Army Medical Research Research Articles

Abstract 3936: The role of megakaryocytes in breast cancer metastasis to bone.

Abstract Breast cancer cells frequently metastasize to bone. Despite the clinical ramifications, very little is understood about the fundamental mechanisms responsible for this phenomenon. While analyzing femur sections from mice that had been inoculated in the left ventricle of the heart with human metastatic MDA-MB-231 breast cancer cells, we saw a several fold increase in the number of megakaryocytes (MKs) in the bone marrow. We hypothesized that either MKs aid in the growth of cancer cells in the bone by preparing a niche for the metastases or that the increase resulted from the altered microenvironment of the marrow due to the presence of the cancer. MKs are the pre-cursors to platelets and normally represent a small portion of all bone marrow cells. However, they can increase exponentially under stressful conditions such as primary thrombocythemia and in chronic myelogenous leukemia. Platelets are known to interact with tumor cells to contribute to hematogenous metastasis and angiogenesis. Thrombocytosis, high platelet count, is a poor prognostic factor for breast cancer metastasis; and moreover, many cancer patients die from thromboembolisms. MKs also play a crucial role in bone metabolism and skeletal homeostasis. Objectives: to determine (1) if the increase in MKs precedes the growth of cancer cells in the bone; (2) the role that cancer cell-osteoblast/stromal interactions play in the increase in megakaryopoiesis. For aim 1, MK numbers in the femurs of athymic mice inoculated with MDA-MB-231-luc intracardially (metastasis) were compared with those inoculated in the mammary gland (no metastasis). Serum was assayed for key MK maturation factors thrombopoietin (TPO) and stromal-derived factor-1(SDF-1). There was on average a two-fold increase in MK numbers in the femurs of mice with metastasic disease. However, this increase was not found in mice with localized growth but no metastasis. The increase correlated with the increase in metastatic tumor burden. There was no increase in platelet count, SDF-1, or TPO even when MK numbers were high. We concluded that the cancer cells preceded the increase of MKs in the bone marrow in a xenograft model. A syngeneic model of Balb/c mice with 4T1.2 cancer cells that metastasize from the mammary gland and 67NR cells that do not are also being compared. Thus far we have found that femurs of mice carrying 4t1.2 cells for 30 days also showed an increase in the numbers of MKs. Finally, Balb/c mice lacking TPO and thus having low MKs will be tested for metastasis. This work was supported by the U.S. Army Medical Research and Materiel Command under W81XWH-10-1-0253. Citation Format: Walter Jackson, Andrea M. Mastro. The role of megakaryocytes in breast cancer metastasis to bone. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3936. doi:10.1158/1538-7445.AM2013-3936

Effects of resuscitation fluids on endothelial glycocalyx (EG) and coagulation in severe hemorrhagic shock (HS)

To study the effects of resuscitation fluids on changes in coagulation and EG in HS, we studied venules of cremaster muscle of anesthetized rats subjected to 1h of HS (40% of blood volume, HEM only) followed by 1h resuscitation with Hextend (HEX), Ringer's lactate (RL), or fresh frozen plasma (FFP). EG thickness was estimated using dextrans of different molecular weights labeled with FITC or Texas Red. Blood gases, hematocrit, cell count, coagulation tests (ROTEM) were performed. EG thickness was 50% lower in HEM, RL and HEX groups. EXTEM: clotting time [CT] was longer for RL compared to other groups. Clot strength [G] in HEM was higher at post‐resuscitation compared to baseline. FIBTEM: maximal clot elasticity [MCE], maximum clot formation [MCF], thrombin generation and G were lower in RL and HEX groups than the others. Resuscitation with FFP was superior in reverting coagulopathy (no differences in CT, G and MCE compared to Sham) and restoring EG thickness. Resuscitation with RL and HEX reestablished mean arterial pressure and tissue perfusion but caused EG shedding and altered coagulation by reducing clot strength and elasticity, and diluting coagulation factors, in contrast to FFP. We showed that ROTEM can indentify changes in coagulation function in massive blood loss and HS‐associated coagulopathy in a rat model that also displayed microvascular changes.Supported by US Army Medical Research & Materiel Command.

