Caring for the carers: an evaluation of the recovery, readjustment and reintegration programme (R3P).

INTRODUCTION: The challenges faced by healthcare workers, not least during the response to the COVID-19 pandemic, have been extensively studied, and concerns continue to be highlighted in relation to their long-term mental health. Identifying the need to support their personnel, a leader-led structured programme of reflection: the recovery, readjustment and reintegration programme (R3P) was designed by the UK Defence Medical Services to mitigate the potential stressors associated with this outbreak and enhance the resilience of the workforce. METHODS: 128 military personnel completed an evaluation of R3P. A survey included measures of anxiety before and after the intervention, perceptions of the discussion themes and whether these brought a sense of closure to areas of distress, and attitudes to help-seeking. RESULTS: Most respondents (86%-92%) rated the five discussion themes either 'helpful' or 'very helpful', 51% of respondents reported a sense of closure about an issue that had been causing distress and 72% of respondents felt better able to seek help should it be necessary. Evaluating the effect R3P had on anxiety, a Wilcoxon signed rank test elicited a statistically significant difference in anxiety pre-R3P and post-R3P; Z=-3.54, p<0.001. The median anxiety rating was 3.5 (IQR 4.75, 95% CI 1.25 to 6.00) before undertaking R3P, which decreased to 3 (IQR 4.75, 95% CI 1.00 to 5.75) after undertaking R3P. 39.1% of participants reported decreased anxiety, 18.8% reported increased anxiety and 42.2% reported no change. CONCLUSION: This evaluation has identified several positive aspects to R3P with many personnel reporting a reduction in anxiety, a sense of closure and increased likelihood of help-seeking. Several participants did report an increase in anxiety and the long-term impact of R3P on mental health and well-being is unclear. Further mixed-methods evaluation incorporating a longer follow-up is required.

Is there a role for an advanced practitioner in UK military prehospital care?

Recruitment and retention of doctors have been highlighted as some of the leading causes of the current perceived crisis within civilian emergency care. Indeed, the NHS recognises the contribution made by other healthcare professionals by supporting accreditation in advanced practice to mitigate the risks associated with these capability gaps. Consequently, roles such as the advanced clinical practitioner are now well established. Previous research and clinical experience in the civilian sector suggest that the advanced practitioner (AP) role could be used within Defence. Operationally, the role could be advantageous for the Defence Medical Services in the delivery of deployed healthcare. However, there is no available research that defines the role of UK military APs and, more specifically, their potential to support deployed prehospital care. Further work is required to determine how an AP might be effectively used within the military prehospital patient care pathway.

Inefficient Magnetic-Field Amplification in Supersonic Laser-Plasma Turbulence.

We report a laser-plasma experiment that was carried out at the LMJ-PETAL facility and realized the first magnetized, turbulent, supersonic (Ma_{turb}≈2.5) plasma with a large magnetic Reynolds number (Rm≈45) in the laboratory. Initial seed magnetic fields were amplified, but only moderately so, and did not become dynamically significant. A notable absence of magnetic energy at scales smaller than the outer scale of the turbulent cascade was also observed. Our results support the notion that moderately supersonic, low-magnetic-Prandtl-number plasma turbulence is inefficient at amplifying magnetic fields compared to its subsonic, incompressible counterpart.

Taking a seat at the table: an educational model for nursing empowerment.

BACKGROUND: The human resources for health crisis has generated much debate as to the radical changes necessary to mitigate the risks to universal health coverage. Nurses can make a significant impact on global health, if only they feel empowered to take their seat at the political table. AIM: The aim of this paper was to outline nurse-led initiatives to enhance organizational culture and clinical processes at the Combined Military Hospital in Rawalpindi, Pakistan. These have been designed and implemented by the United Kingdom (UK) Defence Medical Services to empower the nursing workforce in Pakistan. OUTCOME: An educational model has been developed that will build capacity, within a workforce constrained by numbers, by bridging the gap between nursing theory and practice. It is geared to actively engage Pakistani nurses in quality improvement to ensure care is based on best evidence that will enhance patient outcomes. CONCLUSION AND IMPLICATIONS FOR NURSING & HEALTH POLICY: The wider impact of the model has already been evidenced by nurses, country-wide, who are gaining the necessary skills and confidence to realize their true potential in influencing the patient care pathway and future policy. This is crucial to the recruitment and retention of nurses who might otherwise seek alternative career paths if they lack a sense of value within the profession. Their renewed sense of value will enable them to find their voice and ability to contribute to the sustainable development goals adopted by the United Nations General Assembly in 2015.

