9 e-Letters

published between 2020 and 2023

  • Enlistment of under-18s: Abiding concerns

    Dear Editor

    Dr. Bergman and colleagues’ retrospective cohort study of armed forces veterans in Scotland concluded that their study ‘provides no evidence to support the assertion that early entry to military service is associated with adverse long-term mental health outcomes’ and that concerns about early enlistment are ‘misplaced’ (p. 5).

    This conclusion is justified on the grounds that junior entrants into the armed forces (below the age of 17.5) were found to have had a lower risk of developing a severe mental health disorder when compared to those recruited between the ages of 17.5 and 19; or between the ages of 20 and 24.

    However, all veterans, including those who joined as junior entrants, were significantly more likely to develop mental disorders (especially PTSD) when compared to matched non-veterans. In addition, for the cohort of veterans born between 1975 and 1984, the data suggests that junior entrants have a higher risk of presenting with mental health disorders when compared to older recruits, although this is not statistically significant (Table 1). This cohort is important because it is associated with the multiple major combat deployments to Bosnia, Kosovo, Afghanistan and Iraq.

    For these reasons, while modern day junior entrants to the armed forces in the UK are better protected when compared to ‘child soldiers’ in other countries, or to junior entrants from previous eras, concerns about their vulnerability to mental illness are...

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  • Enlistment of under-18s: Abiding concerns

    Dear Editor

    Margaret Jones and colleagues’ study of armed forces personnel concluded that, for the study cohort as a whole, those who had joined up under the age of 17.5 years (‘junior entrants’) were no more likely than those who enlisted at older ages to report symptoms of mental health disorders. However, the study also found that junior entrants who had enlisted since 2003 showed significantly higher rates of alcohol misuse, somatic symptoms, and a lifetime history of self-harm, relative to older recruits. The study’s data further suggests that PTSD and common mental disorders may also be more prevalent among younger enlistees since 2003, although this is not statistically significant.

    In recent decades, protections for armed forces recruits who are legally children have improved, including a legal prohibition on deployment to zones since 2002. Despite these developments, this study’s findings indicate continuing reason to be concerned about the impact of early enlistment on long-term mental health. It could be relevant that, as this study has shown, once junior entrants turn 18 and may be deployed, they are more likely to be in a combat role such as the frontline infantry.

    Furthermore, the study sample may not reflect the relevant population accurately. Comparing Table 1 with UK armed forces quarterly personnel statistics,(1) higher-ranked personnel appear to be over-represented in the study sample, while those with the lowest ranks are under-repr...

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  • Enlistment of under-18s: Abiding concerns - Authors' response

    Dear Editor,

    Thank you for publishing the Rapid Response to our paper by Cooper et al. The authors agree with our findings that junior entrants to the Armed Forces have a lower risk of developing a severe mental health disorder compared with older entrants, but have noted that we found that all veterans were more likely to develop mental disorders (especially PTSD) then matched non-veterans.
    The increased risk of mental health disorders in veterans overall compared with non-veterans is not a new observation. In our 2016 paper(1) we showed that overall, veterans were at 21% overall increased risk of having experienced mental ill-health compared with matched non-veterans, whilst Goodwin et al.(2) showed that serving personnel had more than double the odds of common mental disorders compared with a general population sample. In our 2016 paper we showed that the risk in veterans is highest in those with the shortest service; Early Service Leavers (ESL) were at 51% increased risk, whilst those with more than 9 years’ service were at no greater risk than the comparison population. ESL who did not complete training, and who could not have deployed operationally, had the highest risk; it is likely that their mental health outcomes (including PTSD) arose predominantly from pre-service vulnerabilities. In our new study, we showed that junior entrants were less likely to be ESL (a finding supported by a House of Commons Written Answer on length of service of junior...

