Humanitarian Assistance Lessons Learned From Providing Acute Medical Care for Afghan Nationals on a U.S. Military Base.

Operation Allies Welcome provided a unique opportunity for military medical personnel to engage in humanitarian assistance operations on military bases in the USA. With thousands of Afghan nationals evacuated from Kabul in August 2021 to various military installations across the USA, the Military Health System was tasked with health screening, emergency care, and disease prevention and surveillance in resource-limited settings. Marine Corps Base Quantico served as a "safe haven" site from August to December 2021, providing refuge to nearly 5000 travelers awaiting resettlement. During this time, active duty medical personnel provided 10,122 primary and acute patient encounters to patients aged < 1 to 90 years. Pediatrics represented 44% of the total encounters and children aged less than 5 years represented nearly 62% of the pediatric visits. In caring for this population, the authors were able to learn important lessons about humanitarian assistance capabilities, the difficulties of establishing acute care centers in a resource-limited environment, and the importance of cultural competency. Recommendations include staffing with medical providers that can see a large volume of pediatric, obstetrics, and urgent care visits, with less emphasis on trauma and surgical capabilities, which are the more traditional focus of military medicine. To this end, the authors advocate for the creation of specific humanitarian assistance supply blocks that would focus more on urgent and primary care treatments as well as an ample supply of pediatric, neonatal, and prenatal medicines. Further, early engagement with telecommunications companies when practicing in a remote location can be crucial to mission success. Finally, the medical care team should maintain continued mindfulness of the cultural norms of the population to which aid is given, particularly the gender norms and expectations of Afghan nationals. The authors hope that these lessons can prove informative and may provide increased readiness for future humanitarian assistance missions.

Effectiveness of and Adherence to Triage Algorithms During Prehospital Response to Mass Casualty Incidents.

Mass casualty incidents (MCIs) can rapidly exhaust available resources and demand the prioritization of medical response efforts and materials. Principles of triage (i.e., sorting) from the 18th century have evolved into a number of modern-day triage algorithms designed to systematically train responders managing these chaotic events. We reviewed reports and studies of MCIs to determine the use and efficacy of triage algorithms. Despite efforts to standardize MCI responses and improve the triage process, studies and recent experience demonstrate that these methods have limited accuracy and are infrequently used.

Feasibility of Obtaining Intraosseous and Intravenous Access Using Night Vision Goggle Focusing Adaptors.

BACKGROUND: The optimal tactical lighting for performing medical procedures under low-light conditions is unclear. METHODS: United States Navy medical personnel (N = 23) performed intravenous (IV) and intraosseous (IO) procedures on mannequins using a tactical headlamp, night vision goggles (NVGs), and night vision goggles with focusing adaptors (NVG+A) utilizing a randomized within-subjects design. Procedure success, time to completion, and user preferences were analyzed using analysis of variance (ANOVA) and nonparametric statistics at p < .05. RESULTS: IV success rates were significantly greater for the headlamp (74%) than for NVG (35%; p < .03) and somewhat greater than for NVG+A (52%; p = .18). IO success rates were high under each lighting condition (96% to 100%). Time to completion was significantly faster using headlamp (IV, 106 ± 28 s; IO, 47 ± 11 s) than NVG (IV, 168 ± 80 s; IO, 56 ± 17 s) or NVG-A (IV, 157 ± 52 s; IO, 59 ± 27 s; each p < .01). Posttesting confidence on a 1-to-5 scale was somewhat higher for NVG+A (IV, 2.9 ± 0.2; IO, 4.2 ± 0.2) than for NVG (IV, 2.6 ± 0.2; IO, 4.0 ± 0.2). Participants cited concerns with NVG+A depth perception and with adjusting the adaptors, and that the adaptors were not integrated into the NVG. CONCLUSION: While this mannequin study was limited by laboratory conditions and by the lack of practice opportunities, we found some small advantages of focusing adaptors over NVG alone but not over headlamp for IV and IO access in low-light conditions.

Variation of anti-A and anti-B titers in group O potential blood donors: A pilot study.

