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.

Use of transcranial low-intensity focused ultrasound for targeted delivery of stem cell-derived exosomes to the brain

The blood-brain barrier (BBB) presents a significant challenge for targeted drug delivery. A proposed method to improve drug delivery across the BBB is focused ultrasound (fUS), which delivers ultrasound waves to a targeted location in the brain and is hypothesized to open the BBB. Furthermore, stem cell-derived exosomes have been suggested as a possible anti-inflammatory molecule that may have neural benefits, if able to pass the BBB. In the present study, transcranial low-intensity focused ultrasound (LIFU), without the use of intravenous microbubbles, was assessed for both (1) its ability to influence the BBB, as well as (2) its ability to increase the localization of intravenously administered small molecules to a specific region in the brain. In vivo rat studies were conducted with a rodent-customized 2 MHz LIFU probe (peak pressure = 1.5 MPa), and injection of labeled stem cell-derived exosomes. The results suggested that LIFU (without microbubbles) did not appear to open the BBB after exposure times of 20, 40, or 60 min; instead, there appeared to be an increase in transcytosis of the dextran tracer. Furthermore, the imaging results of the exosome study showed an increase in exosome localization in the right hippocampus following 60 min of targeted LIFU.

The Importance of Multi-Parametric MRI, PET/CT, and Biopsy for Identifying and Delineating the Extent of Locally Radiorecurrent Prostate Cancer: A Multi-institutional Analysis of the F-SHARP Clinical Trial

PURPOSE/OBJECTIVE(S)

Up to 50% of clinical recurrences after curative-intent radiation are intraprostatic local radiorecurrences (LRR), with improved detection through the recent incorporation of multi-parametric MRI and PET/CT in workup. Salvage local therapy (SLT) is increasingly being offered, particularly focal SLT to try to reduce toxicity due to prior radiation. Limited data exist on the incremental value of each imaging modality and biopsy in defining LRR. The objective of this study is to compare the findings of MRI, PET/CT and biopsy in patients with LRR prostate cancer, and the impact each modality has on identifying recurrence and defining the extent of prostate involvement.

MATERIALS/METHODS

This is a secondary analysis of 58 patients enrolled on the ongoing F-SHARP phase I/II clinical trial of salvage HDR brachytherapy from 3 institutions who underwent PSMA or fluciclovine PET/CT, MRI, and biopsy prior to enrollment. Recurrent tumor was delineated on each imaging modality and by inclusion of involved regions on biopsy. Descriptive statistics were used to compare the imaging-defined tumor with biopsy findings to assess the congruence between the imaging modalities and generate the percentage of patients with disease involvement on biopsy outside of the image-defined targets.

RESULTS

Initial therapy was conventional/moderately hypofractionated photons in 35 patients, LDR in 13, proton therapy in 7, SBRT in 2, and neutrons in 1. Recurrence Gleason grade groups included 1 (n = 3), 2 (17), 3 (12), 4 (8), 5 (9), and uninterpretable (9). MRI/TRUS sextant + fusion biopsy was performed in 40 patients, TRUS saturation biopsy in 4, and TRUS systematic biopsy in 14. The median number of cores involved and obtained were 6 and 14. The median number of discrete lesions on biopsy in different quadrants of the prostate was 3 (1-6). The median number of discrete lesions seen on MRI was 1 (0-4). MRI did not identity a discrete lesion in 4 patients. The sensitivity of MRI for detection of the LRR was 92.8%. The false negative rate for not detecting the focus of LRR on MRI was 7.2%. 68.4% of patients had biopsy-proven cancer outside of the MRI-defined target. Fluciclovine PET/CT was used in 45 patients, and 13 had PSMA PET/CT. The median number of lesions on PET/CT was 1 (0-2). PET/CT did not identify a discrete lesion in 8 patients. The pooled sensitivity of PET/CT in detecting the focus of LRR was 86.2% (Fluciclovine: 82.2%, PSMA: 100%). PET/CT false negative rate of PET/CT for not detecting the focus of LRR was 13.8% (Fluciclovine: 17.8%, PSMA 0%). 72.41% of patients had biopsy-proven cancer outside of the PET/CT-defined target (Fluciclovine: 77.8%, PSMA: 53.8%).

CONCLUSION

Although mpMRI and PET/CT are valuable tools for identifying LRR and delineating the extent of prostate/SV involvement, a thorough biopsy is mandatory if pursuing focal SLT. Such treatment should optimally be performed on a clinical trial with robust integration of all imaging and histopathologic data.

