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IntroductionOut-of-hospital cardiac arrest (OHCA) is a common, life-threatening event encountered routinely by first responders, including police, fire and emergency medical services (EMS). Current literature suggests that there is significant regional variation in outcomes, some of which may be related to modifiable factors. Yet, there is a persistent knowledge gap regarding strategies to guide quality improvement efforts in OHCA care and, by extension, survival. The Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study aims to fill these gaps and to improve outcomes.Methods and analysisThis mixed-methods study includes three aims. In aim I, we will define variation in OHCA survival to the emergency department (ED) among EMS agencies that participate in the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) in order to sample EMS agencies with high-survival and low-survival outcomes. In aim II, we will conduct site visits to emergency medical systems—including 911/dispatch, police, non-transport fire, and EMS agencies—in approximately eight high-survival and low-survival communities identified in aim I. At each site, key informant interviews and a multidisciplinary focus group will identify themes associated with high OHCA survival. Transcripts will be coded using a structured codebook and analysed through thematic analysis. Results from aims I and II will inform the development of a survey instrument in aim III that will be administered to all EMS agencies in Michigan. This survey will test the generalisability of factors associated with increased OHCA survival in the qualitative work to ultimately build an EPOC Toolkit which will be distributed to a broad range of stakeholders as a practical ‘how-to’ guide to improve outcomes.Ethics and disseminationThe EPOC study was deemed exempt by the University of Michigan Institutional Review Board. Findings will be compiled in an ‘EPOC Toolkit’ and disseminated in the USA through partnerships including, but not limited to, policymakers, EMS leadership and health departments.

Aim Care by emergency medical service (EMS) agencies is critical for optimizing prehospital outcomes following out-of-hospital cardiac arrest (OHCA). We explored whether substantial differences exist in prehospital outcomes across EMS agencies in Michigan—specifically focusing on rates of sustained return of spontaneous circulation (ROSC) upon emergency department (ED) arrival. Methods Using data from Michigan Cardiac Arrest Registry to Enhance Survival (MI-CARES) for years 2014–2017, we calculated rates of sustained ROSC upon ED arrival across EMS agencies in Michigan. We used hierarchical logistic regression models that accounted for patient, arrest-, community-, and response-level characteristics to determine adjusted rates of sustained ROSC among EMS agencies. Results A total of 103 EMS agencies and 20,897 OHCA cases were included. Average age of the cohort was 62.5 years (SD = 19.6), 39.7% were female, and 17.9% had an initial shockable rhythm due to ventricular fibrillation or pulseless ventricular tachycardia. The adjusted rate of sustained ROSC upon ED arrival across all EMS agencies was 23.8% with notable variation across EMS agencies (interquartile range [IQR], 20.5–29.2%). The top five EMS agencies had mean adjusted rates of sustained ROSC upon ED arrival of 42.7% (95% CI: 34.6–51.1%) while the bottom five had mean adjusted rates of 9.8% (95% CI: 7.6–12.7%). Conclusions Substantial variation in sustained ROSC upon ED arrival exists across EMS agencies in Michigan after adjusting for patient-, arrest, community-, and response-level features. Such differences suggest opportunities to identify and improve best practices in EMS agencies to advance OHCA care.

In recent years, mass-casualty incidents (MCIs) have become more frequent and deadly, while emergency department (ED) crowding has grown steadily worse and widespread. The ability of hospitals to implement an effective mass-casualty surge plan, immediately and expertly, has therefore never been more important. Yet, mass-casualty exercises tend to be highly choreographed, pre-scheduled events that provide limited insight into hospitals’ true capacity to respond to a no-notice event under real-world conditions. To address this gap, the US Department of Health and Human Services (Washington, DC USA), Office of the Assistant Secretary for Preparedness and Response (ASPR), sponsored development of a set of tools meant to allow any hospital to run a real-time, no-notice exercise, focusing on the first hour and 15 minutes of a hospital’s response to a sudden MCI, with the goals of minimizing burden, maximizing realism, and providing meaningful, outcome-oriented metrics to facilitate self-assessment. The resulting exercise, which was iteratively developed, piloted at nine hospitals nationwide, and completed in 2015, is now freely available for anyone to use or adapt. This report demonstrates the feasibility of implementing a no-notice exercise in the hospital setting and describes insights gained during the development process that might be helpful to future exercise developers. It also introduces the use of ED “immediate bed availability (IBA)” as an objective, dynamic measure of an ED’s physical capacity for new arrivals.WaxmanDA, ChanEW, PillemerF, SmithTWJ, AbirM, NelsonC. Assessing and improving hospital mass-casualty preparedness: a no-notice exercise. Prehosp Disaster Med. 2017;32(6):662–666.

