COVID-19: responding to a pandemic on Operation TORAL

Operation TORAL was the UK's contribution to NATO's Operation RESOLUTE SUPPORT in Kabul, Afghanistan. Approximately 1000 British troops were deployed in Kabul when the arrival of the COVID-19 pandemic in Afghanistan was declared. This article will describe the challenges faced due to COVID-19 in Kabul.Medical planning considerations, occupational health issues, implementation of behaviour change and operating as part of a multinational organisation are all discussed, with challenges encountered detailed and potential solutions offered. The use of a suggested framework for ensuring the medical estimate process covered all areas relevant to an emerging viral pandemic -the 4Ds and 4Cs approach-proved particularly useful in the early stages of the pandemic in Afghanistan.

Lightning in Brunei: a follow-up of a single strike affecting 29 serving personnel of the Royal Gurkha Rifles

INTRODUCTION

On 25 August 2020, 29 British Forces Brunei (BFB) service personnel were hospitalised after being struck by lightning during a company-level training exercise in the Brunei jungle. This paper observes both the initial injury pattern of the personnel and their occupational health status at the 22-month point.

METHOD

All 29 of the personnel affected by the lightning strike on 25 August 2020 were followed up until the 22-month point, allowing observation of injury patterns and management as well as the long-term outcomes. They were all members of two Royal Gurkha Rifles and received local hospital care and British Defence Healthcare input. Initial data were collected for mandatory reporting processes, and cases were followed up as a routine part of the Unit Health processes.

RESULTS

Of the 29 identified as having lightning-related injuries, 28 returned to Medically Fully Deployable status. Acoustic trauma was the most common injury which was treated in several cases by oral steroids with some receiving intratympanic steroids. Multiple personnel suffered transient or short-lasting sensory changes and pain. 1756 service personnel days were covered by restrictions.

CONCLUSION

The pattern of the lightning-related injuries was different to that which would be expected from previous reports. This is likely due to the unique nature of each lightning strike, combined with the ample unit support, the fit and resilient cohort and the rapid initiation of treatment, especially with regard to hearing.Brunei is at high risk of lightning strikes, planning for them is now standard for BFB. Despite lightning strikes having the potential to cause mortality and mass casualty events, this case study shows that such events do not necessarily result in severe long-term injury or mortality.

Priorities of primary care in disaster medicine

The role of primary care in a disaster has too often been poorly defined and poorly understood. Due to its relative low-cost adaptability and closeness to the community, primary care can treat across multiple medical domains. By interacting with stakeholders from international data collection, state health bodies and secondary care to community groups, primary care can generate effect. Minimal standards are defined by Sphere guidelines to work within international, national and local frameworks. Evolution of the understanding of primary care in disaster medicine has resulted in a greater emphasis on maintaining outputs. In a disaster, effect is maximised by using strong local and wider resiliency frameworks to enable adaptation to new inputs and outputs while continuing continuity of care while moving through the disaster cycle. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

The History of the Post-Graduate Medical and Nursing Officers (PGMNO) course in the British Army

Military medicine has been evolving for over 5000 years of recorded civilisation and conflict. The Army Medical Services performed poorly during the Crimean War and the British Army introduced a professional training course for medical officers in 1860. The Army Medical School and the predecessor of today's Post-Graduate Medical and Nursing Officers (PGMNO) course have had to adapt to changes in British foreign policy and military requirements. The Army Medical School instigated a rigorous scientific medical training which led to major advances in the study of tropical diseases and trauma medicine. These advances were quickly included in the training of future cohorts. Although the Army Medical School has now closed, the PGMNO course thrives at its new location at the Defence Medical Academy, Whittington. Modern general duties medical officers (GDMOs) must be able to provide medical care in a range of austere environments, including humanitarian relief and conflict zones. New clinicians complete their basic military training before completing the PGMNO course and the Diploma in the Medical Care of Catastrophes. This programme ensures that GDMOs and military nurse practitioners gain a wide knowledge of the latest military and humanitarian medicine. The current era will require clinicians who are competent generalists, who can perform in small teams in dispersed locations. This article summarises the development of the British Army's PGMNO course and the evolution of its syllabus as part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

1013 DIAGNOSTIC TEST ACCURACY OF FRAILTY SCREENING TOOLS USING DATA IN ELECTRONIC PRIMARY CARE RECORDS

Introduction

Targeted interventions aimed at people living with frailty key to NHS Strategy and is incentivised in the NHS England GP contract. eFrailty, and similar risk prediction tools aim to detect frail people automatically from their electronic primary care health-records and can predict mortality and hospital admission. We carried out a systematic review of currently available risk prediction tools to assess frailty using primary care data.