Prevalence of Trauma History and Symptoms in Patients Who Have Received Vaginal Brachytherapy as Part of their Endometrial Cancer Treatment

PURPOSE/OBJECTIVE(S)

Vaginal brachytherapy (VBT) is an essential component of curative intent treatment for many patients with endometrial cancer. The prevalence of trauma history in this population is unknown and is important to understand considering VBT requires patients to have an instrument vaginally inserted while in the vulnerable lithotomy position. We aim to retrospectively identify patients treated with VBT for early-stage endometrial cancer and collect survey data to assess the prevalence of trauma history, whether VBT re-induced trauma symptoms, and whether VBT was considered an independent traumatic event by patients.

MATERIALS/METHODS

We retrospectively identified patients with endometrial cancer treated with VBT at our institution from January 2017 to August 2022. Patients were mailed a cover letter and unique-identifier coded survey that included the Brief Trauma Questionnaire (BTQ) and Primary Care Post Traumatic Stress Disorder Screen for DSM-V (PC-PTSD-5), both validated instruments. Patients were instructed to fill out the surveys as it relates to their trauma history prior to VBT and again considering any trauma symptomatology related to VBT. BTQ was interpreted as positive if the patient responded yes to any question. PC-PTSD-5 was interpreted positive if the patient responded yes to at least 3 questions. Electronic medical record review was performed to identify clinical and pathologic features. Descriptive statistics and qualitative analysis were used to assess survey responses.

RESULTS

A total of 51 of 206 patients returned the survey at the time of interim analysis. 43 patients (84%) screened positive on the BTQ for having trauma history. Of those patients, 7 (16%) screened positive on the PC-PTSD-5 for a probable PTSD diagnosis. Additionally, 22 (51%)/18 (42%) patients answered yes to at least one/two symptoms on the PC-PTSD-5 respectively. Of the patients who answered yes to at least one question on the PC-PTSD-5, 18% (4 patients) responded that VBT triggered flashbacks of their past trauma. Regarding PC-PTSD-5 considering trauma symptomatology related to VBT, 20 patients (39%) answered yes to any question, though only 2 patients (4%) met the threshold to screen positive for probable PTSD. 20 patients (39%) indicated they would have accepted a referral to psychology before or during VBT. Suggested improvements made via free text responses included minimizing the time the cylinder was inserted and eliminating the need to transfer via hallway from the simulation room to the treatment room.

CONCLUSION

This study provides a baseline for understanding the prevalence of trauma history and trauma related to VBT in patients with endometrial cancer. This data can be used to guide patient centered discussions of endometrial cancer care, importantly including to counsel patients that a possible toxicity of VBT is trauma symptomatology, particularly for those with a history of trauma.

A Multi-Institutional Analysis of MRI-Based Brachytherapy for Medically Inoperable Endometrial Cancer

PURPOSE/OBJECTIVE(S)

Patients with medically inoperable endometrial cancer (MIEC) are curable with brachytherapy (BT)-based treatment yet have competing comorbidities making definitive treatment challenging. MRI demonstrates superior soft tissue anatomy and target volume delineation but with limited data in MIEC patients. We aim to report disease and toxicity outcomes with MRI-based BT and identify dose-volume relationships for toxicities in the treatment of MIEC patients treated with MRI-based BT.

MATERIALS/METHODS

We conducted a retrospective multi-institutional analysis of MIEC patients undergoing definitive MRI-based BT (+/- EBRT). MRI-based BT was delivered with the applicator in situ or coregistered to a planning CT. We identified patient, tumor, and dosimetric factors associated with disease and toxicity outcomes. Kaplan-Meier method was used for survival estimates. Log rank test and Cox proportional hazards were used for univariate and multivariate analyses, respectively. T-test was used for dose-volume toxicity analysis.