Effects of Resuscitation Fluids following Hemorrhagic Shock on Venular Glycocalyx in Rats

The protection mechanisms of resuscitative agents after hemorrhagic shock (HS) are still unclear. For instance, fresh frozen plasma (FFP) may exert its positive effects by replacing lost coagulation factors and by acting upon the endothelium. We compared different resuscitation fluids in their ability to restore the structural integrity of anesthetized rat cremaster venular endothelial glycocalyx (EG) in vivo, as estimated by its thickness using intravital microscopy and fluorescent dextrans. After 1 h of HS (bleeding target: 40% of total blood volume), rats were randomized into 4 groups (6–8 rats/group): HEM‐ no resuscitation; LR– lactated Ringer's; HEX–Hextend and FFP. Baseline EG averaged 0.425 ± 0.015 μm (n=121). After resuscitation, EG was reduced by nearly 70% in HEM, LR and HEX groups to an average 0.132 ± 0.010 μm. However, in rats that received FFP, EG recovered to a thickness of 0.532 ± 0.060 μm, not significantly different from baseline. Syndecan‐1 plasma levels also rose significantly in all groups except in rats that received FFP, where levels returned to baseline. All groups showed significant reductions in venular blood flow, but only HEX rats showed full recovery of flow. The data suggest that plasma but neither colloid nor crystalloid resuscitation support vascular stabilization by reconstitution of EG after HS‐mediated degradation.Supported by US Army Medical Research & Materiel Command.

Adolescent traumatic stress experience shapes adulthood fear conditioning and extinction responses

A traumatic stress paradigm (underwater trauma, UWT) was used to model an intense developmental stress event during adolescence, and evaluate effects on fear and stress response lasting into adulthood. Adolescent rats (P37) were exposed to UWT or swim without submersion. Rats were then allowed to reach adulthood (P114) and fear conditioned using light and sound (conditioned stimulus), with or without footshock (unconditioned stimulus). After a three‐week fear incubation period, rats were given one extinction trial per day for five consecutive days using an operant behavior conditioned suppression task. Preliminary results suggest that adolescent traumatic stress experience shapes some aspects of adulthood stress response severity, and residual fear responses after five extinction trials.This work is supported by the Military Operational Medicine Research Program, US Army Medical Research and Materiel Command.

Biochemical and mood changes dissociate during exposure to intense military training

Exposure to intense stress is known to alter affective and cognitive behavior more profoundly in some individuals than others. Recently, we had the opportunity to examine the biochemical, cognitive and mood changes (Profile of Moods) associated with intense military training known as SERE school (Survive, Evade, Resist, Escape). SERE is a unique environment to examine Soldiers’ responses to stress in a realistic, standardized and carefully monitored military context in which students apply newly learned resistance skills to a variety of captivity scenarios. From baseline to the end of SERE (~2wks), serum testosterone and prolactin were both substantially depressed from 468ng/ml to 156ng/ml and 13.8ng/ml to 5.46ng/ml, respectively (p <.001). In contrast, epinephrine and norepinepherine remained elevated from 41pg/ml to 67pg/ml and 468pg/ml to 754.8pg/ml, respectively (p<.001). Interestingly, changes in mood states were not reflective of these prolonged endocrine alterations, as depression, tension, anger, and confusion returned to approximately baseline levels at recovery. This suggests that changes in these hormonal levels are not reliable biomarkers of mood in this elite population. This research was supported by the Office of Naval Research and US Army Medical Research and Material Command.

Energy expenditure of military helicopter air crews during combat missions assessed by modified factorial method.

PurposeTo estimate metabolic energy expenditures (EEs) during aviation soldiers’ workday while in Iraq or Afghanistan.MethodsMale helicopter crew members (n = 18) with combat flying experience were studied. Volunteers were age: 35 ± 8 yrs; wt: 87 ± 10 kg; ht: 177 ± 7 cm; combat missions flown: 174 ± 115 missions (χ̄ ± SD). Focus groups of 4 to 7 participants were held and video‐taped. Participants described in detail each activity during their last combat mission. The focus group method allowed participants to confirm or contrast their activities with those of other group members participating in the same or similar missions. Videos were transcribed and a timeline of activities to the nearest minute were generated. EEs were estimated using the factorial method: [Body Wt (kg)] × [Time of Activity (min)] × [Activity Level (MET)], comparing each activity to the closest activity listed in Ainsworth et al.'s (1993, 2000) compendia of physical activities.ResultsEstimated EE of these aviator soldiers was 3400 ± 1400 kcal during their 13.0 ± 3.5 hr in‐theatre mission.ConclusionThis modified post‐hoc factorial method provided useful estimates of EE of soldiers who were not available for study in theater. EEs are used to estimate nutritional requirements and heat strain in these aviator soldiers.Funding for this research was provided by the U.S. Army Medical Research and Materiel Command.