Background Respiratory syncytial virus (RSV) is a common cause of illness and hospitalization for infants and children globally. The objective of this study was to characterize the burden of RSV and all-cause bronchiolitis (ACB) inpatient hospitalizations and emergency room department (ED) visits in U.S. infants aged < 1 year with the most recent years of data available. Figure 1. RSV and ACB hospitalizations among US infants Figure 2. ED visits due to RSV and ACB among US infants < 1 year old (NEDS 2016) Methods The National (Nationwide) Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS), which are large national publicly available all-payer databases in the U.S., were used to estimate the burden of RSV in 2016 based on ICD-9 and 10 codes. The proportions of hospitalizations or ED visits due to RSV in infants aged < 1 year were quantified. Due to the potential of missing RSV encounters based on coding practices, ACB was also evaluated. Based on availability of variables and data recency, 2011 NIS data were used to describe RSV burden by age in months. Sensitivity analyses were conducted with NIS and NEDS data from other years (2011-2015). Results A clear seasonal pattern was observed for RSV hospitalizations and RSV ED visits with a peak in December-February and a trough in June-August in 2016. During the RSV season and peak months, RSV was a leading cause of hospitalization (12065/45490=27% in Jan and 12050/45080=27% in Feb) and ED visits (26423/316709=8% in Jan and 24721/306397=8% in Feb)) among U.S. infants under 1 year of age. Similar patterns were seen for ACB in 2016 (38% hospitalization and 17-18% ED visits in Jan and Feb) and for RSV and ACB in the other years. For the inpatient setting in 2011, RSV hospitalizations were the highest among the youngest patients (except those aged Conclusion These results show that during the RSV season, RSV and ACB were a leading cause of hospitalization and ED visit among US infants under 1 year of age. Current policy does not support routine RSV testing of clinical lower respiratory tract infections (LRTIs) among infants. In that context, as an approximation of RSV LRTI visits in each setting, ACB can be considered an upper bound and RSV can be considered a lower bound of the true proportion of hospital encounters associated with RSV in these settings.. Disclosures Mina Suh, MPH, International Health, EpidStrategies (Employee) Xiaohui Jiang, MS, EpidStrategies (Employee)

In this brief, the authors present methods for creating critical care surge capacity in hospitals in response to the COVID-19 pandemic and estimate patient capacity, given the number of doctors, nurses, respiratory therapists, ventilators, and beds.

A Microsoft Excel–based tool that allows decisionmakers at all levels — hospitals, health care systems, states, regions — responding to the COVID-19 crisis to estimate current critical care capacity and rapidly explore strategies for increasing it.