RESULTS

A total of 120 patients were included with a median follow up of 28.0 months. Median age was 68.5 years. ECOG PS was 0-1 in 70%. Clinical stage I was 83.3% and II-IV, 16.7%. Most patients (91.7%) were node negative. Endometrioid and high risk histologies comprised 83.3%, and 16.7%, respectively. EBRT + BT was delivered in 97 patients (80.8%) and BT alone in 23 patients (19.2%). Chemotherapy or hormonal therapy was delivered during treatment in 10 (8.3%) and 11 (9.2%) patients, respectively. Estimated 3-year freedom from local, nodal, and distant recurrence were 88.0%, 96.0%, and 89.1% respectively. Estimated 3-year PFS and OS were 60.9% and 62.9%, respectively. On UVA, older age, PS ≥2, high risk histology, higher grade, and larger GTV at BT were significant (p<0.1). On MVA, older age, higher grade, and larger GTV at BT (p<0.05) predicted for inferior PFS. Fifteen late grade ≥3 toxicities were experienced in 14 (11.6%) patients, 13 of whom received EBRT and BT and 1 who received BT alone. Grade ≥3 toxicities were rectal (2, 1.7%), sigmoid (8, 6.7%), bowel (1, 0.8%), bladder (3, 2.5%), and osseous (1, 0.8%). EBRT was delivered in 7 of 8 sigmoid toxicities. Median sigmoid doses (EQD2a/b = 3Gy) for patients with and without late grade ≥3 sigmoid toxicity were 69.6 Gy and 64.3 Gy, respectively (p = 0.009).

CONCLUSION

MRI-based BT for MIEC patients results in high rates of local control and favorable rates of late grade ≥3 morbidity. Older age, higher grade, and larger GTV at BT predicted for poorer PFS. Sigmoid colon was the predominant organ at risk for grade ≥3 toxicity with a dose -volume relationship observed. Attention to the location of the sigmoid throughout the treatment course may add insight into its predilection for risk. Future work will include additional institutions and dose-volume relationships of target volumes and normal tissues for further disease control and toxicity analysis.

Impact of poor air quality while deployed on respiratory health: a systematic review

INTRODUCTION

British military personnel deploy internationally to areas with high levels of ambient air pollution. Air pollution can cause acute respiratory symptoms which lead to concern about potential long-lasting health effects. There is a requirement for evidence-based policy on chronic respiratory disease associated with military deployments to areas with poor air quality (AQ). This literature review examines the published evidence relating to the development of chronic respiratory disease in military personnel after exposure to poor AQ while deployed.

METHODS

A literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Embase, MEDLINE and Global health databases were searched for English language studies published since 2014 examining the respiratory health of military personnel deployed to Southwest Asia since 2001. A quality appraisal of selected articles was conducted using the Critical Appraisals Skills Programme checklist and a descriptive review completed.

RESULTS

Eleven studies were found, eight of which had objective outcome measures. Two prospective cohort studies were included; the remainder of the data were retrospective.

CONCLUSION

High rates of respiratory symptoms are reported by personnel who deploy to areas of poor AQ, giving rise to high levels of concern. Spirometry testing has found mild deficits, mostly of an obstructive nature, in a third of those with ongoing symptoms post deployment. These have not been consistently linked with deployment length. An increased risk of asthma appears to be multi-factorial in aetiology and there is no evidence for an increased risk of chronic obstructive pulmonary disease or histological pathology post deployment. At present, there is no definitive evidence of chronic respiratory disease due to exposure to poor AQ while deployed. Further objective longitudinal studies are required to continue to investigate the association, diagnosis and management of those with ongoing symptoms.

Comparison between Defence Healthcare Engagement and humanitarian assistance

Humanitarian assistance and Defence Healthcare Engagement have traditionally both been taught on the Medical Humanitarian Stabilisation Operations Course. However, the two activities are distinct. This paper outlines the critical differences between them, focusing on their specific purposes, scope, timescales and ethics. Humanitarian assistance will remain a distinct activity with a focus on the relief of suffering, guided by international norms, while Defence Healthcare Engagement will encompass a broader range of activities, less constrained by internationally agreed principles. This presents an opportunity for the Defence Medical Services to directly contribute to projecting UK influence, preventing conflict and building stability. However, it requires the Defence Medical Services to take responsibility for the ethical issues that Defence Healthcare Engagement raises. This paper recommends the development of an ethical framework that reconciles the strategic aims of Defence Healthcare Engagement with maximising patient welfare at the tactical level. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

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.

Retrospective spatial analysis of cases of COVID-19 in a single military accommodation block corridor, RMAS, January-March 21