Differential modulation of transendothelial electrical resistance by TRPV4 agonists is mediated by apoptosis and/or necrosis.

Transient receptor potential vanilloid 4 (TRPV4) has been implicated in many disease conditions also in the lung. Its activation leads to an increase endothelial permeability in an intracellular calcium-influx dependent manner. We investigated its function in vitro on primary human endothelial cells using two TRPV4 agonists, GSK1016790A and 4α-Phorbol 12,13-didecanoate (4α-PDD) and a selective TRPV4 blocker GSK2193874. Both TRPV4 agonists leaded to a reduction in transendothelial electrical resistance (TER) which was mediated however by differential cytotoxic effects. 4α-PDD induced apoptosis that could not be blocked by TRPV4 inhibition in HUVECs, whereas GSK1016790A selectively activated TRPV4 and reduced TER as a consequence of cellular necrosis. TRPV4 mediated cytotoxicity is poorly described and may provide significant context to the role of TRPV4 in barrier-function.

Rayleigh-Taylor instability experiments on the LULI2000 laser in scaled conditions for young supernova remnants.

We describe a platform developed on the LULI2000 laser facility to investigate the evolution of Rayleigh-Taylor instability (RTI) in scaled conditions relevant to young supernova remnants (SNRs) up to 200 years. An RT unstable interface is imaged with a short-pulse laser-driven (PICO2000) x-ray source, providing an unprecedented simultaneous high spatial (24µm) and temporal (10 ps) resolution. This experiment provides relevant data to compare with astrophysical codes, as observational data on the development of RTI at the early stage of the SNR expansion are missing. A comparison is also performed with FLASH radiative magnetohydrodynamic simulations.

Retrieving fields from proton radiography without source profiles.

Proton radiography is a technique in high-energy density science to diagnose magnetic and/or electric fields in a plasma by firing a proton beam and detecting its modulated intensity profile on a screen. Current approaches to retrieve the integrated field from the modulated intensity profile require the unmodulated beam intensity profile before the interaction, which is rarely available experimentally due to shot-to-shot variability. In this paper, we present a statistical method to retrieve the integrated field without needing to know the exact source profile. We apply our method to experimental data, showing the robustness of our approach. Our proposed technique allows for the retrieval not only of the path-integrated fields, but also of the statistical properties of the fields.

Laboratory study of stationary accretion shock relevant to astrophysical systems.

Accretion processes play a crucial role in a wide variety of astrophysical systems. Of particular interest are magnetic cataclysmic variables, where, plasma flow is directed along the star's magnetic field lines onto its poles. A stationary shock is formed, several hundred kilometres above the stellar surface; a distance far too small to be resolved with today's telescopes. Here, we report the results of an analogous laboratory experiment which recreates this astrophysical system. The dynamics of the laboratory system are strongly influenced by the interplay of material, thermal, magnetic and radiative effects, allowing a steady shock to form at a constant distance from a stationary obstacle. Our results demonstrate that a significant amount of plasma is ejected in the lateral direction; a phenomenon that is under-estimated in typical magnetohydrodynamic simulations and often neglected in astrophysical models. This changes the properties of the post-shock region considerably and has important implications for many astrophysical studies.

Tuning porosity in macroscopic monolithic metal-organic frameworks for exceptional natural gas storage.

Widespread access to greener energy is required in order to mitigate the effects of climate change. A significant barrier to cleaner natural gas usage lies in the safety/efficiency limitations of storage technology. Despite highly porous metal-organic frameworks (MOFs) demonstrating record-breaking gas-storage capacities, their conventionally powdered morphology renders them non-viable. Traditional powder shaping utilising high pressure or chemical binders collapses porosity or creates low-density structures with reduced volumetric adsorption capacity. Here, we report the engineering of one of the most stable MOFs, Zr-UiO-66, without applying pressure or binders. The process yields centimetre-sized monoliths, displaying high microporosity and bulk density. We report the inclusion of variable, narrow mesopore volumes to the monoliths' macrostructure and use this to optimise the pore-size distribution for gas uptake. The optimised mixed meso/microporous monoliths demonstrate Type II adsorption isotherms to achieve benchmark volumetric working capacities for methane and carbon dioxide. This represents a critical advance in the design of air-stable, conformed MOFs for commercial gas storage.

