The Armed Forces operate in a particularly arduous physical and psychological environment. The oc... more The Armed Forces operate in a particularly arduous physical and psychological environment. The occupational health (OH) of all personnel is of paramount importance to sustain the service's fighting ability. Firstly, to bring readers up to date with the current organization and delivery of OH to uniformed personnel in the Armed Forces. Secondly, to review the research that has led to an improvement in OH services and the ways in which the Armed Forces are responding to the various challenges. A description of the type and delivery of OH to the Armed Forces is followed by a review of the relevant contemporaneous literature from both open publications and research dissertations. Although there are some similarities with civilian OH, the principal requirement to prepare and sustain service personnel for operations on land, sea and air adds considerable complexity to the task. Research undertaken by Armed Forces OH professionals has added to the evidence base and enabled attrition in all aspects of the Armed Forces to be reduced. To meet the challenges of the 21st century, Armed Forces OH practitioners must continue to provide the best evidence-based advice to enhance force preparation and sustainment. All consultations in the Armed Forces involve an OH consideration from the simplest consultations through to the input from specialist OH practitioners. While the assessment of fitness to work in home bases and on deployed operations remains the primary output of OH, the provision of support to command policy, procurement and research are also key to the ability to operate worldwide.
One of the most commonly used methods for in vivo MRS detection of γ-aminobutyric acid (GABA) is ... more One of the most commonly used methods for in vivo MRS detection of γ-aminobutyric acid (GABA) is the MEGA-point-resolved spectroscopy (MEGA-PRESS) technique. However, accurate quantification of GABA using MEGA-PRESS is complicated by spectral co-editing of macromolecular resonances. In this article, a new pulse sequence is presented which enables GABA editing at 3T with the removal of macromolecule contamination. This sequence combines the conventional MEGA editing scheme with the SPECIAL localisation technique, and is therefore named MEGA-SPECIAL. Simulations and phantom experiments indicate that this new approach provides improved GABA editing efficiency relative to MEGA-PRESS, and in vivo results demonstrate effective removal of macromolecule contamination. In a study of the occipital lobe of five healthy volunteers, the macromolecule-corrected GABA/creatine ratio was found to be 0.093 ± 0.007 (mean ± standard deviation), whereas prior to macromolecule correction, the ratio was found to be 0.173 ± 0.013.
Few studies have explored the predisposing factors leading to depression within the British Army,... more Few studies have explored the predisposing factors leading to depression within the British Army, and this qualitative investigation provides a novel approach to advance knowledge in this poorly researched area. Information was provided by army mental health (MH) clinicians, with results aligned to theoretical groupings under the headings of: occupational stressors; macho culture, stigma and bullying; unhappy young soldier; relationships and gender. These issues were influenced by peacetime and operational settings; the support offered by the Army Medical Services and unit command. The results indicate that Army personnel are exposed to multi-factorial stressors that are incremental/accumulative in nature. Soldiers can cope with extreme pressures, often in hostile environments, but often cannot cope with a failing relationship. Officers were worried about the occupational implications of reporting ill, and the negative impact on their career, and might seek support from private civilian agencies, which have potentially dangerous ramifications as they may still deploy. GPs refer female soldiers more frequently for a mental health assessment because women express their emotions more openly then men. Young disillusioned soldiers who want to leave the Army form the main group of personnel accessing mental health support, although often they are not clinically depressed.
This paper describes the processes used to prepare the role players who simulate the &amp... more This paper describes the processes used to prepare the role players who simulate the 'patients' in the MRCGP Clinical Skills Assessment (CSA) examination, one of the licensing qualifications for GPs completing their training. Because it is such a high-stakes exam, the CSA must be seen to be fair and trustworthy, and such attributes could be compromised by inadequate role player performance. On a CSA examination day, three role players simulate the same 'patient' simultaneously on three different exam floors, each playing the same case up to 26 times on the day, and these 'patients' must present in a consistent and reliable manner to ensure that all candidates face the same test situation. The paper describes the initial selection and training of the actors, how they are prepared on the day of the exam itself, and the quality assurance processes designed to ensure that the exam has excellent role players performing as the simulated 'patients'.
Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors, 2015
Role-player consistency between candidates is a crucial component of the reliability of the Objec... more Role-player consistency between candidates is a crucial component of the reliability of the Objective Structured Clinical Examination (OSCE) format used for clinical skills assessment (CSA). It is particularly important in a high-stakes licensing assessment such as the Membership of the Royal College of General Practitioners' (MRCGP's) CSA. The current organisation of the CSA examination poses particular challenges for child actors. The stringent licensing process for child actors limits the working hours of children aged under 13 years considerably, making it impossible for them to perform in both the morning and afternoon circuits on examination days. Children aged nine years or younger are not able to complete even a single morning or afternoon circuit. Younger children also appear disproportionately to become fatigued and less consistent with time. All children require significant support from their adult role-player parent. Careful piloting has allowed us to develop a s...
Journal of Cardiovascular Magnetic Resonance, 2015
Temporal patterns of coronary blood flow velocity can provide important information on disease st... more Temporal patterns of coronary blood flow velocity can provide important information on disease state and are currently assessed invasively using a Doppler guidewire. A non-invasive alternative would be beneficial as it would allow study of a wider patient population and serial scanning. A retrospectively-gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Velocity maps were acquired in 8 proximal right and 15 proximal left coronary arteries of 18 subjects who had previously had a Doppler guidewire study at the time of coronary angiography. Cardiovascular magnetic resonance (CMR) velocity-time curves were processed semi-automatically and compared with corresponding invasive Doppler data. When corrected for differences in heart rate between the two studies, CMR mean velocity through the cardiac cycle, peak systolic velocity (PSV) and peak diastolic velocity (PDV) were approximately 40 % of the peak Doppler values with a moderate - good linear relationship between the two techniques (R(2): 0.57, 0.64 and 0.79 respectively). CMR values of PDV/PSV showed a strong linear relationship with Doppler values with a slope close to unity (0.89 and 0.90 for right and left arteries respectively). In individual vessels, plots of CMR velocities at all cardiac phases against corresponding Doppler velocities showed a consistent linear relationship between the two with high R(2) values (mean +/-SD: 0.79 +/-.13). High temporal resolution breath-hold spiral phase velocity mapping underestimates absolute values of coronary flow velocity but allows accurate assessment of the temporal patterns of blood flow.
Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors, 2011
This paper describes the processes used to prepare the role players who simulate the 'patient... more This paper describes the processes used to prepare the role players who simulate the 'patients' in the MRCGP Clinical Skills Assessment (CSA) examination, one of the licensing qualifications for GPs completing their training. Because it is such a high-stakes exam, the CSA must be seen to be fair and trustworthy, and such attributes could be compromised by inadequate role player performance. On a CSA examination day, three role players simulate the same 'patient' simultaneously on three different exam floors, each playing the same case up to 26 times on the day, and these 'patients' must present in a consistent and reliable manner to ensure that all candidates face the same test situation. The paper describes the initial selection and training of the actors, how they are prepared on the day of the exam itself, and the quality assurance processes designed to ensure that the exam has excellent role players performing as the simulated 'patients'.
The mental health (MH) of soldiers remains extremely newsworthy and is regularly featured in high... more The mental health (MH) of soldiers remains extremely newsworthy and is regularly featured in high profile media forums that focus on post-traumatic stress disorder. However, the authors feel that there are distinct benefits to serving within the Army, and that it provides effective occupational medical, MH and welfare support. This research study explores potential benefits and stressors of being in the Army and provides an overview of Army mental health services (AMHS) through the perspectives of AMHS personnel, 84% of which were nurses. The study indicated that the Army can provide a protective community, sharing a bond based on common values and experiences. The Army can provide soldiers with career opportunities that are not available in civilian life, and there are opportunities to develop an employment profile, enhanced by internal and external educational training, and encapsulated within a progressive career pathway. The Army can also be seen to offer an escape route, preventing soldiers entering a life of crime, and supplying the stable family these soldiers had never experienced. The provision of leadership, within an environment where soldiers are valued and stigma is not tolerated can potentially shield against MH problems.
