higher depression, anxiety, and stress symptoms under quarantine conditions. Therapeutic interventions focusing on metacognition problems and mindfulness levels may reduce the negative psychological effects of quarantine.

IntroductionThe COVID-19 pandemic has posed major challenges for infection control within training centres, both civilian and military. Here we present a narrative review of an outbreak that occurred at the Royal Military Academy Sandhurst (RMAS) in January–March 2021, in the context of the circulating, highly transmissible SARS-CoV-2 variant B.1.1.7.MethodsTesting for SARS-CoV-2 was performed using a combination of reverse transcriptase PCR and Lateral Flow Devices (LFDs). Testing and isolation procedures were conducted in line with a pre-established symptom stratification system. Genomic sequencing was performed on 10 sample isolates.ResultsBy the end of the outbreak, 185 cases (153 Officer Cadets, 32 permanent staff) had contracted confirmed COVID-19. This represented 15% of the total RMAS population. This resulted in 0 deaths and 0 hospitalisations, but due to necessary isolation procedures did represent an estimated 12 959 person-days of lost training. 9 of 10 (90%) of sequenced isolates had a reportable lineage. All of those reported were found to be the Alpha lineage B.1.1.7.ConclusionsWe discuss the key lessons learnt from the after-action review by the Incident Management Team. These include the importance of multidisciplinary working, the utility of sync matrices to monitor outbreaks in real time, issues around Officer Cadets reporting symptoms, timing of high-risk training activities, infrastructure and use of LFDs. COVID-19 represents a vital learning opportunity to minimise the impact of potential future pandemics, which may produce considerably higher morbidity and mortality in military populations.

ABSTRACT Healthcare workers (HCWs) providing medical support while facing one of the highest levels of adverse and potentially fatal outcomes due to COVID-19 are put in a vulnerable position leading to the development of mental health problems. The development of any prevention and intervention programs to reduce this risk is possible with better understanding and knowledge of possible vulnerability factors. The aim of the present study is to investigate psychological effect of working directly with patients infected with COVID-19 (WD) and possible individual vulnerability factors for the development of psychological problems in HCWs. The data used in this cross-sectional study were collected using online self-reported questionnaires from 290 HCWs aged 21–61 years old. The mean score of the scales of 145 HCWs-WD and 145 HCWs not WD (HCWs-NWD) were compared by independent sample t test. Associations between childhood traumas, metacognitive dysfunctional beliefs and internalizing symptoms were analyzed using structural equation modelling (SEM). The depression, anxiety, stress symptoms levels, somatization and sleep problem levels were found to be higher in HCWs-WD compared to HCWs-NWD. SEM revealed that childhood trauma levels was associated with the increased risk of internalizing problems, and metacognitive dysfunctional beliefs had a partial mediator role between childhood traumas and internalizing symptoms in HCWs-WD. Improving metacognitive abilities may hence need to be considered in prevention programs for the HCWs. The findings can also be used to set up further research on the specific interventions on the HCWs who are at a risk as their profession entails them being in such traumatic situations.

AbstractIntroductionOral Health‐Related Quality of Life (OHRQoL) is a determinant of an individual's wellbeing and can be affected by dental disease. For military recruits, adverse OHRQoL may result in poor performance, and has safety implications. The aim of this study was to determine the incidence of dental extractions and dental health of a sample of new Infantry recruits.MethodElectronic healthcare recordings of tooth extraction incidence were compared to recruits from the general military population. Clinical dental examinations and patient questionnaires were used to determine the prevalence and impact of caries using the PUFA (Pulp exposure, Ulceration, Fistula, Caries) criteria. The association between caries and PUFA lesions with self‐reported oral health behaviours and beliefs was explored.ResultsThe incidence of tooth extraction was 2.4 times higher in new Army Infantry recruits than recruits in the general UK military population. 211 recruits were assessed, with a 100% response rate. 135/211 (64%) had caries, and 37/21117.5% had a PUFA lesion at the time of inspection. Sleep loss was significantly more likely in those with PUFA lesions than those without (OR 5.62, p < 0.0001).ConclusionsThose military Infantry recruits with caries and PUFA lesions had worse OHRQoL than those that did not. This was evidenced by poorer sleeping patterns and an inability to perform tasks at work. Treatment of dental disease through extractions was higher in Army Infantry recruits and will likely reduce the number of days taken off sick, but its effect on overall OHRQoL cannot yet be substantiated.

AbstractObjectiveThere is a lack of guidance and literature on determining a safe caseload size and how community consultant psychiatrists (CCPs) manage their caseload. This paper therefore aims at exploring effective and safe ways of clinical caseload management by gaining a qualitative understanding of caseload management (CLM) practice of CCPs.DesignCross sectional Qualitative research using semi structured interviews.SettingThe participants were CCPs working in National health service in Hampshire areas of United Kingdom.ParticipantsThe target population comprised 11 CCPs working in the National Health Service (NHS) to get their view on current practice in NHS and compare past and present practices of CLM.Main Outcome MeasuresA qualitative research method was used to explore the topic of CLM by collecting data through observations, interviews, questionnaires and then analysing the data using the coding and emergent themes method.ResultsCaseload size for CCPs was higher than a manageable level and had an impact on their ability to service their other responsibilities such as strategic work; they did not have a shared view on setting a limit to their caseload. Majority of CCPs were not using CLM and did not have enough control on limiting their caseload size. Some CCPs were using time management and audit of caseload as effective CLM strategies. NWW was not being used equitably.ConclusionsAlthough the study represents the perceptions of limited number of CCPs, the findings of this study are unique and an important addition to the slight literature that exists on this topic. The results were in line with existing research that large caseloads can have negative impact on CCPs and their ability to provide effective care to the clients. The key factors determining the caseload size were highlighted. Proactive time management and proactive caseload size management were found to be effective tools for CLM. These supported by job planning meetings, Yearly appraisal, use of electronic data system and New ways of Working could be effective in maintaining a safe caseload size for the provision of safe and effective care. The data from this study can be used for requisite quantitative studies on a larger and statistically significant number of CCPs to find effectiveness of each CLM strategy.

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.

Burns are an unpredictable element of the modern battlespace and humanitarian operations. Most military burns are small and may not be a significant challenge for deployed healthcare assets but usually render the individual combat ineffective until healed. However, larger burns represent a more significant challenge because of the demand for fluid resuscitation therapy, early surgical intervention and regular wound management that can rapidly deplete surgical capabilities. Beyond the initial injury, longer-term consequences, such as psychological morbidity and loss of functional independence, are rarely considered as part of an ongoing care plan. Globally, most of the morbidity and mortality associated with burns are seen in less economically developed countries and are frequently associated with conflicts and natural disasters, but with simple interventions and resources, outcomes in these environments can be markedly improved. Prehospital providers should be confident to manage the initial assessment of a burn, including triaging for evacuation and packaging for safe transfer. This article provides an overview for prehospital providers on the management of thermal burns in military and humanitarian settings, with additional considerations for the management of chemical and electrical injuries.

Martin White and coauthors consider that the commercial food system has the potential to show leadership and support for dietary public health, but systemic change is needed first and this is likely to require governmental action