Method

We searched Medline, Pubmed, CENTRAL, CINHAL and Embase to identify studies comparing a frailty assessment utilising primary care records with face-to-face assessment with a healthcare professional. Studies were quality assessed using QUADAS-2. Sensitivity and specificity values were extracted directly or calculated and pooled using StatsDirect.

Results

The initial search generated 2,245 titles with 10 studies remaining for review after screening. This described 3 different index tests (electronic frailty index (eFI), claims-based frailty index (cFI), and polypharmacy. Frailty Phenotype was the reference standard in each study. 1 study of 60 patients, average age 80.2 examined eFI, with a pooled sensitivity of 0.84 (95% CI 0.55,0.98), and specificity of 0.78 (0.64,0.89). 2 studies of 7,679 patients, average age 75.5, examined cFI, with a pooled sensitivity of 0.84 (95% CI 0.55,0.98), and specificity of 0.78 (0.64,0.89). 7 studies of 34,328 patients, average age 77.4, examined a polypharmacy as a screening tool (defined as ≥5 medications) with a pooled sensitivity of 0.84 (95% CI 0.55,0.98), and specificity of 0.78 (0.64,0.89).

Conclusion

eFI performed best however, for an average UK GP practice with a list size of 10,000, 18% of patients aged over 65, of which 20% were frail, eFI would flag 597 as frail, of which 272 would be actually frail, and an additional 51 frail patients would be missed. In conclusion, existing frailty risk prediction tools would have strictly limited value in UK primary care currently.

Control of three gastrointestinal illness outbreaks in a British Role 1 facility in Afghanistan: a primary care perspective

INTRODUCTION

In 2019, Camp Qargha (QAA), a British-led multinational military camp in Kabul, had three of the largest outbreaks of gastrointestinal illness (GI) experienced by the British Military since 2003. This paper discusses the incidence, the response of the British-led Role 1 (R1) medical treatment facility, identifies potential causative and exacerbating factors, and explains the control measures initiated.

METHOD

GI in QAA results in local and UK military-wide data collection including in the form of local GI questionnaires, FMed85 forms and EpiNATO returns. The data from these was used to identify trends during and after outbreaks and produce environmental health (EH) and local outbreak reports.

RESULTS

Overall, among the outbreaks 56% of stool samples tested positive for norovirus. In each outbreak incidence peaked within the first 3 days, and hardened multiperson rooms were worst affected. 206 patient presentations occurred during the three outbreaks, 706 working days were lost in isolation, with QAA shut down while in quarantine for 27 days.

DISCUSSION

Significant strain was placed on QAA and the R1. Causative factors may include close interaction with the local national (LN) population, a high population density and accommodation being limited by specific national infrastructure protocols in an operational environment.

CONCLUSION

Early recognition of GI, positive standard operating procedures and good hygiene habits are essential to prevent the spread of GI such as norovirus. An early awareness of LN population illness patterns will allow the R1 and command to be better prepared for outbreaks in the future.