Background In 2017, under the supervision of the European Centre for Disease Prevention and Control (ECDC), a list of competencies and knowledge and skill statements for EU professionals working in Public Health Emergency Preparedness (PHEP) systems were identified and integrated into a Competency Model. Building on these efforts, a PHEP competency-based training toolkit was developed, pilot tested and finalized with the goal of providing a standardized training resource for experts involved in response to cross-border threats to health. Objectives Led by the ECDC, an international research team drafted a preliminary version of a curriculum consisting of five modules, with a list of targeted competencies, learning objectives, reading and training methods including case studies and simulation exercises. In May 2018, the curriculum was pilot tested in a 3.5-day training course at the University of Bologna, Italy. The participants included 20 representatives from 8 EU Member States. An evaluation strategy, combining both quantitative and qualitative methods, was designed to assess the impact of the training on participants’ applied knowledge and competence. Results Overall, the participants’ feedback on the pilot course was positive, with scores from 4.0 to 4.8 out of 5 for all the items considered. Several suggestions were made both by the trainers and the trainees to enhance the effectiveness of the learning activities, and the curriculum was integrated into a training toolkit with more exercises, teaching materials and a guide for facilitators. Conclusions This European Public Health Emergency Preparedness Training Toolkit is the first EU competency-based toolkit intended to help Member States improve their response to public health emergencies through standardized training. Designed for individuals working in strategic positions at the national level, its general approach, modular structure and content are relevant and can be tailored to a wider range of professionals. Key messages To improve PHEP in the EU, competency-based curricula and standardized training programs and resources for health professionals are needed. By enhancing the overall public health professionals’ experience and competency, the European PHEP Training Toolkit represents a step towards strengthening preparedness and response systems in the EU.

The treatment paradigm for nonmelanoma skin cancer remains surgical. This fact combined with its remarkably high incidence positions it as the fifth most costly cancer to treat in the Medicare population. To address this, consideration of alternative medical therapeutics is warranted. Intralesional 5-fluorouracil is a potentially affordable option that may demand further investigation. This literature review examines current data on its efficacy and adverse effects.

To demonstrate how public health systems can use root-cause analysis (RCA) to improve learning from critical incidents, the research team utilized a facilitated look-back meeting to examine the public health systems' response to a Salmonella outbreak in the water supply in Alamosa, Colorado. We worked with public health, emergency management agencies, and other stakeholders to identify response challenges related to public health emergency preparedness capabilities, root causes, and lessons learned. The results demonstrate that RCA can help identify systems issues that, if addressed, can improve future responses. Furthermore, RCA can identify more basic issues that go beyond a specific incident or setting, such as the need for effective communication and coordination throughout the public health system, and the social capital needed to support it.

RAND researchers identify opportunities to strengthen the system of care for treating rare but serious infectious diseases, including the use of tiered facilities such as those established during the recent Ebola outbreak, developing a brain trust to provide advice to health care providers, using mobile teams, and enhancing air and ground patient transport. The authors also discuss financial considerations for the sustainability of the system.

Objectives The objective of this study was to present results from a multicenter registry designed to obtain longitudinal clinical outcome data for patients implanted with a neuromodulation system for the management of chronic pain of the trunk and/or limbs. Materials and Methods Interim data from 579 patients across 40 study sites were analyzed from a prospective, observational, noninterventional registry. Institutional review board approval was obtained prior to enrollment. The following were recorded at baseline and at 3, 6, and 12 months postimplant: patient-reported pain relief, categorical ratings of pain relief, Pain Disability Index (PDI) scores, quality of life, medication usage, and patient satisfaction. Pain relief among (tobacco) smokers was also assessed. Descriptive statistics were compiled for all patient outcome measurements, and data are reported as mean (±standard deviation). All statistical analysis was conducted using one-sided t-tests with a significance level of α = 0.05. Device-related adverse events were captured and are reported. Results Patient-reported pain relief was 58.0% (±26.2%) at 3 months, 58.1% (±28.7%) at 6 months, and 57.0% (±29.4%) at 12 months. Mean PDI scores were reduced from 47.7 points at baseline to 33.3, 32.4, and 31.9 points, respectively (p ≤ 0.001). The majority of patients categorized their pain relief as “excellent” or “good” and reported their overall quality of life as “greatly improved” or “improved” at all time points. In addition, greater than 79% of patients were “satisfied” or “very satisfied” with the therapy at all time points assessed, and 47.1% of patients “stopped” or “decreased” use of narcotics/opioids. Pain relief was significantly attenuated by smoking (p = 0.042). The most common adverse event was persistent pain and/or numbness at implantable pulse generator/lead site, which accounted for 18.6% of all events in 3.2% of all patients. Conclusions These results provide evidence to further support the safety, efficacy, and sustainability of neuromodulation in clinical practice.

