Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities.

A recent large civilian randomized controlled trial on the use of tranexamic acid (TXA) for trauma reported important survival benefits. Subsequently, successful use of TXA for combat casualties in Afghanistan was also reported. As a result of these promising studies, there has been growing interest in the use of TXA for trauma. Potential adverse effects of TXA have also been reported. A US Department of Defense committee conducted a review and assessment of knowledge gaps and research requirements regarding the use of TXA for the treatment of casualties that have experienced traumatic hemorrhage. We present identified knowledge gaps and associated research priorities. We believe that important knowledge gaps exist and that a targeted, prioritized research effort will contribute to the refinement of practice guidelines over time.

Rapid identification of dengue virus by reverse transcription-polymerase chain reaction using field-deployable instrumentation.

Dengue virus universal and dengue serotype 1 to 4, fluorogenic probe hydrolysis (TaqMan), reverse transcription-polymerase chain reaction assays were developed for screening and serotype identification of infected mosquito vectors and human sera using a field-deployable, fluorometric thermocycler. Dengue universal and dengue 1 to 4 serotype assay in vitro sensitivity and specificity results were 100% concordant when tested with total nucleic acid extracts of multiple strains of dengue serotype 1 to 4, yellow fever, Japanese encephalitis, West Nile, and St. Louis encephalitis viruses. The in vitro sensitivity and specificity results for all five assays were concordant when tested with a blind panel of 27 dengue virus-infected mosquitoes, 21 non-dengue (yellow fever, West Nile, or St. Louis encephalitis) flavivirus-infected mosquitoes, and 11 uninfected mosquitoes and with clinical specimens consisting of a human serum panel of eight dengue viremic and 31 non-dengue-infected febrile patient serum samples. No cross-reaction occurred with vector species or human genomic DNA. Sample processing and polymerase chain reaction required <2 hours.

Identification of Aedes aegypti and its respective life stages by real-time polymerase chain reaction.

An Aedes aegypti-specific, fluorogenic probe hydrolysis (Taq-Man), polymerase chain reaction assay was developed for real-time screening using a field-deployable thermocycler. Laboratory-based testing of A. aegypti, A. aegypti (Trinidad strain), Culex pipiens, Culex quinquefasciatus, Anopheles stephensi, and Ochlerotatus taeniorhynchus individual adult mosquitoes and mixed pools (n = 10) demonstrated 100% concordance in both in vitro sensitivity (six of six samples) and specificity (10 of 10 samples). A single adult A. aegypti was identified in a pool of 100 non-A. aegypti mosquitoes. The limit of detection of A. aegypti egg pools was five individual eggs. Field testing was conducted in central Honduras. An A. aegypti and Culex spp. panel of individual and mixed pools (n = 30) of adult mosquitoes, pupae, and larvae demonstrated 100% concordance in sensitivity (22 of 22 samples) and 97% concordance in specificity (29 of 30 samples), with one false-positive result. Field testing of an A. aegypti and Culex spp. blind panel (n = 16) consisting of individual and mixed pools of adult mosquitoes, pupae, and larvae demonstrated 90% concordance in sensitivity (nine of 10 samples) and 88% concordance in specificity (14 of 16 samples).

Potential use of microarray technology for rapid identification of central nervous system pathogens.

Outbreaks of central nervous system (CNS) diseases result in significant productivity and financial losses, threatening peace and wartime readiness capabilities. To meet this threat, rapid clinical diagnostic tools for detecting and identifying CNS pathogens are needed. Current tools and techniques cannot efficiently deal with CNS pathogen diversity; they cannot provide real-time identification of pathogen serogroups and strains, and they require days, sometimes weeks, for examination of tissue culture. Rapid and precise CNS pathogen diagnostics are needed to provide the opportunity for tailored therapeutic regimens and focused preventive efforts to decrease morbidity and mortality. Such diagnostics are available through genetic and genomic technologies, which have the potential for reducing the time required in serogroup or strain identification from 500+ hours for some viral cultures to less than 3 hours for all pathogens. In the near future, microarray diagnostics and future derivations of these technologies will change the paradigm used for outbreak investigations and will improve health care for all.

Laboratory response to anthrax bioterrorism, New York City, 2001.

In October 2001, the greater New York City Metropolitan Area was the scene of a bioterrorism attack. The scale of the public response to this attack was not foreseen and threatened to overwhelm the Bioterrorism Response Laboratory's (BTRL) ability to process and test environmental samples. In a joint effort with the Centers for Disease Control and Prevention and the cooperation of the Department of Defense, a massive effort was launched to maintain and sustain the laboratory response and return test results in a timely fashion. This effort was largely successful. The development and expansion of the facility are described, as are the special needs of a BTRL. The establishment of a Laboratory Bioterrorism Command Center and protocols for sample intake, processing, reporting, security, testing, staffing, and and quality control are also described.