Management of a large outbreak of COVID-19 at a British Army training centre: lessons for the future.

INTRODUCTION: The 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. METHODS: Testing 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. RESULTS: By 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. CONCLUSIONS: We 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.

Ballooning-Interchange Instability in the Near-Earth Plasma Sheet and Auroral Beads: Global Magnetospheric Modeling at the Limit of the MHD Approximation.

Explosive magnetotail activity has long been understood in the context of its auroral manifestations. While global models have been used to interpret and understand many magnetospheric processes, the temporal and spatial scales of some auroral forms have been inaccessible to global modeling creating a gulf between observational and theoretical studies of these phenomena. We present here an important step toward bridging this gulf using a newly developed global magnetosphere-ionosphere model with resolution capturing ≲ 30 km azimuthal scales in the auroral zone. In a global magnetohydrodynamic (MHD) simulation of the growth phase of a synthetic substorm, we find the self-consistent formation and destabilization of localized magnetic field minima in the near-Earth magnetotail. We demonstrate that this destabilization is due to ballooning-interchange instability which drives earthward entropy bubbles with embedded magnetic fronts. Finally, we show that these bubbles create localized field-aligned current structures that manifest in the ionosphere with properties matching observed auroral beads.

A modelling study of the budget impact of improved glycaemic control in adults with Type 1 diabetes in the UK.

AIMS: To develop a novel interactive budget impact model that assesses affordability of diabetes treatments in specific populations, and to test the model in a hypothetical scenario by estimating cost savings resulting from reduction in HbA1c from ≥69 mmol/mol (8.5%) to a target of 53 mmol/mol (7.0%) in adults with Type 1 diabetes in the UK. METHODS: A dynamic, interactive model was created using the projected incidence and progression over a 5-year horizon of diabetes-related complications (micro- and macrovascular disease, severe hypoglycaemia and diabetic ketoacidosis) for different HbA1c levels, with flexible input of population size, complications and therapy costs, HbA1c distribution and other variables. The model took a National Health Service and societal perspective. RESULTS: The model was developed, and in the proposed hypothetical situation, reductions in complications and expected costs evaluated. Achievement of target HbA1c in individuals with HbA1c ≥69 mmol/mol (8.5%) would reduce expected chronic complications from 6.8 to 1.2 events per 100 person-years, and diabetic ketoacidosis from 14.5 to 1.0 events per 100 person-years. Potential cumulative direct cost savings achievable in the modelled population were estimated at £687 m over 5 years (£5,585/person), with total (direct and indirect) savings of £1,034 m (£8,400/person). CONCLUSIONS: Implementation of strategies aimed at achieving target glucose levels in people with Type 1 diabetes in the UK has the potential to drive a significant reduction in complication costs. This estimate may provide insights into the potential for investment in achieving savings through improved diabetes care in the UK.

Artificial barriers prevent genetic recovery of small isolated populations of a low-mobility freshwater fish.

Habitat loss and fragmentation often result in small, isolated populations vulnerable to environmental disturbance and loss of genetic diversity. Low genetic diversity can increase extinction risk of small populations by elevating inbreeding and inbreeding depression, and reducing adaptive potential. Due to their linear nature and extensive use by humans, freshwater ecosystems are especially vulnerable to habitat loss and fragmentation. Although the effects of fragmentation on genetic structure have been extensively studied in migratory fishes, they are less understood in low-mobility species. We estimated impacts of instream barriers on genetic structure and diversity of the low-mobility river blackfish (Gadopsis marmoratus) within five streams separated by weirs or dams constructed 45-120 years ago. We found evidence of small-scale (<13 km) genetic structure within reaches unimpeded by barriers, as expected for a fish with low mobility. Genetic diversity was lower above barriers in small streams only, regardless of barrier age. In particular, one isolated population showed evidence of a recent bottleneck and inbreeding. Differentiation above and below the barrier (FST = 0.13) was greatest in this stream, but in other streams did not differ from background levels. Spatially explicit simulations suggest that short-term barrier effects would not be detected with our data set unless effective population sizes were very small (<100). Our study highlights that, in structured populations, the ability to detect short-term genetic effects from barriers is reduced and requires more genetic markers compared to panmictic populations. We also demonstrate the importance of accounting for natural population genetic structure in fragmentation studies.

