Public Health Surveillance via Template Management in Electronic Health Records: Tri-Service Workflow's Rapid Response to an Infectious Disease Crisis.

OBJECTIVE: To describe the use of template-based screening for risk of infectious disease exposure of patients presenting to primary care medical facilities during the 2014 West African Ebola virus outbreak. METHODS: The Military Health System implemented an Ebola risk-screening tool in primary care settings in order to create early notifications and early responses to potentially infected persons. Three time-sensitive, evidence-based screening questions were developed and posted to Tri-Service Workflow (TSWF) AHLTA templates in conjunction with appropriate training. Data were collected in January 2015, to assess the adoption of the TSWF-based Ebola risk-screening tool. RESULTS: Among encounters documented using TSWF templates, 41% of all encounters showed use of the TSWF-based Ebola risk-screening questions by the fourth day. The screening rate increased over the next 3 weeks, and reached a plateau at approximately 50%. CONCLUSIONS: This report demonstrates the MHS capability to deploy a standardized, globally applicable decision support aid that could be seen the same day by all primary care clinics across the military health direct care system, potentially improving rapid compliance with screening directives.

Use of an impedance threshold device improves short-term outcomes following out-of-hospital cardiac arrest.

INTRODUCTION: An impedance threshold device (ITD) has been developed for the treatment of cardiac arrest to augment circulation to the heart and brain during cardiopulmonary resuscitation (CPR). The ITD has ventilation timing lights that flash at 12 min(-1) to discourage excessive ventilation rates. HYPOTHESIS: Implementation of the ITD during conventional manual CPR in a large emergency medical services (EMS) system (Staffordshire, UK) is safe, feasible and will improve short-term survival. METHODS: ITD use was implemented by the Staffordshire Ambulance Trust, which treats 1600 cardiac arrests per year with 90 advanced life support (ALS) units and an average response time of 6.3 min. During training, rescuers learned to use the ventilation timing lights to discourage hyperventilation. Rescuers applied the device after tracheal intubation. They were trained to allow the chest to recoil fully after each compression. Prospective ITD use in adults receiving conventional manual CPR for non-traumatic cardiac arrest was compared to matched historical controls receiving conventional manual CPR without inspiratory impedance. All received similar ALS care. The primary endpoint was admission to the emergency department (ED) alive following cardiac arrest. Chi-square, Fisher's exact and Kolmogorov-Smirnov tests were used for statistical analyses. RESULTS: Survival (alive upon ED admission) in all patients receiving an ITD (61/181 [34%]) improved by 50% compared to historical controls (180/808 [22%]) (P<0.01). Survival in patients presenting in asystole tripled in the group receiving an ITD (26/76 [34%]) compared with historical controls (39/351 [11%]) (P=0.001). There were no significant adverse events. CONCLUSIONS: The ITD was used safely and effectively in a large, diverse EMS system and markedly improved short-term survival for adult patients in non-traumatic cardiac arrest.

Influenza outbreak and response preparedness in the Air National Guard.

A 1997 influenza outbreak with a high case fatality rate reminded public health officials of the serious nature of this disease. Civilian authorities worldwide have initiated planning in preparation for another pandemic, possibly of the magnitude observed in 1918. Military agencies have also begun pandemic preparation. However, planning for influenza outbreaks in the Air National Guard (ANG) has not received a high priority. Through interviews and document reviews, we examined the current policies and procedures of the ANG in relation to influenza surveillance, outbreak response, vaccination, and use of antiviral drugs. Deployment and demographic data were studied and indicated ANG populations were at risk for infection with and dissemination of novel influenza strains. Pandemic planning in the ANG must be given a higher priority, to include initiating laboratory-based surveillance, enhancing communication and coordination with other public health authorities, and considering the potential use of antiviral drugs.

Patient-specific prediction of intrinsic mechanical loadings on sub-muscular pectoral pacemaker implants based on an inter-species transfer function.

With the steady technological development enabling reduced device dimensions and new patient populations, detailed data on mechanical in vivo loads become increasingly important to ensure reliability of implantable medical devices. Based on an intra-species correlation of in-line and transverse force of the Pectoralis major established previously for the Chacma baboon (de Vaal et al., 2010a), a simplified physiological model and a mechanical equivalent model were developed for a sub-muscular pectoral device implant considering Pectoralis major, Pectoralis minor and rib cage. By assessing the morphometric and mechanical parameters of these musculo-skeletal structures and the associated model parameters, the intra-species correlation was shown to exhibit (a) robustness for a larger intra-species subject population and (b) linear scale variance allowing application for humans under consideration of the inter-species difference of the attachment angles of Pectoralis major. The transfer function provides a basis for the prediction of patient-specific maximum mechanical loadings on a sub-muscular pectoral cardiac pacemaker implant through non- or minimal invasive measurements on the patient.

The in vivo assessment of mechanical loadings on pectoral pacemaker implants.