Nerve agents: emergency preparedness

Nerve agents (NAs) are a highly toxic group of chemical warfare agents. NAs are organophosphorus esters with varying physical and chemical properties depending on the individual agent. The most recently developed class of NA is ' Novichok ', the existence of which was first revealed in the early 1990s, just before Russia signed the Chemical Weapons Convention. In 1984, Iraq became the first nation to deploy NA on the battlefield when they used tabun against Iranian military forces in Majnoon Island near Basra. The first terrorist use of an NA is believed to be the attack in Matsumoto, Japan, on 27 June 1994 by the Aum Shinrikyo doomsday cult. Symptoms and ultimate toxicity from NA poisoning are related to the agent involved, the form and degree of exposure, and rapidity of medical treatment. The classic toxidrome of significant exposure to NA comprises bronchorrhoea, bronchospasm, bradycardia and convulsions, with an onset period of as early as a few seconds depending on the mode and extent of exposure. If medical management is not instituted rapidly, death may occur in minutes by asphyxiation and cardiac arrest. In the UK, emergency preparedness for NA poisoning includes an initial operational response programme across all blue light emergency services and key first responders. This paper describes the development, pathophysiology, clinical effects and current guidance for management of suspected NA poisoning. It also summarises the known events in which NA poisoning has been confirmed.

Can a weight management conditioning course help with armed forces recruitment?

British Armed Forces are facing the most significant recruitment crisis since 2010. An important contributing factor to the recruitment crisis is the rise in obesity of the UK population. At Army Training Centre Pirbright, a weight management programme (WMP) has been established for recruits who have failed their initial medical assessment (IMA). To determine the proportion of recruits who entered the WMP and passed basic and initial trade training, allowing entry into the British Army. Retrospective service evaluation of recruits entering WMP from inception in April 2015 to August 2018. Medical records were used to assess whether recruits completed initial training. 72.3% of recruits included in the WMP who would have previously failed their IMA because of a high body mass index (BMI) passed basic and initial trade training. This evaluation demonstrates potential for candidates otherwise excluded based on BMI. This WMP delivers structured nutritional support and encourages physical training. Once a BMI enters the accepted range, recruits could enter basic training. This WMP would deliver structured nutritional support and encourage physical training, with the aim of promoting healthy lifestyles. Neither the Royal Navy nor the Royal Air Force currently have a WMP. There is potential for WMPs to be introduced to all three services. UK Armed Forces face a recruitment crisis and need to be adaptable with a population where obesity is prevalent. At Pirbright 72.3% of candidates in the WMP passed basic and initial trade training.

How a major incident plan can be used in an acute healthcare setting

All NHS Trusts face a diverse range of potential threats and disruptions that can overwhelm the delivery of their routine healthcare services. Major incidents range from significant infrastructure failure to responding to significant casualty numbers from natural disasters and malicious incidents. Major incident plans are one of the body of documents that support trusts and in this instance acute NHS trusts in emergency preparedness. Major incident plans can be used as a reference point for staff of all disciplines, that is, clinical and non-clinical. Major incident plans incorporate the requirements of the Civil Contingencies Act 2004 for NHS-funded providers to ensure trusts conduct risk assessments, emergency planning, cooperating with other organisations, and internal and external communication. This paper summarises some of the key aspects in the construction and the use of major incident plans in acute care trusts.

Summary of latest NHS England Emergency Preparedness Resilience and Response (EPRR) guidance

The National Health Service (NHS) England Emergency Preparedness, Resilience and Response Framework exists to provide a structure by which NHS England and NHS-funded bodies prepare for and respond to a range of emergencies. This framework exists to ensure that in emergencies the NHS retains the capability to deliver appropriate care to patients. Rather than dealing with individual scenarios, the framework aims to maintain the adaptability and capacity to deal with a variety of emergencies, their consequences and guide recovery plans. This paper summarises this guidance and elucidates the reasoning and mechanisms by which this care will be facilitated and delivered.

A new class of hybrid super-supertetrahedral cluster and its assembly into a five-fold interpenetrating network

The first hybrid super-supertetrahedron, formed by five [Ga₁₀S₁₆L₄]²⁻ supertetrahedral clusters, is presented.

Perceived barriers to physical activity among high school students

BACKGROUND

Perceived barriers to physical activity, the factor structure of perceived barriers, and the relationship between perceived barriers and participation in vigorous physical activity were examined.

METHODS

A two-stage cluster sample of high school students (N = 1,041) in a large Metropolitan Toronto school district was used. Students completed a questionnaire (response rate 81.4%) dealing with participation in physical activity in three settings. Factor analysis was used to examine the dimensionality of perceived barriers. Multiple regression analysis was then used to examine the relationship between perceived barriers and participation.