Objective The Epiducer lead delivery system is a novel lead delivery device that can be used to percutaneously implant S-Series paddle leads (St. Jude Medical, Plano, TX, USA) as well as multiple percutaneous leads obviating the need for laminectomy and/or multiple needle sticks, respectively. This study evaluates the safety and usage of the Epiducer lead delivery system. Methods An Institutional Review Board-approved observational data collection study was conducted to evaluate usage patterns of the Epiducer system. In addition to the number and frequency of different lead configurations, the following procedural aspects of the surgery were recorded during the evaluation: angle of entry, distance from entry to final lead placement, and physician feedback. Descriptive statistics on adverse events, procedural aspects, and patient outcomes were compiled. Results Data were collected from 163 patients across 25 investigational sites. Physicians successfully implanted patients using the Epiducer during 89% of the procedures. Seven possible lead configurations were implanted. There were 96% and 92% of physicians “satisfied” or “very satisfied” with accessing the epidural space and placing multiple leads with the Epiducer delivery system, respectfully. Eighty-nine percent of physicians were “satisfied” or “very satisfied” with implanting an S-Series paddle lead using the Epiducer delivery system. Ninety-five percent of physicians were “satisfied” or “very satisfied” with the Epiducer delivery system overall. Ten patients (6%) experienced adverse events. Conclusion Results suggest that the Epiducer delivery system allows for the safe and successful percutaneous implantation of paddle leads and/or multiple lead configurations. Furthermore, physicians are satisfied with the Epiducer delivery system.

Policymakers are increasingly seeking to determine whether the federal government's recent investments in public health preparedness have left the public health system better prepared to respond to large-scale public health emergencies. Yet, there remain questions about how to define “public health emergency preparedness,” how much preparedness is enough, and how preparedness can be measured and assessed. This chapter identifies the key challenges associated with measuring public health preparedness and reviews approaches currently in use. We also identify some emerging measurement techniques that might help address some of these challenges.

Objective This longitudinal, clinical outcome study was a multicenter, prospective, observational, registry with a 24-month assessment of patients implanted with spinal cord stimulation (SCS) systems for the management of chronic pain of the trunk and/or limbs. Methods On informed consent and institutional review board approval, 614 patients from 39 sites were enrolled within 30 days following permanent SCS system implantation. Medication usage, patient-reported pain relief (PRP), categorical ratings of pain relief, pain disability index scores (PDI), quality of life (QoL), and patient satisfaction were assessed at enrollment, 3-, 6-, 12-, 18-, and 24-month postimplant. Device-related adverse events (AEs) were recorded and reported. Results Across all visits, statistically significant improvements were reported on all outcome measures. Mean PRP was 58.5% (± 26.4) at 3 months, 56.8% (± 29.2) at 6 months, 57.7% (± 28.9) at 12 months, 55.6% (± 29.8) at 18 months, and 56.3% (± 30.3) at 24 months. More than 65% of patients at any visit reported a PRP ≥ 50%. Mean PDI scores reduced from 46.9 points at baseline to 32.7, 31.8, 31.5, 32.1, 32.1 points at 3, 6, 12, 18, and 24 months (p ≤ 0.0001), respectively. Greater than 76% of patients at any visit were satisfied with their therapy. The majority of patients categorized pain relief as excellent or good on a 5-item scale and reported overall QoL as greatly improved or improved on a 5-item scale. An average of 88% of patients stopped, decreased, or did not change dose of narcotics/opioids. The most common AE was diminished or loss of pain relief in 11.4% of enrolled patients. Conclusions Most patients experienced substantial pain relief and a significant improvement in all outcome measures. These results further support the safety, efficacy, and sustainability of SCS in clinical practice.