Reduced sizes of implantable cardiac pacemakers and clinical advances have led to a higher feasibility of using such devices in younger patients including children. Increased structural demands deriving from reduced device size and more active recipients require detailed knowledge of in vivo mechanical conditions to ensure device reliability. Objective of this study was the proof of feasibility of a system for the measurement of in vivo mechanical loadings on pacemaker implants. The system comprised the following: implantable instrumented pacemaker (IPM) with six force sensors, accelerometer and radio-frequency (RF) transceiver; RF data logging system and video capture system. Three Chacma baboons (20.6+/-1.15 kg) received one pectoral sub-muscular IPM implant. After wound healing, forces were measured during physical activities. Forces during range of motion of the arm were assessed on the anaesthetized animals prior to device explantation. Mass, volume and dimensions of the excised Pectoralis major muscles were determined after device explantation. Remote IPM activation and data acquisition were reliable in the indoor cage environment with transceiver distances of up to 3m. Sampling rates of up to 1,000 Hz proved sufficient to capture dynamic in vivo loadings. Compressive forces on the IPM in conscious animals reached a maximum of 77.2+/-54.6N during physical activity and were 22.2+/-7.3N at rest, compared with 34.6+/-15.7 N maximum during range of motion and 13.4+/-3.3N at rest in anaesthetized animals. The study demonstrated the feasibility of the developed system for the assessment of in vivo mechanical loading conditions of implantable pacemakers with potential for use for other implantable therapeutic devices.

Department of Defense Global Laboratory-Based Influenza Surveillance: 1998-2005.

The Department of Defense (DoD) Global Laboratory-Based Influenza Surveillance Program was initiated in 1997 to formally consolidate and expand existing influenza surveillance programs within the DoD and in areas where DoD was working. Substantial changes in 2008 provided an opportunity to review the operation of the surveillance program as it existed during seven complete influenza seasons (1998-2005); the review was conducted in 2008. A unique aspect of the DoD program was the global reach for specimen collection and the ability to rapidly ship, process, and evaluate specimens from 27 countries. The resulting epidemiologic data combined with the culture results from >46,000 patients provided information that was shared with similar national and international programs, such as those of the CDC. Likewise, selected influenza isolates were molecularly characterized and shared with the CDC to be compared with other surveillance programs. Timeliness of the samples contributed to the information available for annual influenza vaccine selection.

Mitf dosage as a primary determinant of melanocyte survival after ultraviolet irradiation.

Microphthalmia-associated transcription factor (Mitf) is essential for melanocyte development and function and regulates anti-apoptotic Bcl2 expression. We hypothesized that cellular deficiency of Mitf can influence melanocyte survival in response to ultraviolet (UV) radiation. Primary melanocyte cultures were prepared from neonatal wild-type mice and congenic animals heterozygous for Mitf mutations Mitf (mi-vga9/+) and Mitf(Mi-wh/+) and exposed to UV irradiation. Wild-type melanocytes were more resistant to UV-induced apoptosis than melanocytes partially deficient in Mitf activity, as determined by relative levels of intracellular melanin and relative activation of Mitf target genes Tyr, Tyrp1, Dct, and Cdk2. Comparative experiments with wild-type cells and congenic albino melanocytes demonstrated that these differences are not due to differences in melanin content, implicating Mitf as a primary determinant of UV-dependent melanocyte survival. Mitf activity correlated directly with resistance to UV-induced apoptosis in melanocytes. Mitf was important not only for regulating the expression of anti-apoptotic Bcl-2 following UV irradiation, but also the expression of the pro-apoptotic BH3-only Bad protein and activation of the extrinsic apoptotic pathway. Hence, Mitf is a multifaceted regulator of UV-induced apoptosis in melanocytes.

Asthma hospitalizations among US military personnel, 1994 to 2004.

BACKGROUND: Acute asthma attacks strike unpredictably and may lead to hospitalization in otherwise healthy individuals. The burden of asthma hospitalization on the US health care system has greatly interested health care workers, many of whom see the incidence of asthma as increasing. OBJECTIVES: To examine the annual incidence of hospitalization and the frequency of subsequent hospitalization for asthma among all active-duty US military personnel between 1994 and 2004 and to determine demographic and occupational risk factors of asthma hospitalization within this generally healthy US population. METHODS: Annual demographic and occupational data were combined with electronic hospitalization records for patients with a discharge diagnosis of asthma. Using Cox proportional hazard modeling, the authors investigated demographic and occupational risk factors for asthma hospitalization. RESULTS: Women, married persons, health care workers, enlisted personnel, US Army personnel, and older persons were found to have a significantly greater risk of asthma hospitalization. Yearly rates of hospitalization declined from 22.3 per 100,000 persons to 12.6 per 100,000 persons between 1994 and 2004. CONCLUSIONS: Although these data have some limitations, they suggest that the burden of asthma hospitalizations in the large, healthy population of US military personnel has declined during the last decade. The decrease in hospitalization potentially reflects improved outpatient management strategies.

Human metapneumovirus, Peru.

We retrospectively studied 420 pharyngeal swab specimens collected from Peruvian and Argentinean patients with influenzalike illness in 2002 and 2003 for evidence of human metapneumovirus (HMPV). Twelve specimens (2.3%) were positive by multiple assays. Six specimens yielded HMPV isolates. Four of the 6 isolates were of the uncommon B1 genotype.

Innovative surveillance methods for rapid detection of disease outbreaks and bioterrorism: results of an interagency workshop on health indicator surveillance.

A system designed to rapidly identify an infectious disease outbreak or bioterrorism attack and provide important demographic and geographic information is lacking in most health departments nationwide. The Department of Defense Global Emerging Infections System sponsored a meeting and workshop in May 2000 in which participants discussed prototype systems and developed recommendations for new surveillance systems. The authors provide a summary of the group's findings, including expectations and recommendations for new surveillance systems. The consensus of the group was that a nationally led effort in developing health indicator surveillance methods is needed to promote effective, innovative systems.