BACKGROUND: Resuscitation with fresh whole blood is vital to preserving life on the battlefield. Transfusing low titer O whole blood (LTOWB), defined as anti-A and anti-B titer levels of <1:256, is safe because LTOWB alleviates the risk for hemolytic transfusion reactions. Because of possible variations in titer levels over time, a study was needed using US Navy and Marine Corps personnel to assess how these titers change across two assessments. METHODS: Retrospective data from group O marines and sailors (M = 25 years of age; range, 19-35 years) stationed in the San Diego region were acquired from the Armed Services Blood Program and the Composite Health Care System. Of 972 group O donors between January 2016 and November 2019, 55 donors with 2 samples were identified (N = 55). Analysis included contrasting rates of high (≥1:256) and low (<1:256) anti-A and anti-B titers on the initial and second blood tests, along with the time between testings. RESULTS: The average time between testing was 332 days (range, 35-1,121 days), which far exceeded the recommended 90-day interval (p < 0.00001). Only 45% met the 90-day recommendation. Titer status changed frequently, from low to high (anti-A, 18%; anti-B, 13%; LTOWB to not LTOWB, 21%) or from high to low (anti-A, 62%; anti-B, 78%; not LTOWB to LTOWB, 62%). CONCLUSIONS: Anti-A and anti-B titers change frequently enough to warrant testing immediately before deployment and even during deployment. The observed time elapsed between testing is unacceptably long. The present pilot study provides a foundation for a larger formal study to more fully characterize titer changes over repeated testing. LEVEL OF EVIDENCE: Diagnostic test, level IV.

The cytokine MIF controls daily rhythms of symbiont nutrition in an animal-bacterial association.

The recent recognition that many symbioses exhibit daily rhythms has encouraged research into the partner dialogue that drives these biological oscillations. Here we characterized the pivotal role of the versatile cytokine macrophage migration inhibitory factor (MIF) in regulating a metabolic rhythm in the model light-organ symbiosis between Euprymna scolopes and Vibrio fischeri As the juvenile host matures, it develops complex daily rhythms characterized by profound changes in the association, from gene expression to behavior. One such rhythm is a diurnal shift in symbiont metabolism triggered by the periodic provision of a specific nutrient by the mature host: each night the symbionts catabolize chitin released from hemocytes (phagocytic immune cells) that traffic into the light-organ crypts, where the population of V. fischeri cells resides. Nocturnal migration of these macrophage-like cells, together with identification of an E. scolopes MIF (EsMIF) in the light-organ transcriptome, led us to ask whether EsMIF might be the gatekeeper controlling the periodic movement of the hemocytes. Western blots, ELISAs, and confocal immunocytochemistry showed EsMIF was at highest abundance in the light organ. Its concentration there was lowest at night, when hemocytes entered the crypts. EsMIF inhibited migration of isolated hemocytes, whereas exported bacterial products, including peptidoglycan derivatives and secreted chitin catabolites, induced migration. These results provide evidence that the nocturnal decrease in EsMIF concentration permits the hemocytes to be drawn into the crypts, delivering chitin. This nutritional function for a cytokine offers the basis for the diurnal rhythms underlying a dynamic symbiotic conversation.

The impact of persistent colonization by Vibrio fischeri on the metabolome of the host squid Euprymna scolopes.

Associations between animals and microbes affect not only the immediate tissues where they occur, but also the entire host. Metabolomics, the study of small biomolecules generated during metabolic processes, provides a window into how mutualistic interactions shape host biochemistry. The Hawaiian bobtail squid, Euprymna scolopes, is amenable to metabolomic studies of symbiosis because the host can be reared with or without its species-specific symbiont, Vibrio fischeri In addition, unlike many invertebrates, the host squid has a closed circulatory system. This feature allows a direct sampling of the refined collection of metabolites circulating through the body, a focused approach that has been highly successful with mammals. Here, we show that rearing E. scolopes without its natural symbiont significantly affected one-quarter of the more than 100 hemolymph metabolites defined by gas chromatography mass spectrometry analysis. Furthermore, as in mammals, which harbor complex consortia of bacterial symbionts, the metabolite signature oscillated on symbiont-driven daily rhythms and was dependent on the sex of the host. Thus, our results provide evidence that the population of even a single symbiont species can influence host hemolymph biochemistry as a function of symbiotic state, host sex and circadian rhythm.

Critical symbiont signals drive both local and systemic changes in diel and developmental host gene expression.