Tissue antioxidant status in hemorrhaged inbred rat strains fed diets for 9 weeks varying in levels of methyl group donors

We reported previously that inbred rats fed a diet deficient in methyl group donors (SD) during ages 4–13 weeks, had altered liver antioxidant status compared to rats fed a sufficient (SC) or supplemented (SS) methyl group donor diet. The present study reports similar variables in lung, kidney, small intestine and brain (cortex) from this same study. After feeding the diets for 9 weeks, inbred rats [Dark agouti (DA), and Brown Norway/Medical College of Wisconsin (BN/Mcwi)] were bled 50% of their blood volume and survival time from hemorrhage observed up to 240 min. Tissues were collected at death and frozen at −80°C until assayed for total antioxidant potential, TBARS, reduced glutathione (GSH), nitric oxide (NO), NADH and select antioxidant enzyme activities. No significant differences in these variables were noted in any of the SS fed DA or BN/Mcwi rats compared to the SC groups. DA rats fed the SD diet had higher lung TBARS and lower GSH as well as higher kidney TBARS and lower NADH levels than corresponding SC rats. Also, certain antioxidants were generally higher in lung, kidney and jejunum in BN/Mcwi than DA rats. Taken together, these data support a potential role of lower antioxidant status in DA rats contributing to shorter survival time after hemorrhage (p<0.013) in DA than BN/Mcwi rats for all diets. Supported by US Army Medical Research Materiel Command

Tempering the risk: Rift Valley fever and bioterrorism

Rift Valley fever virus (RVFV) is an arthropod-borne pathogen that primarily affects ruminants in eastern and sub-Saharan Africa first described following an outbreak on a farm in Kenya in 1931. Periodic outbreaks of RVFV since that time have resulted in significant losses to the African livestock industry as well as large numbers of infections in some of the most impoverished human populations. In one 2006/2007 outbreak across Kenya, Somalia and Tanzania alone, there were an estimated 145 000 human cases, and the ban imposed on imports after the 1997/1998 outbreak in Somalia led to a collapse of the vital livestock industry. Previously ignored, it is only in the past decade that the international community has started to take an increased interest in the disease. This followed the recognition of its potential to spread beyond the confines of the African continent after a large outbreak in Saudi Arabia in 2000. There has also been acknowledgement of the widespread presence of arthropod vectors capable of transmitting RVFV in many nonendemic regions of the world. This has led to a range of increased efforts in better understanding the virus and developing tools to predict outbreaks, combat the disease and limit its spread (Anyamba et al. 2010; Pepin et al. 2010). However, a more longstanding, parallel interest in the disease has also developed internationally; one centred around the biosecurity implications of the virus. The United States for instance, included RVFV as a candidate pathogen in its offensive biological weapons programme; a programme officially closed in 1969 (Borio et al. 2002). In more recent times, the classification of the virus as a potential bioterrorism agent has spurred investment and activity, particularly in the area of vaccine development and diagnostics (Borio et al. 2002; Sidwell & Smee 2003). While biosecurity interest has contributed to this increased funding over the past few decades, most notably from military sources such as the US Army Medical Research Institute of Infectious Diseases (USAMRIID), it may have acted as an impediment to international collaboration, with research being restricted to fewer, more expensive laboratories. After the signing of the US Patriot Act of 2002 and the classification of RVFV as a ‘select agent’, visiting experts and scientific collaborators are, for instance, now required to provide fingerprints, signed affidavits and be registered with intelligence services before working with the pathogen. Such measures are likely to act as a disincentive amongst scientists wanting to study the virus and could ultimately serve to drive experts to dedicate their efforts to other pathogens with fewer working restrictions (Animal & Plant Health Inspection Service, Centre for Disease Control & Prevention 2005, 2011). These restrictions have also been applied in parts of Europe as well, with national legislation such as the Anti-terrorism, Crime and Security Act 2001 of the UK, which also includes RVFV as a potential bioterrorism agent. For comparison and contrast, we include the current lists of biological agents and toxins around which bioterrorism legislation has been passed in the US and UK in Table 1. Focus on US policy internationally stems from its greater leadership role within the global community and the influence and impact its decisions have on people and institutions far beyond its borders. With large numbers of laboratories worldwide affected by US policy either directly through funding or indirectly as a result of political influence, restrictions have also resulted in the transfer between laboratories of RVFV samples for culture also becoming constrained and increasingly expensive. This undermines efforts to lower the industrial production costs of existing vaccines and of commercial kits for virus neutralisation and ELISA diagnostic tests (currently the prescribed tests for international livestock trade) (World Organization for Animal Health 2008). Expertise and experience thus tends to remain confined to a limited number of laboratories and companies by and large located in high income countries where investigation of the disease is neither a significant economic or health priority nor considered sufficiently profitable for drug companies. The resulting monopolies on expert technical knowledge and skills not only delays progress in developing new therapies

