Concurrent Biological, Electromagnetic Pulse, And Cyber Attacks - A Challenge To The Interagency Response

The U.S. including its military depends on an electrical grid and electricity-based critical infrastructure. An electromagnetic pulse (EMP) and cyber attack can disable not just a significant portion of the electrical grid and critical infrastructure, but also the networkcentric military response to such an attack. There is a large range of actors that might attempt EMP attacks against the U.S.. Health surveillance systems are network-centric, and if mass destruction is the goal of an adversary, launching a biological attack concurrently with EMP and cyber attacks may achieve this goal. Current agency response plans focus on one WMD attack at a time but combined attacks without emergency management plans may compromise a timely response. An EMP and cyber attack could amplify the effects of a biological attack because the loss of the electrical grid and electricity-based critical infrastructure could disable detection and response efforts as well as disrupt interagency efforts to coordinate a medical response. EMP is often perceived as science fiction because the immediate effect does not result in loss of life, but the cascading failures of critical infrastructure will affect civilian and military capabilities to support survival and recovery. Key steps to mitigate the catastrophic effects of an EMP attack should be taken and include: prevent an attack in the first place, prepare so personnel can respond after an attack, protect the critical infrastructure to limit the impact, and recover after an attack to restore power and critical infrastructure

The Challenges of Implementing Next Generation Sequencing Across a Large Healthcare System, and the Molecular Epidemiology and Antibiotic Susceptibilities of Carbapenemase-Producing Bacteria in the Healthcare System of the U.S. Department of Defense.

OBJECTIVE:We sought to: 1) provide an overview of the genomic epidemiology of an extensive collection of carbapenemase-producing bacteria (CPB) collected in the U.S. Department of Defense health system; 2) increase awareness of the public availability of the sequences, isolates, and customized antimicrobial resistance database of that system; and 3) illustrate challenges and offer mitigations for implementing next generation sequencing (NGS) across large health systems. DESIGN:Prospective surveillance and system-wide implementation of NGS. SETTING:288-hospital healthcare network. METHODS:All phenotypically carbapenem resistant bacteria underwent CarbaNP® testing and PCR, followed by NGS. Commercial (Newbler and Geneious), on-line (ResFinder), and open-source software (Btrim, FLASh, Bowtie2, an Samtools) were used for assembly, SNP detection and clustering. Laboratory capacity, throughput, and response time were assessed. RESULTS:From 2009 through 2015, 27,000 multidrug-resistant Gram-negative isolates were submitted. 225 contained carbapenemase-encoding genes (most commonly blaKPC, blaNDM, and blaOXA23). These were found in 15 species from 146 inpatients in 19 facilities. Genetically related CPB were found in more than one hospital. Other clusters or outbreaks were not clonal and involved genetically related plasmids, while some involved several unrelated plasmids. Relatedness depended on the clustering algorithm used. Transmission patterns of plasmids and other mobile genetic elements could not be determined without ultra-long read, single-molecule real-time sequencing. 80% of carbapenem-resistant phenotypes retained susceptibility to aminoglycosides, and 70% retained susceptibility to fluoroquinolones. However, among the CPB-confirmed genotypes, fewer than 25% retained susceptibility to aminoglycosides or fluoroquinolones. CONCLUSION:Although NGS is increasingly acclaimed to revolutionize clinical practice, resource-constrained environments, large or geographically dispersed healthcare networks, and military or government-funded public health laboratories are likely to encounter constraints and challenges as they implement NGS across their health systems. These include lack of standardized definitions and quality control metrics, limitations of short-read sequencing, insufficient bandwidth, and the current limited availability of very expensive and scarcely available sequencing platforms. Possible solutions and mitigations are also proposed

Overview of Carbapenemase-producing Genotypes in the Health and Surveillance Systems of the U.S. Department of Defense.

<p>Overview of Carbapenemase-producing Genotypes in the Health and Surveillance Systems of the U.S. Department of Defense.</p

Considerations and Challenges of Implementing Next Generation Sequencing Across Large Health Systems.

<p>Considerations and Challenges of Implementing Next Generation Sequencing Across Large Health Systems.</p

Phylogeny of Carbapenemase-producing Klebsiella and Carbapenemase-producing Acinetobacter.

<p>A-C represent the same <i>Klebsiella</i> isolates from the same outbreak event, and Fig 2D–2F represent the same <i>Acinetobacter</i> isolates from a separate same outbreak event. However, depending on the clustering method and software program used, different results can be obtained. This highlights the need for standardized approaches.</p

How companies motivate entrepreneurial employees: the case of organizational spin-alongs

This paper investigates how high-profile employees with entrepreneurial abilities can be attracted, retained, and nurtured in order to foster companies’ corporate entrepreneurship through innovations. We find that the spin-along design provides entrepreneurial employees with a combination of flexibility and security (flexicurity), corporate management, and control. Based on five in-depth case studies within an innovative company, our results show that the organizational spin-along structure supports and enhances entrepreneurial employees’ motivation and leads to the attraction, nurturing, and retention of such employees. We also find that senior management has a critical leadership role in enabling such an organization design by balancing flexibility and security with control

Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: A subgroup analysis of the ARISTOTLE trial

Background: In the ARISTOTLE trial, the rate of stroke or systemic embolism was reduced by apixaban compared with warfarin in patients with atrial fibrillation (AF). Patients with AF and previous stroke or transient ischaemic attack (TIA) have a high risk of stroke. We therefore aimed to assess the efficacy and safety of apixaban compared with warfarin in prespecified subgroups of patients with and without previous stroke or TIA. Methods: Between Dec 19, 2006, and April 2, 2010, patients were enrolled in the ARISTOTLE trial at 1034 clinical sites in 39 countries. 18 201 patients with AF or atrial flutter were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalised ratio 2·0-3·0). The median duration of follow-up was 1·8 years (IQR 1·4-2·3). The primary efficacy outcome was stroke or systemic embolism, analysed by intention to treat. The primary safety outcome was major bleeding in the on-treatment population. All participants, investigators, and sponsors were masked to treatment assignments. In this subgroup analysis, we estimated event rates and used Cox models to compare outcomes in patients with and without previous stroke or TIA. The ARISTOTLE trial is registered with ClinicalTrials.gov, number NTC00412984. Findings: Of the trial population, 3436 (19%) had a previous stroke or TIA. In the subgroup of patients with previous stroke or TIA, the rate of stroke or systemic embolism was 2·46 per 100 patient-years of follow-up in the apixaban group and 3·24 in the warfarin group (hazard ratio [HR] 0·76, 95% CI 0·56 to 1·03); in the subgroup of patients without previous stroke or TIA, the rate of stroke or systemic embolism was 1·01 per 100 patient-years of follow-up with apixaban and 1·23 with warfarin (HR 0·82, 95% CI 0·65 to 1·03; p for interaction=0·71). The absolute reduction in the rate of stroke and systemic embolism with apixaban versus warfarin was 0·77 per 100 patient-years of follow-up (95% CI -0·08 to 1·63) in patients with and 0·22 (-0·03 to 0·47) in those without previous stroke or TIA. The difference in major bleeding with apixaban compared with warfarin was 1·07 per 100 patient-years (95% CI 0·09-2·04) in patients with and 0·93 (0·54-1·32) in those without previous stroke or TIA. Interpretation: The effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA. Owing to the higher risk of these outcomes in patients with previous stroke or TIA, the absolute benefits of apixaban might be greater in this population. Funding: Bristol-Myers Squibb and Pfizer. © 2012 Elsevier Ltd