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  • Enlistment of under-18s: Abiding concerns – Authors’ response

    Dear Editor
    We read with interest the comments made by Cooper et al to our paper comparing experiences and mental health of personnel who joined service as junior entrants compared to adult entrants. Participants in the King's Centre for Military Health Research (KCMHR) cohort study were sampled from the trained and, consequently, deployable strength of the UK Armed Forces (UKAF) since the primary purpose of the cohort study was to measure the health consequences of deployment to Iraq and Afghanistan[1]. The participants were not sampled from personnel at recruitment but on the basis of their deployment to Iraq or Afghanistan. We had no data about individuals who joined service at the same time but who did not remain in service until the time of sampling and this is a fully acknowledged limitation in the paper. We have no evidence that there may have been differential attrition on the basis of mental health between the comparison groups. Those who joined before 2003 could represent a sub sample of particularly successful personnel (both those who joined as Junior Entrants and those who joined as adults). That is why we carried out a subgroup analysis of the smaller number of participants who had joined the trained strength after 2003 (the replenishment samples). In that analysis there were some significant associations that are of concern, but PTSD and common mental disorders were not, as suggested, among them as they were far from being statistically significan...

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  • RE: Efficacy of mirror therapy and virtual reality therapy in alleviating phantom limb pain

    With great interest, I have read the review article entitled “Efficacy of mirror therapy and virtual reality therapy in alleviating phantom limb pain: a meta-analysis and systematic review” written by Rajendram et al (1). The authors conducted a meta-analysis to evaluate the effects of mirror therapy (MT) and virtual reality (VR) therapy on phantom limb pain (PLP). Both therapies led to a reduction of visual analogue scale (VAS) scores on PLP, and there was no statistically significant difference in pain alleviation between two therapies. The authors recommended that factors such as gender, cause of amputation, site of limb loss or length of time from amputation should be considered for the analysis. I present additional information regarding the effect of MT on PLP.
    Wang et al. also conducted a meta-analysis, handling randomized controlled trials (RCTs) (2). The pooled standardized mean difference (SMD) (95% confidence interval [CI]) of MT group was -0.81 (-1.36 to -0.25), which was compared with other 6 methods (four covered mirror, one phantom exercise, three mental visualization, one sensorimotor exercise, one transcutaneous electrical nerve stimulation, and one tactile stimuli). They concluded that MT was beneficial for reducing phantom limb pain. There is a fact that the authors did not consider follow-up intervals, and a control group was consisted a complex of traditional treatments for patients with PLP. I suppose that heterogeneous treatments may have diff...

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  • Statistical problems in the vitamin C and common cold trial with South Korean army recruits

    The report on vitamin C for preventing the common cold in the Republic of South Korea army recruits by Kim et al. [1] has several statistical problems.

    First, Kim et al. did not follow the intention-to-treat [ITT] approach. Figure 1 shows that 49 participants were excluded because they “stopped intake of vitamin C”, and 84 participants were excluded because they “stopped intake of placebo” [1]. The CONSORT recommendation for ITT analysis states as follows [2, Box 6]: “participants who … did not take all the intended treatment ... exclusion of any participants for such reasons is incompatible with intention-to-treat analysis”.

    Second, Altman et al. pointed out that “The odds ratio should not be interpreted as an approximate relative risk [RR] unless the events are rare in both groups (say, less than 20-30%)”[3]. The common cold is not rare. Over 50% of the participants in the Kim et al. trial had the common cold during the trial period which greatly exceeds the 20-30% limit. Furthermore, there is no need to use the OR as the approximation for RR, because the RR can be calculated from the trial data in Table 1, RR = 0.916 (= 0.538/0.587) [1].

    Third, in their abstract, Kim et al. wrote “the vitamin C group had a 0.80-fold lower risk of getting a common cold” implying that vitamin C decreased the incidence of colds by 20%. However, the correct effect estimate is given by the RR above, which indicates only 8.4% lower risk of colds in the vitamin C group....