RESULTS

Time constraints due to school work, other interests, and family activities were three of the four barriers considered most important. Females cited consistently higher levels of perceived barriers than males. Two empirically distinct and theoretically meaningful factors emerged from the analysis--perceived internal barriers and perceived external barriers. Perceived internal barriers were predictive of physical activity in overall activity and outside of school activity. Perceived external barriers were predictive of overall physical activity and other school activity, but in the direction opposite to that hypothesized.

CONCLUSIONS

It was concluded that perceived barriers may be predictive of physical activity participation among high school students only under specific conditions.

Self-efficacy and participation in vigorous physical activity by high school students

The relationship between physical activity self-efficacy and participation in vigorous physical activity by high school students is examined in this article. Self-efficacy is hypothesized to be positively related to participation in three settings (physical education class, other school-related activities, and outside of school). The effects of age, gender, perceived barriers, and actual barriers are also examined. The sample consists of 1,041 grade 9 and 11 students from a large Metropolitan Toronto school board. Factors derived from a previous (factor) analysis were used to examine the effects of self-efficacy, perceived barriers, and life strain (an actual barrier). The results of multiple regression analysis indicate that physical activity self-efficacy, despite external barriers (but not internal barriers), is predictive of physical activity participation in the hypothesized direction. Other results show consistent age and gender effects on physical activity participation and some support for the hypothesized relationship between perceived barriers and participation.

Internal structure of a measure of self-efficacy in physical activity among high school students

The preliminary development of a measure of self-efficacy to participate in vigorous physical activity when confronted with specific perceived barriers to physical activity is described. Measures used in previous research ([Hofstetter, C.R., Hovell, M.F., Sallis, J.F., 1990a. Social learning correlates of exercise self-efficacy: Early experiences with physical activity, Social Science and Medicine, 31, 1169-1176.]; [Hofstetter, C.R., Sallis, J.F., Hovell, M.F., 1990b. Some health dimensions of self-efficacy: Analysis of theoretical specificity, Social Science and Medicine, 31, 1051-1056.]; [Reynolds, K.D., Killen, J.D., Bryson, M.S., Maron, D.J., Taylor, C.B., Maccoby, N., Farquhar, J.W., 1990. Psychosocial predictors of physical activity in adolescents, Preventive Medicine, 19, 541-551.]; [Sallis, J.F., Pinski, R.B., Grossman, R.M., Patterson, T.L., Nader, P.R., 1988. The development of self-efficacy scales for health-related diet and exercise behaviors, Health Education Research, 3, 283-292.]) were adapted and original items were developed. The 20-item measure has a 5-point Likert format ranging from not at all confident (1) to very confident (5). An earlier pilot study of 200 secondary school students showed that the measure was free of social desirability. The data were derived from a survey of 1041 secondary school students from a Metropolitan Toronto board of education. Principal component analysis (PCA) with oblique rotation of the data yielded two factors: self-efficacy to overcome external barriers and self-efficacy to overcome internal barriers. The 12-item external barriers subscale had a coefficient alpha of 0.88 and the 8-item internal barriers subscale had a coefficient alpha of 0.87. The subscales significantly correlated with the frequency of participation in vigorous physical activity. In summary, the results provide some support for the internal consistency reliability, construct validity, criterion validity, and discriminant validity of the measure. Though further psychometric research is warranted, the self-efficacy measure shows promise for physical activity research.

Using a program logic model that focuses on performance measurement to develop a program

A program logic model is used to make a program ready for an evaluation. It diagrammatically shows the relationships between the objectives of the program, program activities, indicators, and resources. This article describes an expanded logic model that has a greater focus on measurement of program performance. The expanded logic model specifies both outcome and process indicators, whereas other logic models only show service delivery indicators. Also, this article describes how the expanded logic model was used to develop a bicycle safety program. A workgroup established program boundaries and reviewed documents early in the process of developing the logic model. The workgroup developed the logic model which was subsequently reviewed by other stakeholders. The workgroup continually assessed the plausibility of the logic model. Challenges and advantages in using the logic model are discussed.