Towards Effective Emerging Infectious Diseases Surveillance: Evidence from Kenya, Peru, Thailand, and the U.S.­-Mexico Border

This paper examines the political economy of emerging infectious disease (EID) surveillance programs. It provides lessons learned for U.S. military medical research laboratories collaborating with developing countries and is comprised of four case studies: Kenya (U.S. Army Medical Research Unit-K or USAMRU-K), Peru (U.S. Naval Area Medical Research Unit-6 or NAMRU-6), Thailand (Armed Forces Research Institute of Medical Sciences or AFRIMS), and the U.S.-Mexico Border (Early Warning Infectious Disease Surveillance or EWIDS). The paper provides policy makers tools for improving the effectiveness of new or existing EID surveillance programs. Moreover, it offers host countries the opportunity to incorporate ideas, provide opinions, and debate the management of political and economic constraints facing their programs. Constraints are found for each case study and general recommendations are given for improving global emerging infectious disease surveillance across political, economic, and cultural dimensions. Recommendations: Involve local experts in EID surveillance; Support technology that facilitates communication (e.g. U.S.-Mexico); Develop projects in a way that benefits both parties (e.g. host country Principal Investigator instead of a foreign PI); Centralize health networks, and separate civilian and military sector influence in EID surveillance so functions do not overlap; To improve outcomes, use lessons from other regions that have experienced outbreaks.

Genome Sequence of Moraxella macacae 0408225, a Novel Bacterial Species Isolated from a Cynomolgus Macaque with Epistaxis

Moraxella macacae is a recently described bacterial species that has been associated with at least two outbreaks of epistaxis in macaques. Here we present the first genome sequence of this novel species, isolated from a symptomatic cynomolgus macaque at the U.S. Army Medical Research Institute of Infectious Diseases.

Abstract 53: Cerebral Hemodynamic Changes in Patients with Wartime Traumatic Brain Unjury

Cerebral vasospasm (VSP) is a frequent complication after aneurysmal and traumatic subarachnoid hemorrhage (SAH) and carries significant morbidity and mortality. Traumatic brain injury (TBI) is associated with the severest casualties from Operation Iraqi Freedom and Operation Enduring Freedom. From Oct. 1, 2008 the US Army Medical Department initiated a transcranial Doppler (TCD) ultrasound service for TBI; included patients were retrospectively evaluated for TCD-determined incidence of posttraumatic cerebral vasospasm and intracranial hypertension after wartime TBI. Patients were identified using a computerized registry and a prospective TCD database maintained in the Sentient NeuroCare Services. TCD recordings of mean cerebral blood flow velocities (CBFV) and Pulsatility Indices of the anterior and posterior circulation vessels were recorded using a 2-MHz transducer (Doppler Box, DWL/Compumedics, USA, Germany/Australia). Comprehensive TCD protocol was applied in all cases: if mean CBFV equaled or exceeded 100 cm/sec., 140 cm.sec and 200 cm/sec the TCD signs of mild vasospasm, moderate vasospasm and severe vasospasm respectively were considered present. 122 patients were investigated with daily TCD studies and comprehensive TCD protocol and published diagnostic criteria for VSP and raised intracranial pressure (ICP) were applied. TCD signs of mild, moderate and severe VSP involving anterior circulation vessels were observed in 71%, 42% and 16% of patients, respectively. TCD signs of mild, moderate and severe VSP involving posterior circulation vessels were observed in 57%, 32% and 14% of patients, respectively. TCD signs of intracranial hypertension were recorded in 43%, eight patients (7%) underwent transluminal angioplasty for post-traumatic symptomatic vasospasm treatment. These findings demonstrate that cerebral arterial VSP and intracranial hypertension are frequent and significant complications of combat TBI, therefore daily TCD monitoring is recommended for their recognition and subsequent management. Acknowledgements. The opinions and views expressed herein belong solely to those of the authors. They are not nor should they be implied as being endorsed by the Uniformed Services University of the Health Sciences, Department of the Army, Department of the Navy, Department of Defense or any other branch of the Federal government of the United States. This paper supported in part, by the US Army Medical Research and Material Command’s Telemedicine and Advanced Technology Research Center (Fort Detrick, MD, USA).