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  • Advice on how to navigate the MODREC process for junior researchers in the Defence Medical Services

    Dear Sir,

    The paper by Dr Schmidt details the history of the first independent Research Ethics Committee (REC) at Porton Down in the 1960’s. This REC was created to address ethical and legal concerns about research on human subjects. Since the 1960’s the emphasis has rightly shifted from “the doctor/scientist is always right” to “the participants must be protected from any unnecessary harms”. This has led to an expansion of the ethics review process and level of scrutiny, which has left many junior researchers feeling frustrated when their plans are criticised or delayed.

    This letter will list some advice for junior researchers in the Defence Medical Services on how to navigate the process and improve the quality of their research and the chance of a successful ethical approval for research involving human participants:
    1. First, use the NHS Health Research Authority tool to confirm that your study design is research and that it requires ethical approval.
    2. Read JSP 536 Pt 1 (48 pages) and 2 (64 pages).
    3. Be familiar with the main tenets of medical ethics - respect for autonomy, beneficence, non-maleficence, justice and equipoise.
    4. Involve patients and other stakeholders in the design of the study.
    5. Do not underestimate the time required, it may take six to 12 months.
    6. Be resilient and ensure you have support. It will be stressful.
    7. The REC process is a combination of prestigious journal submission and viv...

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  • Penthrox for the military: Possilbly, but you need to understand what you are using

    The article by Cohen and Wolstenholme provides a useful overview of Penthrox but is unfortunately incomplete.

    Compared with modern anaesthetic agents, Penthrox is an unclean drug and would not get a product license if invented today. The high fat solubility means a tissue reservoir persists for ≈1 week. About 70% is biotransformed, and this continues after administration until the tissue reservoir is empty. Nephrotoxicity was not just “a concern” but actually happened; ≈20 people died [1].

    It has only been possible to use Penthrox 5 million times safely because of essential pre-use checks to ensure no contraindications. It is worth remembering that methoxyflurane was used 10-12 million times before the nephrotoxic potential was established [1].

    Penthrox produces nephrotoxic metabolites at all doses, but this only becomes clinically significant above a certain level. The claim that Penthrox use is not nephrotoxic is technically correct, however, the presence of other factors that can also induce renal injury will reduce the Penthrox safety net. Of relevance to military use, this includes crush injury, hypovolaemic shock and patients subsequently requiring nephrotoxic antibiotics. Other potential issues for military use: (1) Limit to ≈50min administration (two bottles); (2) Activated charcoal adsorber is only effective IF the patient exhales through it. The patient will continue to exhale small amounts of drug for hours after administration; (3) There i...

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  • Hyperbaric oxygen treatment can be an early adjunctive therapy in sudden deafness

    We read with interest the article by Bayoumy et al. concerning the effects of hyperbaric oxygen therapy (HBOT) associated with corticosteroid therapy in military personnel with acute acoustic trauma1. This paper helps to discuss about the most appropriate treatment of sudden deafness (SD). As recently stated, a spontaneous recovery, in the general population, is less than 40%. The precise role of HBOT has not yet been clearly established2. Our clinical experience during the last 15 years in a second referral hyperbaric center indicates the need of clear guide-lines, for the treatment of this acute disease. Nowadays there are two main therapeutic approaches to SD of different origin, the corticosteroid medication and HBOT.
    Clearly, at first, it has to be ascertained the nature of a deafness excluding, cerebral diseases, vascular, traumatic and neoplastic. A subsequent otolaryngology evaluation enables to ascertain possible associated vestibular diseases, and to measure Pure Tone Average. Medical contraindications to HBOT and corticosteroids medication have to be excluded. An early treatment, not beyond the first 48 hours after the acute event is recommended 1. Today the HBOT standardized protocol, consists in a daily oxygen 100% at 2.2-2.5 atmosphere for 90 minutes, for a minimum of 10 sessions in case of satisfying functional recovery. On the contrary, in case of absolutely negative results, the treatment should be interrupted. Otherwise, HBOT can be prolonged to a...

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