Supersonic plasma turbulence in the laboratory.

The properties of supersonic, compressible plasma turbulence determine the behavior of many terrestrial and astrophysical systems. In the interstellar medium and molecular clouds, compressible turbulence plays a vital role in star formation and the evolution of our galaxy. Observations of the density and velocity power spectra in the Orion B and Perseus molecular clouds show large deviations from those predicted for incompressible turbulence. Hydrodynamic simulations attribute this to the high Mach number in the interstellar medium (ISM), although the exact details of this dependence are not well understood. Here we investigate experimentally the statistical behavior of boundary-free supersonic turbulence created by the collision of two laser-driven high-velocity turbulent plasma jets. The Mach number dependence of the slopes of the density and velocity power spectra agree with astrophysical observations, and supports the notion that the turbulence transitions from being Kolmogorov-like at low Mach number to being more Burgers-like at higher Mach numbers.

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

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<0.0001. 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.

TRPV4 inhibition attenuates stretch-induced inflammatory cellular responses and lung barrier dysfunction during mechanical ventilation.

Mechanical ventilation is an important tool for supporting critically ill patients but may also exert pathological forces on lung cells leading to Ventilator-Induced Lung Injury (VILI). We hypothesised that inhibition of the force-sensitive transient receptor potential vanilloid (TRPV4) ion channel may attenuate the negative effects of mechanical ventilation. Mechanical stretch increased intracellular Ca2+ influx and induced release of pro-inflammatory cytokines in lung epithelial cells that was partially blocked by about 30% with the selective TRPV4 inhibitor GSK2193874, but nearly completely blocked with the pan-calcium channel blocker ruthenium red, suggesting the involvement of more than one calcium channel in the response to mechanical stress. Mechanical stretch also induced the release of pro-inflammatory cytokines from M1 macrophages, but in contrast this was entirely dependent upon TRPV4. In a murine ventilation model, TRPV4 inhibition attenuated both pulmonary barrier permeability increase and pro-inflammatory cytokines release due to high tidal volume ventilation. Taken together, these data suggest TRPV4 inhibitors may have utility as a prophylactic pharmacological treatment to improve the negative pathological stretch-response of lung cells during ventilation and potentially support patients receiving mechanical ventilation.

Laboratory evidence of dynamo amplification of magnetic fields in a turbulent plasma.

Magnetic fields are ubiquitous in the Universe. The energy density of these fields is typically comparable to the energy density of the fluid motions of the plasma in which they are embedded, making magnetic fields essential players in the dynamics of the luminous matter. The standard theoretical model for the origin of these strong magnetic fields is through the amplification of tiny seed fields via turbulent dynamo to the level consistent with current observations. However, experimental demonstration of the turbulent dynamo mechanism has remained elusive, since it requires plasma conditions that are extremely hard to re-create in terrestrial laboratories. Here we demonstrate, using laser-produced colliding plasma flows, that turbulence is indeed capable of rapidly amplifying seed fields to near equipartition with the turbulent fluid motions. These results support the notion that turbulent dynamo is a viable mechanism responsible for the observed present-day magnetization.

A 'mixed reality' simulator concept for future Medical Emergency Response Team training.

The UK Defence Medical Service's Pre-Hospital Emergency Care (PHEC) capability includes rapid-deployment Medical Emergency Response Teams (MERTs) comprising tri-service trauma consultants, paramedics and specialised nurses, all of whom are qualified to administer emergency care under extreme conditions to improve the survival prospects of combat casualties. The pre-deployment training of MERT personnel is designed to foster individual knowledge, skills and abilities in PHEC and in small team performance and cohesion in 'mission-specific' contexts. Until now, the provision of airborne pre-deployment MERT training had been dependent on either the availability of an operational aircraft (eg, the CH-47 Chinook helicopter) or access to one of only two ground-based facsimiles of the Chinook's rear cargo/passenger cabin. Although MERT training has high priority, there will always be competition with other military taskings for access to helicopter assets (and for other platforms in other branches of the Armed Forces). This paper describes the development of an inexpensive, reconfigurable and transportable MERT training concept based on 'mixed reality' technologies-in effect the 'blending' of real-world objects of training relevance with virtual reality reconstructions of operational contexts.