Few studies have explored the predisposing factors leading to depression within the British Army,... more Few studies have explored the predisposing factors leading to depression within the British Army, and this qualitative investigation provides a novel approach to advance knowledge in this poorly researched area. Information was provided by army mental health (MH) clinicians, with results aligned to theoretical groupings under the headings of: occupational stressors; macho culture, stigma and bullying; unhappy young soldier; relationships and gender. These issues were influenced by peacetime and operational settings; the support offered by the Army Medical Services and unit command. The results indicate that Army personnel are exposed to multi-factorial stressors that are incremental/accumulative in nature. Soldiers can cope with extreme pressures, often in hostile environments, but often cannot cope with a failing relationship. Officers were worried about the occupational implications of reporting ill, and the negative impact on their career, and might seek support from private civilian agencies, which have potentially dangerous ramifications as they may still deploy. GPs refer female soldiers more frequently for a mental health assessment because women express their emotions more openly then men. Young disillusioned soldiers who want to leave the Army form the main group of personnel accessing mental health support, although often they are not clinically depressed.
Tissue phase velocity mapping (TPVM) is capable of reproducibly measuring regional myocardial vel... more Tissue phase velocity mapping (TPVM) is capable of reproducibly measuring regional myocardial velocities. However acquisition durations of navigator gated techniques are long and unpredictable while current breath-hold techniques have low temporal resolution. This study presents a spiral TPVM technique which acquires high resolution data within a clinically acceptable breath-hold duration. Ten healthy volunteers are scanned using a spiral sequence with temporal resolution of 24 ms and spatial resolution of 1.7 × 1.7 mm. Retrospective cardiac gating is used to acquire data over the entire cardiac cycle. The acquisition is accelerated by factors of 2 and 3 by use of non-Cartesian SENSE implemented on the Gadgetron GPU system resulting in breath-holds of 17 and 13 heartbeats, respectively. Systolic, early diastolic, and atrial systolic global and regional longitudinal, circumferential, and radial velocities are determined. Global and regional velocities agree well with those previously reported. The two acceleration factors show no significant differences for any quantitative parameter and the results also closely match previously acquired higher spatial resolution navigator-gated data in the same subjects. By using spiral trajectories and non-Cartesian SENSE high resolution, TPVM data can be acquired within a clinically acceptable breath-hold.
The Armed Forces operate in a particularly arduous physical and psychological environment. The oc... more The Armed Forces operate in a particularly arduous physical and psychological environment. The occupational health (OH) of all personnel is of paramount importance to sustain the service's fighting ability. Firstly, to bring readers up to date with the current organization and delivery of OH to uniformed personnel in the Armed Forces. Secondly, to review the research that has led to an improvement in OH services and the ways in which the Armed Forces are responding to the various challenges. A description of the type and delivery of OH to the Armed Forces is followed by a review of the relevant contemporaneous literature from both open publications and research dissertations. Although there are some similarities with civilian OH, the principal requirement to prepare and sustain service personnel for operations on land, sea and air adds considerable complexity to the task. Research undertaken by Armed Forces OH professionals has added to the evidence base and enabled attrition in all aspects of the Armed Forces to be reduced. To meet the challenges of the 21st century, Armed Forces OH practitioners must continue to provide the best evidence-based advice to enhance force preparation and sustainment. All consultations in the Armed Forces involve an OH consideration from the simplest consultations through to the input from specialist OH practitioners. While the assessment of fitness to work in home bases and on deployed operations remains the primary output of OH, the provision of support to command policy, procurement and research are also key to the ability to operate worldwide.
One of the most commonly used methods for in vivo MRS detection of γ-aminobutyric acid (GABA) is ... more One of the most commonly used methods for in vivo MRS detection of γ-aminobutyric acid (GABA) is the MEGA-point-resolved spectroscopy (MEGA-PRESS) technique. However, accurate quantification of GABA using MEGA-PRESS is complicated by spectral co-editing of macromolecular resonances. In this article, a new pulse sequence is presented which enables GABA editing at 3T with the removal of macromolecule contamination. This sequence combines the conventional MEGA editing scheme with the SPECIAL localisation technique, and is therefore named MEGA-SPECIAL. Simulations and phantom experiments indicate that this new approach provides improved GABA editing efficiency relative to MEGA-PRESS, and in vivo results demonstrate effective removal of macromolecule contamination. In a study of the occipital lobe of five healthy volunteers, the macromolecule-corrected GABA/creatine ratio was found to be 0.093 ± 0.007 (mean ± standard deviation), whereas prior to macromolecule correction, the ratio was found to be 0.173 ± 0.013.