Medical support to military airborne training and operations.

INTRODUCTION: Airborne operations enable large numbers of military forces to deploy on the ground in the shortest possible time. This however must be balanced by an increased risk of injury. The aim of this paper is to review the current UK military drop zone medical estimate process, which may help to predict the risk of potential injury and assist in planning appropriate levels of medical support. METHOD: In spring 2015, a British Airborne Battlegroup (UKBG) deployed on a 7-week overseas interoperability training exercise in the USA with their American counterparts (USBG). This culminated in a 7-day Combined Joint Operations Access Exercise, which began with an airborne Joint Forcible Entry (JFE) of approximately 2100 paratroopers.The predicted number of jump-related injuries was estimated using Parachute Order Number 8 (PO No 8). Such injuries were defined as injuries occurring from the time the paratrooper exited the aircraft until they released their parachute harness on the ground. RESULTS: Overall, a total of 53 (2.5%) casualties occurred in the JFE phase of the exercise, lower than the predicted number of 168 (8%) using the PO No 8 tool. There was a higher incidence of back (30% actual vs 20% estimated) and head injuries (21% actual vs 5% estimated) than predicted with PO No 8. CONCLUSION: The current method for predicting the incidence of medical injuries after a parachute drop using the PO No 8 tool is potentially not accurate enough for current requirements. Further research into injury rate, influencing factors and injury type are urgently required in order to provide an evidence base to ensure optimal medical logistical and clinical planning for airborne training and operations in the future.

Synergism between fluconazole and methylene blue-photodynamic therapy against fluconazole-resistant Candida strains.

Photodynamic therapy (PDT) has been proved to be effective against fungi and it may be employed as a coadjutant to conventional antifungal agents, leading to a more effective microbial control minimising side effects. This work evaluates the combined effect of PDT and fluconazole against resistant Candida albicans, Candida glabrata and Candida krusei. The yeasts were submitted to methylene blue-PDT (MB-PDT) in sub-inhibitory concentrations. In the present work, MB-PDT combined with fluconazole was more efficient in the inhibition of the C. albicans and C. glabrata than each treatment alone, being possible to infer that the treatments are synergic.

Identifying environmental correlates of intraspecific genetic variation.

Genetic variation is critical to the persistence of populations and their capacity to adapt to environmental change. The distribution of genetic variation across a species' range can reveal critical information that is not necessarily represented in species occurrence or abundance patterns. We identified environmental factors associated with the amount of intraspecific, individual-based genetic variation across the range of a widespread freshwater fish species, the Murray cod Maccullochella peelii. We used two different approaches to statistically quantify the relative importance of predictor variables, allowing for nonlinear relationships: a random forest model and a Bayesian approach. The latter also accounted for population history. Both approaches identified associations between homozygosity by locus and both disturbance to the natural flow regime and mean annual flow. Homozygosity by locus was negatively associated with disturbance to the natural flow regime, suggesting that river reaches with more disturbed flow regimes may support larger, more genetically diverse populations. Our findings are consistent with the hypothesis that artificially induced perennial flows in regulated channels may provide greater and more consistent habitat and reduce the frequency of population bottlenecks that can occur frequently under the highly variable and unpredictable natural flow regime of the system. Although extensive river regulation across eastern Australia has not had an overall positive effect on Murray cod numbers over the past century, regulation may not represent the primary threat to Murray cod survival. Instead, pressures other than flow regulation may be more critical to the persistence of Murray cod (for example, reduced frequency of large floods, overfishing and chemical pollution).

Proficiency testing assessments for nematode worm egg counting based on Poisson variation.

The Poisson distribution provides an appropriate model for the variation within laboratories in worm egg counting. This is demonstrated by the results from annual quality assessment exercises in which laboratories in Australia tested multiple samples from the same mixtures prepared using different worm egg densities. Confidence intervals based on simulations using the Poisson distribution are recommended in the analysis of the results to identify laboratories showing significant bias or overdispersion, hence indicating possible procedural errors.

Evaluation of a copro-antigen ELISA to detect Fasciola hepatica infection in sheep, cattle and horses.

