The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

There have been several global epidemics of chronic kidney disease of unknown etiology (CKDu). Some, such as Itai-Itai disease in Japan and Balkan endemic nephropathy, have been explained, whereas the etiology of others remains unclear. In countries such as Sri Lanka, El Salvador, Nicaragua, and India, CKDu is a major public health problem and causes significant morbidity and mortality. Despite their geographical separation, however, there are striking similarities between these endemic nephropathies. Young male agricultural workers who perform strenuous labor in extreme conditions are the worst affected. Patients remain asymptomatic until end-stage renal failure. Biomarkers of tubular injury are raised, and kidney biopsy shows chronic interstitial nephritis with associated tubular atrophy. In many of these places access to dialysis and transplantation is limited, leaving few treatment options. In this review we briefly describe the major historic endemic nephropathies. We then summarize the epidemiology, clinical features, histology and clinical course of CKDu in Mesoamerica, Sri Lanka, India, Egypt, and Tunisia. We draw comparisons between the proposed etiologies and supporting research. Recognition of the similarities may reinforce the international drive to establish causality and to effect prevention.

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p less than or equal to 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p less than 0.01); and bypass grafting to the dorsalis pedis artery (p less than 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.

No abstract

Evidence from civilian athletes raises the question of whether reproductive dysfunction may be seen in female soldiers as a result of military training. Such reproductive dysfunction consists of impaired ovulation with or without long term subfertility. We critically review pertinent evidence, which points towards reduced energy availability as the most likely explanation for exercise-induced reproductive dysfunction. Evidence also suggests reproductive dysfunction is mediated by activation of the hypothalamic-pituitary-adrenal axis and suppression of the hypothalamic-pituitary-gonadal axis, with elevated ghrelin and reduced leptin likely to play an important role. The observed reproductive dysfunction exists as part of a female athletic triad, together with osteopenia and disordered eating. If this phenomenon was shown to exist with UK military training this would be of significant concern. We hypothesise that the nature of military training and possibly field exercises may contribute to greater risk of reproductive dysfunction among female military trainees compared with exercising civilian controls.We discuss the features of military training and its participants, such as energy availability, age at recruitment, body phenotype, type of physical training, psychogenic stressors, altered sleep pattern and elemental exposure as contributors to reproductive dysfunction. We identify lines of future research to more fully characterise reproductive dysfunction in military women, and suggest possible interventions which, if indicated, could improve their future wellbeing. words 3 Key Points Evidence suggests that reproductive dysfunction could be prevalent among female military trainees.  The pathology associated with such reproductive dysfunction is associated with reduced energy intake and could predispose women to injury.  Evidence from civilian athletes points to reduced energy availability as the key cause. Other factors specific to military training may also be likely to contribute.  Further research could be beneficial in assessing the scale of reproductive dysfunction in UK military women, and understanding its aetiology.

Background 31 Basic military training (BMT) is a useful model of prolonged exposure to multiple stressors. 8-12 week BMT is associated with perturbations in the hypothalamic-pituitary-adrenal (HPA) axis which could 33 predispose recruits to injury and psychological strain. However, characterisations of HPA axis adaptations during BMT have not been comprehensive and most studies included few if any women. Methods 37 We studied women undertaking an arduous, 44-week BMT programme in the UK. Anxiety, depression and resilience questionnaires, average hair cortisol concentration (HCC), morning and evening saliva cortisol and morning plasma cortisol were assessed at regular intervals throughout. A 1-h dynamic cortisol response to 1µg adrenocorticotrophic hormone-1-24 was performed during weeks 1 and 29. Results Fifty-three women (aged 24 ±2.5 years) completed the study. Questionnaires demonstrated increased depression and reduced resilience during training (F 6.93 and F 7.24, respectively, both p<0.001). HCC increased from 3 months before training to the final 3 months of training (median (IQR) 9.63 (5.38, 16.26) versus 11.56 (6.2, 22.45) pg/mg, p=0.003). Morning saliva cortisol increased during the first 7 weeks of training (0.44 ±0.23 versus 0.59 ±0.24 µg/dl p<0.001) and decreased thereafter, with no 48 difference between the first and final weeks (0.44 ±0.23 versus 0.38 ±0.21 µg/dl, p=0.2). Evening saliva cortisol did not change. Fasting cortisol decreased during training (beginning, mid and endtraining concentrations: 701 ±134, 671 ±158 and 561 ±177 nmol/l, respectively, p<0.001). Afternoon basal cortisol increased during training while there was a trend towards increased peak stimulated cortisol (177 ±92 versus 259 ± 13 nmol/l, p=0.003, and 589 ±164 versus 656 ±135, p=0.058, respectively).

RM (2018) Risk of heat illness in men and women: a systematic review and meta-analysis. Environmental Research.

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