The colonization of an animal's tissues by its microbial partners creates networks of communication across the host's body. We used the natural binary light-organ symbiosis between the squid Euprymna scolopes and its luminous bacterial partner, Vibrio fischeri, to define the impact of colonization on transcriptomic networks in the host. A night-active predator, E. scolopes coordinates the bioluminescence of its symbiont with visual cues from the environment to camouflage against moon and starlight. Like mammals, this symbiosis has a complex developmental program and a strong day/night rhythm. We determined how symbiont colonization impacted gene expression in the light organ itself, as well as in two anatomically remote organs: the eye and gill. While the overall transcriptional signature of light organ and gill were more alike, the impact of symbiosis was most pronounced and similar in light organ and eye, both in juvenile and adult animals. Furthermore, the presence of a symbiosis drove daily rhythms of transcription within all three organs. Finally, a single mutation in V. fischeri-specifically, deletion of the lux operon, which abrogates symbiont luminescence-reduced the symbiosis-dependent transcriptome of the light organ by two-thirds. In addition, while the gills responded similarly to light-organ colonization by either the wild-type or mutant, luminescence was required for all of the colonization-associated transcriptional responses in the juvenile eye. This study defines not only the impact of symbiont colonization on the coordination of animal transcriptomes, but also provides insight into how such changes might impact the behavior and ecology of the host.

Symbiotic organs shaped by distinct modes of genome evolution in cephalopods.

Microbes have been critical drivers of evolutionary innovation in animals. To understand the processes that influence the origin of specialized symbiotic organs, we report the sequencing and analysis of the genome of Euprymna scolopes, a model cephalopod with richly characterized host-microbe interactions. We identified large-scale genomic reorganization shared between E. scolopes and Octopus bimaculoides and posit that this reorganization has contributed to the evolution of cephalopod complexity. To reveal genomic signatures of host-symbiont interactions, we focused on two specialized organs of E. scolopes: the light organ, which harbors a monoculture of Vibrio fischeri, and the accessory nidamental gland (ANG), a reproductive organ containing a bacterial consortium. Our findings suggest that the two symbiotic organs within E. scolopes originated by different evolutionary mechanisms. Transcripts expressed in these microbe-associated tissues displayed their own unique signatures in both coding sequences and the surrounding regulatory regions. Compared with other tissues, the light organ showed an abundance of genes associated with immunity and mediating light, whereas the ANG was enriched in orphan genes known only from E. scolopes Together, these analyses provide evidence for different patterns of genomic evolution of symbiotic organs within a single host.

Persistent Interactions with Bacterial Symbionts Direct Mature-Host Cell Morphology and Gene Expression in the Squid-Vibrio Symbiosis.

In horizontally transmitted symbioses, structural, biochemical, and molecular features both facilitate host colonization by specific symbionts and mediate their persistent carriage. In the association between the squid Euprymna scolopes and its luminous bacterial partner Vibrio fischeri, the symbionts interact with two epithelial fields; they interact (i) transiently with the superficial ciliated field that potentiates colonization and regresses within days of colonization and (ii) persistently with the cells that line the internal crypts, whose ultrastructure changes in response to the symbionts. Development of the association creates conditions that promote the symbiotic partner over the lifetime of the host. To determine whether light organ maturation requires continuous interactions with V. fischeri or only the signaling that occurs during its initiation, we compared 4-week-old squid that were uncolonized with those colonized either persistently by wild-type V. fischeri or transiently by a V. fischeri mutant that triggers early events in morphogenesis but does not persist. Microscopic analysis of the light organs showed that, while morphogenesis of the superficial ciliated field is greatly accelerated by V. fischeri colonization, its eventual outcome is largely independent of colonization state. In contrast, the symbiont-induced changes in crypt cell shape require persistent host-symbiont interaction, reflected in the similarity between uncolonized and transiently colonized animals. Transcriptomic analyses reflected the microscopy results; host gene expression at 4 weeks was due primarily to the persistent interactions of host and symbiont cells. Further, the transcriptomic signature of specific pathways reflected the daily rhythm of symbiont release and regrowth and required the presence of the symbionts. IMPORTANCE A long-term relationship between symbiotic partners is often characterized by development and maturation of host structures that harbor the symbiont cells over the host's lifetime. To understand the mechanisms involved in symbiosis maintenance more fully, we studied the mature bobtail squid, whose light-emitting organ, under experimental conditions, can be transiently or persistently colonized by Vibrio fischeri or remain uncolonized. Superficial anatomical changes in the organ were largely independent of symbiosis. However, both the microanatomy of cells with which symbionts interact and the patterns of gene expression in the mature animal were due principally to the persistent interactions of host and symbiont cells rather than to a response to early colonization events. Further, the characteristic pronounced daily rhythm on the host transcriptome required persistent V. fischeri colonization of the organ. This experimental study provides a window into how persistent symbiotic colonization influences the form and function of host animal tissues.