OBJECTIVE: To determine the specificity and sensitivity of a commercial copro-antigen ELISA for the detection of Fasciola hepatica infection in cattle and sheep and to assess the suitability of the test for use in horses. METHODS: Testing was done on more than 100 negative faecal samples from each of sheep, cattle and horses and on at least 40 positive faecal samples from each species. Positive samples were selected based on a positive sedimentation test for liver fluke eggs. Faecal samples of animals from Western Australia, which is free of liver fluke infection, served as negative controls. Specificity and sensitivity were assessed for each species using the recommended kit cut-off and also custom cut-offs specific for each species based on the mean plus 3-fold standard deviation of the mean of the negative samples for each species. RESULTS: Using the cut-off recommended by the kit manufacturer, the specificity was 100% for all species and the sensitivity was 88%, 80% and 9% for sheep, cattle and horses, respectively. Using the lower custom cut-offs for each species improved the sensitivity to 100% for sheep, 87% for cattle and 28% for horses, while maintaining the specificity above 99% for all species. CONCLUSIONS: The sensitivity of the commercial copro-antigen ELISA can be improved by using custom cut-off values for each species. With this modification, it is a suitable alternative screening test to the currently used sedimentation test for border control of sheep and cattle movement. The test is not suitable for use in horses.

Risk factors for recurrent preterm birth in multiparous Utah women: a historical cohort study.

OBJECTIVE: To describe risk factors for recurrent preterm birth (PTB) in the second and third birth. DESIGN: Historical cohort study. SETTING: Utah, USA. POPULATION: Women who had their first three singleton live births in Utah between 1989 and 2007 and a preterm first or second birth were included. METHODS: Maternally linked birth records were used. Multivariable-adjusted risk ratios were calculated for recurrent PTB. Results were stratified by spontaneous and indicated PTB and by pattern of birth outcomes. MAIN OUTCOME MEASURES: Risk ratios and 95% confidence intervals for risk factors for recurrent PTB. RESULTS: Among women with PTB in their first or second live birth, recurrent PTB occurred in 21% of second live births (n = 1011/4805) and 22% of third live births (n = 1872/8468). Risk factors for recurrence included short inter-pregnancy interval, underweight prepregnancy body mass index, pre-existing maternal medical conditions, history of PTB at 28-32 weeks of gestation (versus 33-36 weeks), the presence of a fetal anomaly, and young maternal age. Risk factors for spontaneous, but not indicated PTB included young maternal age and less than appropriate gestational weight gain. Risk factors also varied in women experiencing a first versus second recurrence in their third birth. CONCLUSIONS: Risk factors may vary by the clinical subtype of the most recent PTB and the pattern of term and preterm outcomes across births 1-3; some of the risk factors identified in this study may be modifiable through interventions targeted at women in the inter-conception period.

What are the implications of variation in root hair length on tolerance to phosphorus deficiency in combination with water stress in barley (Hordeum vulgare)?

BACKGROUND AND AIMS: Phosphorus commonly limits crop yield and is frequently applied as fertilizer; however, supplies of quality rock phosphate for fertilizer production are diminishing. Plants have evolved many mechanisms to increase their P-fertilizer use efficiency, and an understanding of these traits could result in improved long-term sustainability of agriculture. Here a mutant population is utilized to assess the impact of root hair length on P acquisition and yield under P-deficient conditions alone or when combined with drought. METHODS: Mutants with various root hair phenotypes were grown in the glasshouse in pots filled with soil representing sufficient and deficient P treatments and, in one experiment, a range of water availability was also imposed. Plants were variously harvested at 7 d, 8 weeks and 14 weeks, and variables including root hair length, rhizosheath weight, biomass, P accumulation and yield were measured. KEY RESULTS: The results confirmed the robustness of the root hair phenotypes in soils and their relationship to rhizosheath production. The data demonstrated that root hair length is important for shoot P accumulation and biomass, while only the presence of root hairs is critical for yield. Root hair presence was also critical for tolerance to extreme combined P deficit and drought stress, with genotypes with no root hairs suffering extreme growth retardation in comparison with those with root hairs. CONCLUSIONS: The results suggest that although root hair length is not important for maintaining yield, the presence of root hairs is implicit to sustainable yield of barley under P-deficient conditions and when combined with extreme drought. Root hairs are a trait that should be maintained in future germplasm.