Spleen tyrosine kinase inhibition blocks airway constriction and protects from Th2-induced airway inflammation and remodeling.

BACKGROUND: Spleen tyrosine kinase (Syk) is an intracellular nonreceptor tyrosine kinase, which has been implicated as central immune modulator promoting allergic airway inflammation. Syk inhibition has been proposed as a new therapeutic approach in asthma. However, the direct effects of Syk inhibition on airway constriction independent of allergen sensitization remain elusive. METHODS: Spectral confocal microscopy of human and murine lung tissue was performed to localize Syk expression. The effects of prophylactic or therapeutic Syk inhibition on allergic airway inflammation, hyperresponsiveness, and airway remodeling were analyzed in allergen-sensitized and airway-challenged mice. The effects of Syk inhibitors BAY 61-3606 or BI 1002494 on airway function were investigated in isolated lungs of wild-type, PKCα-deficient, mast cell-deficient, or eNOS-deficient mice. RESULTS: Spleen tyrosine kinase expression was found in human and murine airway smooth muscle cells. Syk inhibition reduced allergic airway inflammation, airway hyperresponsiveness, and pulmonary collagen deposition. In naïve mice, Syk inhibition diminished airway responsiveness independently of mast cells, or PKCα or eNOS expression and rapidly reversed established bronchoconstriction independently of NO. Simultaneous inhibition of Syk and PKC revealed additive dilatory effects, whereas combined inhibition of Syk and rho kinase or Syk and p38 MAPK did not cause additive bronchodilation. CONCLUSIONS: Spleen tyrosine kinase inhibition directly attenuates airway smooth muscle cell contraction independent of its protective immunomodulatory effects on allergic airway inflammation, hyperresponsiveness, and airway remodeling. Syk mediates bronchoconstriction in a NO-independent manner, presumably via rho kinase and p38 MAPK, and Syk inhibition might present a promising therapeutic approach in chronic asthma as well as acute asthma attacks.

Scaled laboratory experiments explain the kink behaviour of the Crab Nebula jet.

The remarkable discovery by the Chandra X-ray observatory that the Crab nebula's jet periodically changes direction provides a challenge to our understanding of astrophysical jet dynamics. It has been suggested that this phenomenon may be the consequence of magnetic fields and magnetohydrodynamic instabilities, but experimental demonstration in a controlled laboratory environment has remained elusive. Here we report experiments that use high-power lasers to create a plasma jet that can be directly compared with the Crab jet through well-defined physical scaling laws. The jet generates its own embedded toroidal magnetic fields; as it moves, plasma instabilities result in multiple deflections of the propagation direction, mimicking the kink behaviour of the Crab jet. The experiment is modelled with three-dimensional numerical simulations that show exactly how the instability develops and results in changes of direction of the jet.

A pilot study to evaluate the utility of live training (LIVEX) in the operational preparedness of UK military trauma teams.

BACKGROUND: With the end of UK military operations in Iraq and Afghanistan, it is essential that peacetime training of Defence Medical Services (DMS) trauma teams ensures appropriate future preparedness. A new model of pre-deployment training involves placement of formed military trauma teams into civilian trauma centres. This study evaluates the benefit of 'live training during an exercise period' (LIVEX) for DMS trauma teams. METHODS: A cross-sectional questionnaire-based survey of participants was conducted. Quantitative data were collected prior to the start and on the final day. Written reports were collected from the coordinators. Thematic analysis was used to identify emergent themes in a supplementary, qualitative analysis. RESULTS: Each team comprised 13 personnel and results should be interpreted with knowledge of this small sample size. The response rate for both the pre-LIVEX and post-LIVEX questionnaire was 100%. By the end of the week, 89% of participants (n=23) stated LIVEX was an 'appropriate or very appropriate' way of preparing for an operational role compared with 40% (n=9) before the exercise (p<0.01). However, completing LIVEX made no difference to participants' personal perception of their own operational preparedness. Thematic analysis suggested greater training benefit for more junior members of the team; from Regulars and Reservists training together; and from two-way exchange of information between DMS and National Health Service medical staffs. CONCLUSIONS: Completing LIVEX made no statistically significant difference to participants' personal perception of their own operational preparedness, but the perception of LIVEX as an appropriate training platform improved significantly after conducting the training exercise.