Background Antiplatelet therapy is a complicating factor in patients with traumatic brain injuries (TBI), as well as those with hemorrhagic cerebrovascular accidents (CVAs). Platelet Function Assay (PFA)-100 is a coagulation device that can detect platelet dysfunction caused by aspirin and adenosine diphosphate inhibition. Our retrospective study reviewed the effectiveness of PFA-100 in detecting platelet dysfunction caused by aspirin and clopidogrel and determined its clinical importance. Methods All patients with PFA-100 tests from January 2013 to February 2014 were collected. Diagnoses indicative of a TBI or CVA were chosen for analysis. Patients with a normal PFA-100 indicating no platelet dysfunction but with documented aspirin and/or clopidogrel use were selected. An extensive chart review was performed to determine the relevance to their clinical care. Results A total of 475 patients were evaluated with a PFA-100 from January 2013 to February 2014. PFA-100 detected platelet dysfunction as the result of pre-injury use of antiplatelet agents in TBI and CVA patients with a sensitivity of only 48.6% and a specificity of 74.8%. Had these antiplatelet medications been known during initial workup, these patients would have had a change in management that may have impacted their outcomes. Conclusion Despite its common usage, the PFA-100 is an unreliable tool to assist in the management of TBI and CVA patients. Additional investigation into alternative methods for detecting platelet dysfunction is warranted.

Background The use of the conventional halo is accompanied by the possibility of serious complications, especially in the pediatric population. Complications could include penetration of pin into the skull, pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores. The noninvasive "pinless" halo was introduced in an attempt to mitigate these problems while retaining the effectiveness of the conventional halo. The purpose of this study is to determine the indications and complications related to pinless halo application. Methods We retrospectively reviewed 61 patients, whose treatment included the use of a pinless halo device, presenting to our institution between 2004 and 2012. Results There were 35 male and 26 female patients with an average age of 6.04 years. Indications of pinless halo application included postoperative immobilization for congenital muscular torticollis in 38 cases, conservative management of atlantoaxial rotatory subluxation in 11 cases, postoperative immobilization following cervical fusion in 10 cases, and immobilization for occipital condyle fracture in 2 cases. The average duration of the pinless halo application was 32.68 days. Thirteen patients had complications, among which major complications were seen in 2 patients, each of whom developed a pressure sore; one on the scalp and the other on the chest. Both the pressure sores responded to local treatment; however, 1 resulted in permanent alopecia. Conclusions The use of the noninvasive pinless halo was found to be safe with few complications in our study. The complications were infrequent and patients were compliant to treatment, indicating that this modality is patient-friendly. Effectiveness of this treatment in comparison with invasive halos and other cervical orthoses was not determined and is a limitation of this study. Level of evidence Level IV-Case series.

Health departments use after-action reports to collect data on their experience in responding to actual public health emergencies. To address deficiencies in the use of such reports revealed in the 2009 H1N1 influenza pandemic and to develop an effective approach to learning from actual public health emergencies, we sought to understand how the concept and operations of a "critical incident registry," commonly used in other industries, could be adapted for public health emergency preparedness. We conducted a workshop with public health researchers and practitioners, reviewed the literature on learning from rare events, and sought to identify the optimal characteristics of a critical incident registry (CIR) for public health emergency preparedness. Several key critical characteristics are needed for a CIR to be feasible and useful. A registry should: (1) include incidents in the response in which public health agencies played a substantial role, are "meaningful," test one or more emergency preparedness capabilities, and are sufficiently limited in scope to isolate specific response issues; (2) be supported by a framework and standard protocols for including reports based on rigorous analysis of individual incidents and methods for cross-case analysis; and (3) include explicit incentives for reporting, to overcome intrinsic disincentives. With proper incentives in place, a critical incident registry can be a useful tool for improving public health emergency preparedness. Standard protocols for reporting critical events and probing analysis are needed to enable identification of patterns of successes and failures.

BACKGROUND: Recent genome-wide association studies (GWAS) have identified novel loci associated with sudden cardiac death (SCD). Despite this progress, identified DNA variants account for a relatively small portion of overall SCD risk, suggesting that additional loci contributing to SCD susceptibility await discovery. The objective of this study was to identify novel DNA variation associated with SCD in the context of coronary artery disease (CAD).METHODS AND FINDINGS: Using the MetaboChip custom array we conducted a case-control association analysis of 119,117 SNPs in 948 SCD cases (with underlying CAD) from the Oregon Sudden Unexpected Death Study (Oregon-SUDS) and 3,050 controls with CAD from the Wellcome Trust Case-Control Consortium (WTCCC). Two newly identified loci were significantly associated with increased risk of SCD after correction for multiple comparisons at: rs6730157 in the RAB3GAP1 gene on chromosome 2 (P = 4.93×10(-12), OR = 1.60) and rs2077316 in the ZNF365 gene on chromosome 10 (P = 3.64×10(-8), OR = 2.41).CONCLUSIONS: Our findings suggest that RAB3GAP1 and ZNF365 are relevant candidate genes for SCD and will contribute to the mechanistic understanding of SCD susceptibility.