Abstract A51: Identification of cytokine network signaling abnormalities in immune cells from cancer patients.

Abstract The innate and adaptive immune systems have the capacity to recognize and eliminate transformed cells while the ability of tumors to evade and abrogate immune functions appears to be a requisite for disease progression. Abnormalities in essentially every immune population have been documented in cancer patients and murine tumor models. Thus, the immune system is a crucial target for cancer therapeutics in order to achieve a true cure. The cytokine JAK-STAT signaling network is a key instrument of immune system communication and directs a multitude of immune functions. Because of the integral role in regulation of immune functions as well as the intricate crosstalk that occurs within cytokine signaling networks, alterations in these networks in cancer patients are likely to be key contributing factors in immune dysfunction. We have previously shown that IFNα and IFNγ signaling are impaired in lymphocytes from breast cancer, melanoma, and gastrointestinal cancer patients. In this study we sought to determine whether additional cytokine signaling pathways are altered in immune cells from cancer patients. Phospho-flow cytometry was used to measure STAT phosphorylation in response to 10 cytokines from the IFN, gp130, γC, and the IL3 cytokine families, to provide a broad picture of the global cytokine network in peripheral blood immune cells. Included in this analysis were patient cohorts with various carcinomas including breast, lung, gastrointestinal, and melanoma, as well as patients with psoriasis, an epidermal hyperplasia resulting from chronic inflammatory cytokine production by persistently activated immune cells. Preliminary analysis of our study has revealed that compared with healthy controls, cancer and psoriasis patients exhibit altered responses to multiple additional cytokines in various immune cell subsets. We hypothesize that chronic inflammation which occurs in the settings of both cancer and psoriasis contributes to cytokine signaling defects and are exploring the mechanisms and the functional consequences of these defects on T cell function. Understanding how alterations in cytokine responsiveness contribute to immune dysfunction will enable correction of these signaling defects to restore anti-tumor immune function and enhance the ability of the host immune response to control cancer. This work was supported by the U.S. Army Medical Research and Materiel Command under W81XWH-10-1-0616 and W81XWH-06-1-0417, NIH Molecular and Cellular Immunobiology Training Grant No. 5 T32 AI07290-24, and NIH R01 CA130817. Citation Format: Andrea K. Miyahira, Diana L. Simons, Frederick Dirbas, Ellie Guardino, Shruti Sheth, Robert Carlson, Peter P. Lee. Identification of cytokine network signaling abnormalities in immune cells from cancer patients. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology: Multidisciplinary Science Driving Basic and Clinical Advances; Dec 2-5, 2012; Miami, FL. Philadelphia (PA): AACR; Cancer Res 2013;73(1 Suppl):Abstract nr A51.

EL4 Cell-Based Colorimetric Toxin Neutralization Activity Assays for Determination of Neutralizing Anti-Ricin Antibodies

A recombinant ricin toxin A-chain 1-33/44-198 vaccine (RVEc), developed at the United States Army Medical Research Institute of Infectious Diseases as a vaccine candidate, is under investigation in a phase 1 clinical study. To effectively evaluate the immunogenicity of this ricin vaccine and to eliminate the use of radioactive material, an EL4 cell-based colorimetric toxin neutralization activity (TNA) assay using a CellTiter 96 AQueous One Solution Cell Proliferation Assay Reagent has been developed, optimized, and applied in the vaccine efficacy studies. The TNA assay measures the protective neutralizing anti-ricin antibodies in animal sera by determining the cell viability after ricin exposure in the assay system and comparing it to a purified mouse polyclonal antiricin IgG standard curve. The standard curve of the anti-ricin TNA assay closely fits a four-parameter logistic regression model. The unknown test sample concentration was expressed as microg/mL, but not the 50% effective concentration (EC50), which was determined by most TNA assays. The neutralizing endpoint titers, not the 50% effective dilution (ED50), of human specimens were measured with the TNA assay in support of the clinical study of the RVEc vaccine. The optimal amount of ricin toxin, EL4 cells, and concentration of standards used in the assay system was established to minimize false-negative and false-positive results of serum specimens from the nonclinical and clinical studies of RVEc. The testing conditions were adjusted to optimize assay performance. The colorimetric TNA assay replaced a radioactive TNA assay previously used in the ricin vaccine studies.