Shared ablutions and stairwells, corridor cross-ventilation and non-deliberate perflation (natural draft blowing through a space) are potential risk factors for COVID-19 transmission in corridor-based accommodation. This paper uses retrospective spatial analysis to identify potential built environmental risk factors during the January-March 2021 outbreak in Victory College, Royal Military Academy Sandhurst.Distance was measured in units of single room spacing. Odds, ORs and 95% CIs were calculated to identify and measure associations between distance from exposure and having COVID-19. Distance response trends were assessed using Pearson's χ2 for trend test. Linear relationships were tested using the t-test or rank-sum test.Stairwells and ablutions were not identified as likely sources of infection for all corridor occupants. Assuming occupants used their nearest ablutions, closer distance among those attributed to using ablutions 2 (one of four sets of ablutions), was identified as a risk factor (p=0.05). Testing distance response by χ2 linear trend testing showed a potential association between nearest adjacent positive room and COVID-19 (p=0.06), strongest if dominant air movement along the corridor length was from the left (p=0.10) compared with the right (p=0.24).Formal qualitative spatial analysis and environmental assessment of ventilation and air movement has a role in outbreak investigation in assessing factors related to the built environment. Environmental investigations would best inform outbreak investigations if undertaken contemporaneously. Pre-emptive and retrospective studies can help inform public health advice to military establishments in business continuity planning for isolation facilities, during outbreaks or in future development of the built environment.

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.

European Hernia Society guidelines on management of rectus diastasis

BACKGROUND

The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD.

METHOD

The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated.

RESULTS

Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias.

CONCLUSION

RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.

Microbial composition and omasal flows of bacterial, protozoal, and nonmicrobial amino acids in lactating dairy cows fed fresh perennial ryegrass (Lolium perenne L.) not supplemented or supplemented with rolled barley

The objective of this study was to evaluate the effect of rolled barley supplementation on microbial composition and omasal flows of bacterial, protozoal, and nonmicrobial AA in cows fed fresh perennial ryegrass (Lolium perenne L.; PRG). Ten ruminally cannulated multiparous Holstein cows averaging (mean ± standard deviation) 49 ± 23 d in milk and 513 ± 36 kg of body weight were assigned to 1 of 2 treatments in a switchback design. The treatment diets were PRG only or PRG plus 3.5 kg of dry matter rolled barley (G+RB). The study consisted of three 29-d periods where each period consisted of 21 d of diet adaptation and 8 d of data and sample collection. A double-marker system was used to quantify nutrient flow entering the omasal canal along with ¹⁵N-ammonium sulfate to label and measure the microbial and nonmicrobial omasal flow of AA. Overall, rolled barley supplementation had no effect on the AA composition of the omasal liquid-associated and particle-associated bacteria. Rolled barley supplementation affected the AA concentrations of omasal protozoa; however, the differences were nutritionally minor. Particle-associated bacteria AA flow was increased for all AA, except for Trp and Pro, in cows fed the G+RB diet. Rolled barley supplementation had no effect on protozoal AA flow. On average, protozoa accounted for 23% of the microbial essential AA flow, which ranged from 17 to 28% for Trp and Lys, respectively. The flow of all AA in omasal true digesta increased in cows fed the G+RB diet compared with the PRG-only diet, resulting in a 228 g/d increase in total AA flow in cows fed the G+RB diet. This increase in total AA flow in cows fed the G+RB diet was due to an increase in microbial AA flow. Rolled barley supplementation had no effect on nonmicrobial AA flow. The nonmicrobial AA flow modestly contributed to total AA flow, accounting for 15.6% on average. These results indicated that extensive ruminal degradation of PRG AA occurred (83.5%), and we demonstrated that cows consuming PRG-based diets exhibit a large dependence on microbial AA to support metabolizable AA supply. Rolled barley supplementation can increase the omasal flow of microbial AA in cows consuming PRG-based diets. However, further research is required to elucidate if this increased AA supply can support higher milk yield under such dietary conditions.

Recovery of individual Service personnel in the COVID-19 recovery phase

To deny the SARS-CoV-2 virus easy options for sustained transmission, commanders should model adherence to, and ensure implementation of, social mitigation measures. While some measures can be achieved at the organisational level through policy, every Service person's experience of the COVID-19 pandemic will have differed, affected by a range of personal, occupational and geographical factors. A successful recovery phase for each Service personnel (SP) therefore relies on localised assessments and individualised support plans. The return of SP to the physical environment must be safe, and the financial needs of their whole family must be considered. Commanders must understand the need for balance in supporting social reconnection both personally and in the workplace. Commanders have an important role in the development of SPs' mental resilience; supporting mental well-being, early recognition of deteriorating mental health and signposting, and compassionate understanding of the needs of SP deployed or bereaved. Disruptions to healthcare service provision will impact the duration of medical downgrading, workforce capacity and operational effectiveness according to extant parameters, which must be understood by commanders. Likewise, functional fitness may have been adversely affected. Physical health and fitness recovery can be supported by time-based extensions to occupational health policy and graduated return to work physical training programmes.