Objective: The paucity of evidence and wide variation among communities creates challenges for developing congressionally mandated national performance standards for public health preparedness. Using countermeasure dispensing as an example, we present an approach for developing standards that balances national uniformity and local flexibility, consistent with the quality of evidence available.Methods: We used multiple methods, including a survey of community practices, mathematical modeling, and expert panel discussion.Results: The article presents recommended dispensing standards, along with a general framework that can be used to analyze tradeoffs involved in developing other preparedness standards.Conclusions: Standards can be developed using existing evidence, but would be helped immensely by a stronger evidence base.(Disaster Med Public Health Preparedness. 2010;4:285-290)

Policy makers need to know whether federal programs can improve community-level readiness for large-scale public health emergencies, and how to design such programs to increase their impact. This article describes an evaluation of the Cities Readiness Initiative, a federal program to improve communities’ ability to dispense medications rapidly during emergencies. The program helped increase staffing, improve planning and partnerships, and streamline medication-dispensing procedures. The evaluation results indicate that clear goals, technical assistance, and a balance between threat-specific and more-general “all hazards” planning might improve the effectiveness of federal readiness programs.

Antibody-drug conjugates (ADC), potent cytotoxic drugs covalently linked to antibodies via chemical linkers, provide a means to increase the effectiveness of chemotherapy by targeting the drug to neoplastic cells while reducing side effects. Here, we systematically examine the potential targets and linker-drug combinations that could provide an optimal ADC for the treatment for non–Hodgkin's lymphoma. We identified seven antigens (CD19, CD20, CD21, CD22, CD72, CD79b, and CD180) for potential treatment of non–Hodgkin's lymphoma with ADCs. ADCs with cleavable linkers mediated in vivo efficacy via all these targets; ADCs with uncleavable linkers were only effective when targeted to CD22 and CD79b. In target-independent safety studies in rats, the uncleavable linker ADCs showed reduced toxicity, presumably due to the reduced release of free drug or other toxic metabolites into the circulation. Thus, our data suggest that ADCs with cleavable linkers work on a broad range of targets, and for specific targets, ADCs with uncleavable linkers provide a promising opportunity to improve the therapeutic window for ADCs in humans. [Cancer Res 2009;69(6):2358–64]

This research highlight summarizes the findings of RAND's initial evaluation of the Cities Readiness Initiative and the program's impact on communities' readiness to conduct mass dispensing of medications and other medical supplies.

The lack of frequent real-world opportunities to study preparedness for large-scale public health emergencies has hindered the development of an evidence base to support best practices, performance measures, standards, and other tools needed to assess and improve the nation’s multibillion dollar investment in public health preparedness. In this article, we argue that initial funding priorities for public health systems research on preparedness should focus on using engineering-style methods to identify core preparedness processes, developing novel data sources and measures based on smaller-scale proxy events, and developing performance improvement approaches to support the translation of research into practice within the wide variety of public health systems found in the nation. (Disaster Med Public Health Preparedness. 2008;2:247–250)

This fact sheet summarizes the results of a RAND initiative to develop performance standards for distributing antibiotics and other lifesaving medical countermeasures on a large scale within the critical first 48 hours of a public health emergency.