Structural identification of caged vanadium doped silicon clusters.

The geometry of cationic silicon clusters doped with vanadium, Si(n)V(+) (n=12-16), is investigated by using infrared multiple photon dissociation of the corresponding rare gas complexes in combination with ab initio calculations. It is shown that the clusters are endohedral cages, and evidence is provided that Si(16)V(+) is a fluxional system with a symmetric Frank-Kasper geometry.

Design and evaluation of a wireless electronic health records system for field care in mass casualty settings.

BACKGROUND: There is growing interest in the use of technology to enhance the tracking and quality of clinical information available for patients in disaster settings. This paper describes the design and evaluation of the Wireless Internet Information System for Medical Response in Disasters (WIISARD). MATERIALS AND METHODS: WIISARD combined advanced networking technology with electronic triage tags that reported victims' position and recorded medical information, with wireless pulse-oximeters that monitored patient vital signs, and a wireless electronic medical record (EMR) for disaster care. The EMR system included WiFi handheld devices with barcode scanners (used by front-line responders) and computer tablets with role-tailored software (used by managers of the triage, treatment, transport and medical communications teams). An additional software system provided situational awareness for the incident commander. The WIISARD system was evaluated in a large-scale simulation exercise designed for training first responders. A randomized trial was overlaid on this exercise with 100 simulated victims, 50 in a control pathway (paper-based), and 50 in completely electronic WIISARD pathway. All patients in the electronic pathway were cared for within the WIISARD system without paper-based workarounds. RESULTS: WIISARD reduced the rate of the missing and/or duplicated patient identifiers (0% vs 47%, p<0.001). The total time of the field was nearly identical (38:20 vs 38:23, IQR 26:53-1:05:32 vs 18:55-57:22). CONCLUSION: Overall, the results of WIISARD show that wireless EMR systems for care of the victims of disasters would be complex to develop but potentially feasible to build and deploy, and likely to improve the quality of information available for the delivery of care during disasters.

Magnetosphere sawtooth oscillations induced by ionospheric outflow.

The sawtooth mode of convection of Earth's magnetosphere is a 2- to 4-hour planetary-scale oscillation powered by the solar wind-magnetosphere-ionosphere (SW-M-I) interaction. Using global simulations of geospace, we have shown that ionospheric O(+) outflows can generate sawtooth oscillations. As the outflowing ions fill the inner magnetosphere, their pressure distends the nightside magnetic field. When the outflow fluence exceeds a threshold, magnetic field tension cannot confine the accumulating fluid; an O(+)-rich plasmoid is ejected, and the field dipolarizes. Below the threshold, the magnetosphere undergoes quasi-steady convection. Repetition and the sawtooth period are controlled by the strength of the SW-M-I interaction, which regulates the outflow fluence.

Preparing for an operational tour as a medical officer in southern.

At the time of writing, Afghanistan is the pre-eminent theatre of operations for UK military forces, which form a lead element in the International Security Assistance Force. Many junior medical officers (MOs) can expect to see service on Operation HERRICK in the south of the country, in support of deployed battlegroup formations. MO's will often find themselves supporting Company Group formations, either within the Company Aid Post, or on dismounted/vehicle borne operations. This article presents some of the challenges faced by those deployed in such circumstances, and proposes possible strategies to address them.

A randomised trial of home energy efficiency improvement in the homes of elderly COPD patients.

A randomised trial of 178 patients in Aberdeen, UK with a previous hospital admission for chronic obstructive pulmonary disease (COPD) was carried out in order to determine whether improving home energy efficiency improves health-related quality of life in COPD patients. 118 patients were randomised and 60 agreed to monitoring only. Energy efficiency upgrading was carried out in 42% of homes randomised to intervention. Independent energy efficiency action was taken by 15% of control participants and 18% in the monitoring group. The main outcome measures were respiratory and general health status, home energy efficiency and hospital admissions. Intention-to-treat analysis found no difference in outcomes between the two groups. In 45 patients, who had energy efficiency action independent of original randomisation, there were significant improvements in respiratory symptom scores (adjusted mean 9.0, 95% CI 2.5-15.5), decreases in estimated annual fuel costs (- pound65.3, 95% CI - pound31.9- - pound98.7) and improved home energy efficiency rating (1.1, 95% CI 0-1.4). COPD patients are unlikely to take up home energy efficiency upgrading, if offered. Secondary "pragmatic" analysis suggests that those who do take action may achieve clinically significant improvement in respiratory health, which is not associated with an increase in indoor warmth.