Increased Notching of the Corpus Callosum in Fetal Alcohol Spectrum Disorder: A Callosal Misunderstanding?

BACKGROUND AND PURPOSE

In the medicolegal literature, notching of the corpus callosum has been reported to be associated with fetal alcohol spectrum disorders. Our purpose was to analyze the prevalence of notching of the corpus callosum in a fetal alcohol spectrum disorders group and a healthy population to determine whether notching occurs with increased frequency in the fetal alcohol spectrum disorders population.

MATERIALS AND METHODS

We performed a multicenter search for cases of fetal alcohol spectrum disorders and included all patients who had a sagittal T1-weighted brain MR imaging. Patients with concomitant intracranial pathology were excluded. The corpus callosum was examined for notches using previously published methods. A χ² test was used to compare the fetal alcohol spectrum disorders and healthy groups.

RESULTS

Thirty-three of 59 patients with fetal alcohol spectrum disorders (0-44 years of age) identified across all centers had corpus callosum notching. Of these, 8 had an anterior corpus callosum notch (prevalence, 13.6%), 23 had a posterior corpus callosum notch (prevalence, 39%), and 2 patients demonstrated undulated morphology (prevalence, 3.4%). In the healthy population, the anterior notch prevalence was 139/875 (15.8%), posterior notch prevalence was 378/875 (43.2%), and undulating prevalence was 37/875 (4.2%). There was no significant difference among the anterior (P = .635), posterior (P = .526), and undulating (P = .755) notch prevalence in the fetal alcohol spectrum disorders and healthy groups.

CONCLUSIONS

There was no significant difference in notching of the corpus callosum between patients with fetal alcohol spectrum disorders and the healthy population. Although reported to be a marker of fetal alcohol spectrum disorders, notching of the corpus callosum should not be viewed as a specific finding associated with fetal alcohol spectrum disorders.

Urinary LAM grade, culture positivity, and mortality among HIV-infected South African out-patients

SETTING

Four ambulatory clinics in Durban, South Africa.

OBJECTIVE

To test the relationships of patient characteristics, time to mycobacterial culture positivity, and mortality with urinary lipoarabinomannan (LAM) grade category.

DESIGN

Newly diagnosed human immunodeficiency virus (HIV) infected adults were screened for tuberculosis (TB) using sputum culture, tested for urinary LAM, and followed for up to 12 months. We performed multivariable ordinal logistic regression of risk factors for low (1 or 2) or high (3, 4, or 5) LAM grade. We used adjusted Cox regression models to determine the hazard ratios of time to culture positivity and death.

RESULTS

Among 683 HIV-infected adults, median CD4 count was 215 cells/mm³ (interquartile range 86-361 cells/mm³), 17% had culture-confirmed TB, and 11% died during follow-up. Smoking, tachycardia (pulse > 100 beats/minute), CD4 count < 100 cells/mm³, and TB culture positivity were each associated with higher LAM grade. In multivariate models, a high urine LAM grade was associated with four-fold increased hazard of culture positivity (P = 0.001) and two-fold increased hazard of mortality (P = 0.02). Among patients treated for TB, these associations were no longer statistically significant.

CONCLUSION

In this population, a higher urine LAM grade was associated with shorter time to culture positivity and mortality; however, these associations were not present for those starting anti-tuberculosis treatment.

Fumes and faeces in Kabul

Soldiers deploy worldwide, often in hostile and remote locations. Considerable effort is made to ensure British soldiers deploy to locations with the correct force health protection, such as vaccinations and antimalarial chemoprophylaxis. British soldiers are currently serving, among other places, in Kabul, Afghanistan. The poor air quality in this area is something that cannot be easily mitigated, other than advising to minimise time spent outdoors. This article reviews the data from a self-reported questionnaire about the respiratory symptoms soldiers experienced while serving in Kabul. It appears that during their deployment up to 90% of soldiers experienced nasal congestion, among other things. A detailed air quality study in the capital of Afghanistan may help us to better understand the reported symptoms and, if attributed to the air quality, to help provide better advice to those soldiers in the future.