Since September 11, 2001, and the anthrax attacks that followed, a substantial federal investment—totaling well in excess of $5 billion—has been made to increase our nation’s ability to prepare for, and respond to, public health emergencies. Yet despite anecdotal reports suggesting that progress has been made, it is unclear whether these investments have left the nation better prepared to respond to a bioterrorist attack, pandemic influenza, or any other large-scale public health emergency. This situation is not because of a shortage of measures of preparedness. Over the past 5 years, federal agencies, state health departments, and various nongovernmental organizations have proposed and implemented myriad measures of public health emergency preparedness. But these efforts have not resulted in a clear picture of the nation’s preparedness owing to ambiguous and uncertain preparedness goals, a lack of agreement about what the measures should aim at and how they should be interpreted, and a weak system of accountability for producing results.1 Measures often vary considerably across agencies and shift dramatically from year to year, leaving state and local health officials, businesses, nonprofits, and citizens confused and perplexed by a maze of overlapping and sometimes contradictory requirements, checklists, and ideas about what constitutes preparedness.2–4 What our nation needs in order to bring coherence to the debate is a clear definition of public health emergency preparedness and an articulation of the key elements that characterize a well-prepared community. In this editorial, we propose a candidate definition of public health emergency preparedness and describe its key elements. Both the definition and the elements were developed by a diverse panel of experts convened by RAND in February 2007. We propose the following definition: public health emergency preparedness (PHEP) is the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action. In developing the definition, we considered what constitutes a public health emergency, what public health emergency preparedness requires, and who is involved in it.

Quality improvement (QI) methods have been used in many industries to improve performance and outcomes. This chapter reviews key QI concepts and their application to public health emergency preparedness (PHEP). We conclude that for QI to flourish and become standard practice, changes to the status quo are necessary. In particular, public health should build its capabilities in QI, enhance implementation, and align incentives to facilitate use of QI.

This fact sheet summarizes interrelated RAND projects to examine public health infrastructure and how public health preparedness is transforming public health agencies.

The etiology of the porokeratoses is unknown. Overexpression of the p53 tumor suppressor protein and disregulated cell cycle control have been pathogenically implicated. The p53 tumor suppressor gene product is regulated by mdm2 and both gene products influence cell cycle progression through the cyclin-dependent kinase inhibitor p21. Thirty-three cases of the various types of porokeratosis were immunohistochemically studied for p53, mdm2, and p21 proteins. Each of the cases showed increased p53 and decreased mdm2 and p21 expression within keratinocytes underlying cornoid lamella. This study confirms the previous findings of increased p53 staining and expands the potential roles of mdm2 and p21 in the pathogenesis of the porokeratoses.

Previous studies of dopamine metabolism in iron-deficient rats demonstrated an elevation in extra-neuronal levels of dopamine and a depression in the number of dopamine D 2 receptors; however, the importance of anemia per se and the reversibility of these observations are not completely resolved. The purpose of this study was to determine if in vivo reuptake of caudate dopamine is altered by iron deficiency anemia, if it is reversible with iron therapy, and if anemia per se produced the same effects on dopamine metabolism. Male Sprague-Dawley rats (21-d old) were fed an iron-deficient diet (4 mg Fe/kg diet) and then iron repleted (5 mg iron dextran), or were fed an iron adequate diet (35 mg Fe/kg diet) and then given phenylhydrazine to induce hemolytic anemia. In vivo microdialysis was performed in steady-state conditions both before and after iron or no therapy and was followed by an intraperitoneal injection of a dopamine reuptake blocker (cocaine-HCI 30 mg/kg). Thirty percent higher extracellular dopamine levels in the caudate-putamen were observed in iron-deficient rats compared with control rats, but no differences were observed in tissue levels. Hemolytic anemic and iron-repleted rats had normal extracellular dopamine levels. The response to dopamine reuptake blockade was significantly attenuated in iron-deficient rats compared with control, iron-repleted, or hemolytic anemic rats. These experiments provide evidence that iron deficiency blunts the dopamine reuptake mechanism, that this is a reversible process in postweaning rats, and that anemia per se does not cause the increased extracellular dopamine levels.

identification of cases. One surveillance method may identify VAP that the other fails to detect, leading to concerns that the exclusive use of just one of these methods may lead to under-detection of actual VAP cases. In the interest of improving the sensitivity and accuracy of VAP identification at our institution, a surveillance approach that combines these methodologies was developed and implemented.