Model systems for the study of how symbiotic associations between animals and extracellular bacterial partners are established and maintained.

This contribution describes the current state of experimental model development and use as a strategy for gaining insight into the form and function of certain types of host-microbe associations. Development of quality models for the study of symbiotic systems will be critical not only to facilitate an understanding of mechanisms underlying symbiosis, but also for providing insights into how drug development can promote healthy animal-microbe interactions as well as the treatment of pathogenic infections. Because of the growing awareness over the last decade of the importance of symbiosis in biology, a number of model systems has emerged to examine how these partnerships are maintained within and across generations of the host. The focus here will be upon host-bacterial symbiotic systems that, as in humans, (i) are acquired from the environment each generation, or horizontally transmitted, and (ii) are defined by interactions at the interface of their cellular boundaries, i.e., extracellular symbiotic associations. As with the use of models in other fields of biology where complexity is daunting (e.g., developmental biology or brain circuitry), each model has its strengths and weaknesses, i.e., no one model system will provide easy access to all the questions defining what is conserved in cell-cell interactions in symbiosis and what creates diversity within such partnerships. Rather, as discussed here, the more models explored, the richer our understanding of these associations is likely to be.

A genomic comparison of 13 symbiotic Vibrio fischeri isolates from the perspective of their host source and colonization behavior.

Newly hatched Euprymna scolopes squid obtain their specific light-organ symbionts from an array of Vibrio (Allivibrio) fischeri strains present in their environment. Two genetically distinct populations of this squid species have been identified, one in Kaneohe Bay (KB), and another in Maunaloa Bay (MB), Oahu. We asked whether symbionts isolated from squid in each of these populations outcompete isolates from the other population in mixed-infection experiments. No relationship was found between a strain's host source (KB or MB) and its ability to competitively colonize KB or MB juveniles in a mixed inoculum. Instead, two colonization behaviors were identified among the 11 KB and MB strains tested: a 'dominant' outcome, in which one strain outcompetes the other for colonization, and a 'sharing' outcome, in which two strains co-colonize the squid. A genome-level comparison of these and other V. fischeri strains suggested that the core genomic structure of this species is both syntenous and highly conserved over time and geographical distance. We also identified ~250 Kb of sequence, encoding 194 dispersed orfs, that was specific to those strains that expressed the dominant colonization behavior. Taken together, the results indicate a link between the genome content of V. fischeri strains and their colonization behavior when initiating a light-organ symbiosis.

Features governing symbiont persistence in the squid-vibrio association.

Experimental studies of the interaction between host and symbiont in a maturing symbiotic organ have presented a challenge for most animal-bacterial associations. Advances in the rearing of the host squid Euprymna scolopes have enabled us to explore the relationship between a defect in symbiont light production and late-stage development (e.g. symbiont persistence and tissue morphogenesis) by experimental colonization with specific strains of the symbiont Vibrio fischeri. During the first 4 weeks postinoculation of juvenile squid, the population of wild-type V. fischeri increased 100-fold; in contrast, a strain defective in light production (Δlux) colonized normally the first day, but exhibited an exponential decline to undetectable levels over subsequent weeks. Co-colonization of organs by both strains affected neither the trajectory of colonization by wild type nor the decline of Δlux levels. Uninfected animals retained the ability to be colonized for at least 2 weeks posthatch. However, once colonized by the wild-type strain for 5 days, a subsequent experimentally induced loss of the symbionts could not be followed by a successful recolonization, indicating the host's entry into a refractory state. However, animals colonized by the Δlux before the loss of their symbionts were receptive to recolonization. Analyses of animals colonized with either a wild-type or a Δlux strain revealed slight, if any, differences in the developmental regression of the ciliated light-organ tissues that facilitate the colonization process. Thus, some other feature(s) of the Δlux strain's defect also may be responsible for its inability to persist, and its failure to induce a refractory state in the host.