Position statement on defining and standardizing an oncoplastic approach to breast-conserving surgery in Canada

Although mastectomy is an effective procedure, it can have a negative effect on body image, sense of attractiveness, and sexuality. As opposed to the combination of breast oncologic surgery and plastic surgery, whose primary focus is on replacing lost volume, breast-conserving oncoplastic surgery (ops) redistributes remaining breast tissue in a manner that requires vision, anatomic knowledge, and an appreciation of esthetics, symmetry, and breast function. Modern surgical treatment of breast cancer can be realized only with breast and plastic surgeons working together using oncoplastic techniques to deliver superior cosmetic and cancer outcomes alike. Using this collaborative approach, oncologic and plastic surgeons in Canada have a significant opportunity to improve the care of their breast cancer patients. We propose a tri-level classification for volume displacement procedures to act as a rubric for the training of general surgeons and oncologic breast surgeons in oncoplastic breast-conserving therapy techniques. It is our position that ops enhances outcomes for many women with breast cancer and should become part of the standard repertoire of procedures used by Canadian oncologic surgeons treating breast cancer.

Defining the Normal Dorsal Contour of the Corpus Callosum with Time

BACKGROUND AND PURPOSE

Morphological changes of the corpus callosum have been associated with a large number of congenital neurocognitive and psychiatric disorders. Focal defects or notches of the dorsal surface of the corpus callosum have not been well characterized. Our purpose was the following; 1) to characterize the dorsal contour of the corpus callosum during the life span, 2) to characterize the relationship of contour deviations to neighboring vessels, and 3) to determine whether contour deviations are congenital or acquired.

MATERIALS AND METHODS

We retrospectively reviewed normal sagittal T1-weighted brain MR images. A "notch" was defined as a concavity in the dorsal surface at least 1 mm in depth. The corpus callosum was considered to be "undulating" if there were >2 notches, including an anterior and posterior notch. The presence of a pericallosal artery and its relationship to a notch were assessed.

RESULTS

We reviewed 1639 MR imaging studies, spanning 0-89 years of age. A total of 1102 notches were identified in 823 studies; 344 (31%) were anterior, 660 (60%) were posterior, and 98 (9%), undulating. There was a positive correlation between the prevalence (P < .001) and depth (P = .028) of an anterior notch and age and a negative correlation between the prevalence of a posterior notch and age (P < .001). There was no difference between patient sex and corpus callosum notching (P = .884). Of the 823 studies with notches, 490 (60%) were associated with a pericallosal artery (P < .001).

CONCLUSIONS

The prevalence and depth of notches in the anterior corpus callosum increase significantly with age; this finding suggests that most notches are acquired. There is a significant positive association between the presence of a corpus callosum notch and adjacent pericallosal arteries, suggesting that this may play a role in notch formation.

The SK™ external fixation system: description of components, instrumentation, and application techniques

The SK™ external fixator was designed to overcome the problems commonly encountered with clinical use of the Kirschner-Ehmer (KE) splint. It enables the use of a range of different fixation pin diameters within a construct, improved pin centering within the bone, increased flexibility in frame construction and disassembly, and a decreased need for the use of full-pins to achieve fracture stabilization. The SK™ external fixator is available in three sizes: mini, small, and large. This report describes the components of the SK™ ESF system, the instrumentation needed to apply it, and the recommended application techniques.

Feeding by Leucopis argenticollis and Leucopis piniperda (Diptera: Chamaemyiidae) from the western USA on Adelges tsugae (Hemiptera: Adelgidae) in the eastern USA

Leucopis argenticollis (Zetterstedt) and Leucopis piniperda (Malloch) are known to feed on the lineage of Adelges tsugae Annand that is native to western North America, but it is not known if they will survive on the lineage that was introduced from Japan to the eastern USA. In 2014, western Leucopis spp. larvae were brought to the laboratory and placed on A. tsugae collected in either Washington (North American A. tsugae lineage) or Connecticut (Japanese lineage). There were no significant differences in survival or developmental times between flies reared on the two different adelgid lineages. In 2015 and 2016, western Leucopis spp. adults were released at two different densities onto enclosed branches of A. tsugae infested eastern hemlock (Tsuga canadensis (L.) Carr.) in Tennessee and New York. Cages were recovered and their contents examined 4 weeks after release at each location. Leucopis spp. larvae and puparia of the F1 generation were recovered at both release locations and adults of the F1 generation were collected at the Tennessee location. The number of Leucopis spp. offspring collected increased with increasing adelgid density, but did not differ by the number of adult flies released. Flies recovered from cages and flies collected from the source colony were identified as L.argenticollis and L. piniperda using DNA barcoding. These results demonstrate that Leucopis spp. from the Pacific Northwest are capable of feeding and developing to the adult stage on A. tsugae in the eastern USA and they are able to tolerate environmental conditions during late spring and early summer at the southern and northern extent of the area invaded by A. tsugae in the eastern USA.