Mutants with heteroresistance to amphotericin B and fluconazole in Candida

Several studies have reported the occurrence of infections caused by Candida yeasts as well as the increasing prevalence of non albicans species. The aim of the present work is focused on the obtaining of heteroresistance to amphotericin B and fluconazole in Candida species using two distinct methodologies: selection and induction. Resistant samples were obtained by selective pressure using a medium with fluconazole for growth, followed by growth in a medium with amphotericin B. The selective pressure was also created beginning with growth in amphotericin B medium followed by growth in fluconazole medium. Concomitantly, samples were submitted to the induction of resistance through cultivation in increasing concentrations of fluconazole, followed by cultivation in increasing concentrations of amphotericin B. Subsequently, the induction began with amphotericin B followed by fluconazole. Three samples resistant to fluconazole and amphotericin B were obtained, two by induction (C. glabrata and C. tropicalis) and one by selection (C. tropicalis). Both C. tropicalis originated from the same wild sample. After successive transfers for drug free medium, only the sample obtained by selection was able to maintain the resistance phenotype. These results suggest that the phenotype of heteroresitance to fluconazole and amphotericin B can be produced by two methodologies: selection and induction.

Attention deficit hyperactivity disorder and increased risk of injury.

PURPOSE: This study describes the influence of attention deficit hyperactivity disorder (ADHD) on the incidence rates of selected injuries. METHODS: A retrospective cohort study design was employed using medical claims data from the Deseret Mutual Benefit Administrators (DMBA), a health insurance company for employees of the Church of Jesus Christ of Latter-day Saints (LDS) and their spouses and dependent children. ADHD diagnosis, injury, medication, and demographic data were extracted from claims files during 1998-2005 for all enrollees aged 0-64 years. RESULTS: Incidence rates of ADHD were 1.83 (95% CI 1.68-2.00) times greater in males than females and highest in the age group 5-9 years and income group $80,000 or greater. ADHD increased the risk of selected injuries. The most common injuries involved sprains and strains of joints, then open wounds of the head, neck and trunk, and upper/lower limb, and then fractures of the upper/lower limb. Medication did not significantly protect against injury in ADHD patients. The rate of severe injury (i.e., fracture of skull, neck and trunk; intracranial injury excluding those with skull fracture; and injuries to nerves and spinal cord) was 3.07 (95% CI 2.37-3.98) times more common in ADHD enrollees compared with non-ADHD enrollees. Those with 1, 2, 3, or 4 or more injuries were 1.67 (1.50-1.86), 2.11 (1.75-2.56), 2.63 (1.80-3.84), and 2.94 (1.47-5.87) times more likely to have ADHD, respectively. CONCLUSIONS: ADHD is positively associated with injuries. More severe injuries have a significantly stronger associated with ADHD than less severe injuries.

Mutants with heteroresistance to amphotericin B and fluconazole in Candida.

Several studies have reported the occurrence of infections caused by Candida yeasts as well as the increasing prevalence of non albicans species. The aim of the present work is focused on the obtaining of heteroresistance to amphotericin B and fluconazole in Candida species using two distinct methodologies: selection and induction. Resistant samples were obtained by selective pressure using a medium with fluconazole for growth, followed by growth in a medium with amphotericin B. The selective pressure was also created beginning with growth in amphotericin B medium followed by growth in fluconazole medium. Concomitantly, samples were submitted to the induction of resistance through cultivation in increasing concentrations of fluconazole, followed by cultivation in increasing concentrations of amphotericin B. Subsequently, the induction began with amphotericin B followed by fluconazole. Three samples resistant to fluconazole and amphotericin B were obtained, two by induction (C. glabrata and C. tropicalis) and one by selection (C. tropicalis). Both C. tropicalis originated from the same wild sample. After successive transfers for drug free medium, only the sample obtained by selection was able to maintain the resistance phenotype. These results suggest that the phenotype of heteroresitance to fluconazole and amphotericin B can be produced by two methodologies: selection and induction.