Epidemiology of 2009 Pandemic Influenza A Virus Subtype H1N1 Among Kenyans Aged 2 Months to 18 Years, 2009–2010

The US Army Medical Research Unit-Kenya (USAMRU-K) conducts surveillance for influenza-like illness (ILI) in Kenya. We describe the temporal and geographic progression of A(H1N1)pdm09 as it emerged in Kenya and characterize the outpatient population with A(H1N1)pdm09 infection. We included patients with ILI aged 2 months to 18 years enrolled during June 2009-August 2010. Respiratory specimens were tested by real-time reverse-transcription polymerase chain reaction for influenza virus. Patients with A(H1N1)pdm09 infection were compared to those with seasonal influenza A virus infection and those with ILI who had no virus or a virus other than influenza virus identified (hereafter, "noninfluenza ILI"). Of 4251 patients with ILI, 193 had laboratory-confirmed A(H1N1)pdm09 infection. The first pandemic influenza case detected by USAMRU-K surveillance was in August 2009; peak activity nationwide occurred during October-November 2009. Patients with A(H1N1)pdm09 infection were more likely to be school-aged, compared with patients with seasonal influenza A virus infection (prevalence ratio [PR], 2.0; 95% confidence interval [CI], 1.3-3.1) or noninfluenza ILI (PR, 3.2; 95% CI, 2.4-4.3). USAMRU-K ILI surveillance detected the geographic and temporal distribution of pandemic influenza in Kenya. The age distribution of A(H1N1)pdm09 infections included more school-aged children, compared with seasonal influenza A virus infection and noninfluenza ILI.

A model for predicting primary blast lung injury

This article presents a model-based method for predicting primary blast injury. On the basis of the normalized work injury mechanism from previous work, this method presents a new model that accounts for the effects of blast orientation and species difference. The analysis used test data from a series of extensive experimental studies sponsored by the US Army Medical Research and Materiel Command. In these studies, more than 1200 sheep were exposed to air blast in free-field and confined enclosures, and lung injuries were quantified as the percentage of surface area contused. Blast overpressure data were collected using blast test devices placed at matching locations to represent loadings to the thorax. Adopting the modified Lobdell model with further modifications specifically for blast and scaling, the thorax deformation histories for the left, chest, and right sides of the thorax were calculated for all sheep subjects. Using the calculated thorax velocities, effective normalized work was computed for each test subject representing the irreversible work performed on the lung tissues normalized by lung volume and ambient pressure. Dose-response curves for four categories of injuries (trace, slight, moderate, and severe) were developed by performing log-logistic correlations of the computed normalized work with the injury outcomes, including the effect of multiple shots. A blast lethality correlation was also established. Validated by sheep data, the present work revalidates the previous understanding and findings of the blast lung injury mechanism and provides an anthropomorphic model for primary blast injury prediction that can be used for occupational and survivability analysis. Economic and decision analysis, level III.

Education and Experience of Army Flight Medics in Iraq and Afghanistan

Adequate training levels and an appropriate amount of continuing education for Army flight medics (AFM) is a highly contested topic. We sought to obtain a cross-section of the education, experience, and time spent by flight medics on patient care before and in between deployments. We also sought the opinions of AFM regarding training, transport staffing, and medical oversight. This was a prospective survey study administered electronically via SurveyMonkey.com to AFM deployed or recently deployed. This study was conducted under a protocol reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board, and in accordance with the approved protocol. Of the 53 AFM that participated, 57% stated they spend less than 10 h/mo on patient care and 28% reported getting no exposure to patients at all when not deployed. A majority (85%) felt that training to the paramedic level was optimal for their mission. Regarding time between deployments, 77% disagreed that they spent enough time on patient care and 96% agreed they would benefit from medical rotations. Almost half agreed they had been in situations while deployed they felt unprepared for medically. Results from this study seem to indicate AFM feel their training and patient contact is too limited prior to and in between deployments. These findings support a need for the reassessment of initial and ongoing training standards for AFM in order to best take care of our sick and wounded service members.