Few studies have explored the predisposing factors leading to depression within the British Army,... more Few studies have explored the predisposing factors leading to depression within the British Army, and this qualitative investigation provides a novel approach to advance knowledge in this poorly researched area. Information was provided by army mental health (MH) clinicians, with results aligned to theoretical groupings under the headings of: occupational stressors; macho culture, stigma and bullying; unhappy young soldier; relationships and gender. These issues were influenced by peacetime and operational settings; the support offered by the Army Medical Services and unit command. The results indicate that Army personnel are exposed to multi-factorial stressors that are incremental/accumulative in nature. Soldiers can cope with extreme pressures, often in hostile environments, but often cannot cope with a failing relationship. Officers were worried about the occupational implications of reporting ill, and the negative impact on their career, and might seek support from private civilian agencies, which have potentially dangerous ramifications as they may still deploy. GPs refer female soldiers more frequently for a mental health assessment because women express their emotions more openly then men. Young disillusioned soldiers who want to leave the Army form the main group of personnel accessing mental health support, although often they are not clinically depressed.
This paper describes the processes used to prepare the role players who simulate the &amp... more This paper describes the processes used to prepare the role players who simulate the 'patients' in the MRCGP Clinical Skills Assessment (CSA) examination, one of the licensing qualifications for GPs completing their training. Because it is such a high-stakes exam, the CSA must be seen to be fair and trustworthy, and such attributes could be compromised by inadequate role player performance. On a CSA examination day, three role players simulate the same 'patient' simultaneously on three different exam floors, each playing the same case up to 26 times on the day, and these 'patients' must present in a consistent and reliable manner to ensure that all candidates face the same test situation. The paper describes the initial selection and training of the actors, how they are prepared on the day of the exam itself, and the quality assurance processes designed to ensure that the exam has excellent role players performing as the simulated 'patients'.
Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors, 2015
Role-player consistency between candidates is a crucial component of the reliability of the Objec... more Role-player consistency between candidates is a crucial component of the reliability of the Objective Structured Clinical Examination (OSCE) format used for clinical skills assessment (CSA). It is particularly important in a high-stakes licensing assessment such as the Membership of the Royal College of General Practitioners' (MRCGP's) CSA. The current organisation of the CSA examination poses particular challenges for child actors. The stringent licensing process for child actors limits the working hours of children aged under 13 years considerably, making it impossible for them to perform in both the morning and afternoon circuits on examination days. Children aged nine years or younger are not able to complete even a single morning or afternoon circuit. Younger children also appear disproportionately to become fatigued and less consistent with time. All children require significant support from their adult role-player parent. Careful piloting has allowed us to develop a s...
Journal of Cardiovascular Magnetic Resonance, 2015
Temporal patterns of coronary blood flow velocity can provide important information on disease st... more Temporal patterns of coronary blood flow velocity can provide important information on disease state and are currently assessed invasively using a Doppler guidewire. A non-invasive alternative would be beneficial as it would allow study of a wider patient population and serial scanning. A retrospectively-gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Velocity maps were acquired in 8 proximal right and 15 proximal left coronary arteries of 18 subjects who had previously had a Doppler guidewire study at the time of coronary angiography. Cardiovascular magnetic resonance (CMR) velocity-time curves were processed semi-automatically and compared with corresponding invasive Doppler data. When corrected for differences in heart rate between the two studies, CMR mean velocity through the cardiac cycle, peak systolic velocity (PSV) and peak diastolic velocity (PDV) were approximately 40 % of the peak Doppler values with a moderate - good linear relationship between the two techniques (R(2): 0.57, 0.64 and 0.79 respectively). CMR values of PDV/PSV showed a strong linear relationship with Doppler values with a slope close to unity (0.89 and 0.90 for right and left arteries respectively). In individual vessels, plots of CMR velocities at all cardiac phases against corresponding Doppler velocities showed a consistent linear relationship between the two with high R(2) values (mean +/-SD: 0.79 +/-.13). High temporal resolution breath-hold spiral phase velocity mapping underestimates absolute values of coronary flow velocity but allows accurate assessment of the temporal patterns of blood flow.
Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors, 2011
This paper describes the processes used to prepare the role players who simulate the 'patient... more This paper describes the processes used to prepare the role players who simulate the 'patients' in the MRCGP Clinical Skills Assessment (CSA) examination, one of the licensing qualifications for GPs completing their training. Because it is such a high-stakes exam, the CSA must be seen to be fair and trustworthy, and such attributes could be compromised by inadequate role player performance. On a CSA examination day, three role players simulate the same 'patient' simultaneously on three different exam floors, each playing the same case up to 26 times on the day, and these 'patients' must present in a consistent and reliable manner to ensure that all candidates face the same test situation. The paper describes the initial selection and training of the actors, how they are prepared on the day of the exam itself, and the quality assurance processes designed to ensure that the exam has excellent role players performing as the simulated 'patients'.
The mental health (MH) of soldiers remains extremely newsworthy and is regularly featured in high... more The mental health (MH) of soldiers remains extremely newsworthy and is regularly featured in high profile media forums that focus on post-traumatic stress disorder. However, the authors feel that there are distinct benefits to serving within the Army, and that it provides effective occupational medical, MH and welfare support. This research study explores potential benefits and stressors of being in the Army and provides an overview of Army mental health services (AMHS) through the perspectives of AMHS personnel, 84% of which were nurses. The study indicated that the Army can provide a protective community, sharing a bond based on common values and experiences. The Army can provide soldiers with career opportunities that are not available in civilian life, and there are opportunities to develop an employment profile, enhanced by internal and external educational training, and encapsulated within a progressive career pathway. The Army can also be seen to offer an escape route, preventing soldiers entering a life of crime, and supplying the stable family these soldiers had never experienced. The provision of leadership, within an environment where soldiers are valued and stigma is not tolerated can potentially shield against MH problems.
Few studies have explored the predisposing factors leading to depression within the British Army,... more Few studies have explored the predisposing factors leading to depression within the British Army, and this qualitative investigation provides a novel approach to advance knowledge in this poorly researched area. Information was provided by army mental health (MH) clinicians, with results aligned to theoretical groupings under the headings of: occupational stressors; macho culture, stigma and bullying; unhappy young soldier; relationships and gender. These issues were influenced by peacetime and operational settings; the support offered by the Army Medical Services and unit command. The results indicate that Army personnel are exposed to multi-factorial stressors that are incremental/accumulative in nature. Soldiers can cope with extreme pressures, often in hostile environments, but often cannot cope with a failing relationship. Officers were worried about the occupational implications of reporting ill, and the negative impact on their career, and might seek support from private civilian agencies, which have potentially dangerous ramifications as they may still deploy. GPs refer female soldiers more frequently for a mental health assessment because women express their emotions more openly then men. Young disillusioned soldiers who want to leave the Army form the main group of personnel accessing mental health support, although often they are not clinically depressed.
Tissue phase velocity mapping (TPVM) is capable of reproducibly measuring regional myocardial vel... more Tissue phase velocity mapping (TPVM) is capable of reproducibly measuring regional myocardial velocities. However acquisition durations of navigator gated techniques are long and unpredictable while current breath-hold techniques have low temporal resolution. This study presents a spiral TPVM technique which acquires high resolution data within a clinically acceptable breath-hold duration. Ten healthy volunteers are scanned using a spiral sequence with temporal resolution of 24 ms and spatial resolution of 1.7 × 1.7 mm. Retrospective cardiac gating is used to acquire data over the entire cardiac cycle. The acquisition is accelerated by factors of 2 and 3 by use of non-Cartesian SENSE implemented on the Gadgetron GPU system resulting in breath-holds of 17 and 13 heartbeats, respectively. Systolic, early diastolic, and atrial systolic global and regional longitudinal, circumferential, and radial velocities are determined. Global and regional velocities agree well with those previously reported. The two acceleration factors show no significant differences for any quantitative parameter and the results also closely match previously acquired higher spatial resolution navigator-gated data in the same subjects. By using spiral trajectories and non-Cartesian SENSE high resolution, TPVM data can be acquired within a clinically acceptable breath-hold.
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