Hypothermia and hemostasis in severe trauma

The hypothermia and hemostasis in severe trauma (HYPOSTAT): a new crossroads workshop was convened to evaluate the interplay among hypothermia, hemostasis, and severe trauma/hemorrhage. Trauma is the major cause of death in young individuals in the United States, with uncontrolled hemorrhage representing the major cause of preventable deaths. This workshop organized by the National Heart, Lung, and Blood Institute and the US Army Medical Research and Material Command as a forum for exchange of ideas among experts from diverse fields. The specific workshop goals were to (1) identify state-of-the-art and needs in knowledge of biology of hypothermia and hemostasis in the setting of significant traumatic injury; (2) provide an interdisciplinary forum to enhance knowledge regarding early detection of traumatic shock and monitoring of the level and effect of controlled hypothermia in severe trauma settings; and (3) identify future research directions of the role of therapeutic-oriented hypothermia and hemostasis in trauma with severe blood loss. Not applicable. Expert opinion and literature review. This document provides a summary of the expert opinion and highlights the recommendations that came out of the discussions at this workshop to guide scientific efforts in basic, translational, and clinical research in this area.

Challenges, Solutions, and Best Practices in Telemental Health Service Delivery Across the Pacific Rim—A Summary

The Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, in conjunction with the American Telemedicine Association's Annual Mid-Year Meeting, conducted a 1-day workshop on how maturing and emerging processes and applications in the field of telemental health (TMH) can be expanded to enhance access to behavioral health services in the Pacific Rim. The purpose of the workshop was to bring together experts in the field of TMH from the military, federal agencies, academia, and regional healthcare organizations serving populations in the Pacific Rim. The workshop reviewed current technologies and systems to better understand their current and potential applications to regional challenges, including the Department of Defense and other federal organizations. The meeting was attended by approximately 100 participants, representing military, government, academia, healthcare centers, and tribal organizations. It was organized into four sessions focusing on the following topic areas: (1) Remote Screening and Assessment; (2) Post-Deployment Adjustment Mental Health Treatment; (3) Suicide Prevention and Management; and (4) Delivery of Training, Education, and Mental Health Work Force Development. The meeting's goal was to discuss challenges, gaps, and collaborative opportunities in this area to enhance existing or create new opportunities for collaborations in the delivery of TMH services to the populations of the Pacific Rim. A set of recommendations for collaboration are presented.

Pathology in Practice

Abstract : A young adult male Hartley guinea pig (Cavia porcellus) weighing 197 g (0.43 lb) was evaluated at the Comparative Pathology Branch, US Army medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Edgewood, Md, for a complete necropsy following sudden death; it had been observed alive approximately 1 hour earlier. The guinea pig, originally assigned to an active neurobehavior research protocol, was not used for that study because of low weight and poor growth.

Comparison of nucleic acid extraction platforms for detection of select biothreat agents for use in clinical resource limited settings

High-quality nucleic acids are critical for optimal PCR-based diagnostics and pathogen detection. Rapid sample processing time is important for the earliest administration of therapeutic and containment measures, especially in the case of biothreat agents. In this context, we compared the Fujifilm QuickGene-Mini80 to Qiagen's QIAamp Mini Purification kits for extraction of DNA and RNA for potential use in austere settings. Qiagen (QIAamp) column-based extraction is the currently recommended purification platform by United States Army Medical Research Institute for Infectious Diseases for both DNA and RNA extraction. However, this sample processing system requires dedicated laboratory equipment including a centrifuge. In this study, we investigated the QuickGene-Mini80, which does not require centrifugation, as a suitable platform for nucleic acid extraction for use in resource-limited locations. Quality of the sample extraction was evaluated using pathogen-specific, real-time PCR assays for nucleic acids extracted from viable and γ-irradiated Bacillus anthracis, Yersinia pestis, vaccinia virus, Venezuelan equine encephalitis virus, or B. anthracis spores in buffer or human whole blood. QuickGene-Mini80 and QIAamp performed similarly for DNA extraction regardless of organism viability. It was noteworthy that γ-irradiation did not have a significant impact on real-time PCR for organism detection. Comparison with QIAamp showed a less than adequate performance of the Fujifilm instrument for RNA extraction. However, QuickGene-Mini80 remains a viable alternative to QIAamp for DNA extraction for use in remote settings due to extraction quality, time efficiency, reduced instrument requirements, and ease of use.