Search

Scientists are working together to establish a standardized international scale for measuring and reporting the intensities and impacts of earthquake shaking.

Supplemental Figures. This file contains supplemental figures concerning analysis of megakaryocyte progenitor and erythroid progenitor analysis in the leukemia marrow, platelet and megakaryocyte progenitor analysis after DBZ treatment of leukemia mice, as well as CXCL12 promoter CHIP analysis

Supplemental Figure Legends

More than half of T-cell acute lymphoblastic leukemia (T-ALL) patients harbor gain-of-function mutations in the intracellular domain of Notch1. Diffuse infiltration of the bone marrow commonly occurs in T-ALL and relapsed B-cell acute lymphoblastic leukemia patients, and is associated with worse prognosis. However, the mechanism of leukemia outgrowth in the marrow and the resulting biologic impact on hematopoiesis are poorly understood. Here, we investigated targetable cellular and molecular abnormalities in leukemia marrow stroma responsible for the suppression of normal hematopoiesis using a T-ALL mouse model and human T-ALL xenografts. We found that actively proliferating leukemia cells inhibited normal hematopoietic stem and progenitor cell (HSPC) proliferation and homing to the perivascular region. In addition, leukemia development was accompanied by the suppression of the endosteum-lining osteoblast population. We further demonstrated that aberrant Notch activation in the stroma plays an important role in negatively regulating the expression of CXLC12 on osteoblasts and their differentiation. Notch blockade reversed attenuated HSPC cycling, leukemia-associated abnormal blood lineage distribution, and thrombocytopenia as well as recovered osteoblast and HSPC abundance and improved the hematopoietic-supportive functions of osteoblasts. Finally, we confirmed that reduced osteoblast frequency and enhanced Notch signaling were also features of the marrow stroma of human ALL tissues. Collectively, our findings suggest that therapeutically targeting the leukemia-infiltrated hematopoietic niche may restore HSPC homeostasis and improve the outcome of ALL patients. Cancer Res; 76(6); 1641–52. ©2016 AACR.

Supplemental Materials and Methods This file contains detailed methods of IHC, WB, CHIP assay, luciferase reporter assay, qRT-PCR and 2-photon imaging analysis and etc.

Background Patient understanding of surgical procedures is often incomplete at the time they are performed, invalidating consent, and exposing healthcare providers to complaints and claims of failure to inform. Remote consultations, language barriers and patient factors can hinder an effective consent pathway. New approaches are needed to support communication and shared decision-making. Methods Multi-language digital animations explaining laparoscopic cholecystectomy were introduced at The Royal London Hospital for patients who attended for elective surgery (www.explainmyprocedure.com). Patients completed questionnaires on the day of their procedure both before and after introduction of the animations. We assessed patient-reported understanding of the procedure, its intended benefits, the possible risks, and alternatives to treatment in 72 consecutive patients, 37 before (no animation group) and after 35 after introducing the animations into the consent pathway (animation group). Patient understanding in the two groups was compared. Results The two groups were well matched in respect of age, sex and whether English was their first spoken language. The proportions of patients who reported they completely understood the procedure, its benefits, risks, and alternatives in the no animation group were 54%, 57%, 38% and 24% and in the animation group, 91%, 91%, 74% and 77% respectively; p Conclusions The integration of multi-language laparoscopic cholecystectomy video animations into the patient consent pathway was associated with substantial improvement in reported understanding of the procedure, benefits, risks, and alternatives to treatment. This approach can be applied across all surgical disciplines in a standardised manner in an era of accelerated elective work and remote consultations.

The combination of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) has been demonstrated to be at least equally effective to ATRA and chemotherapy (CHT) in non-high-risk acute promyelocytic leukemia (APL). However, the efficacy of ATRA-ATO compared to ATRA-ATO plus CHT in high-risk APL remains unknown. Here we performed a randomized multi-center non-inferiority phase III study to compare the efficacy of ATRA-ATO and ATRA-ATO plus CHT in newly diagnosed all-risk APL to address this question. Patients were assigned to receive ATRA-ATO for induction, consolidation and maintenance or ATRA-ATO plus CHT for induction followed by three cycles of consolidation therapy, and maintenance therapy with ATRA-ATO. In the non-CHT group, hydroxyurea was used to control leukocytosis. A total of 128 patients were treated. The complete remission rate was 97% in both groups. The 2-year disease-free, event-free survival rates in the non-CHT group and CHT group in all-risk patients were 98% v 97%, and 95% v 92%, respectively (P = 0.62 and P = 0.39, respectively). And they were 94% v 87%, and 85% v 78% in the high-risk patients (P = 0.52 and P = 0.44, respectively). This study demonstrated that ATRA-ATO had the same efficacy as the ATRA-ATO plus CHT in the treatment of patients with all-risk APL.

TPS273 Background: Natural killer (NK) cell therapy is emerging as a promising therapy for patients (pts) with solid tumors and hematologic malignancies with no reported toxicity associated with the cell therapy product itself. NK cell trials in solid tumors are limited by immune inhibitory tumor microenvironments that prevent trafficking and activity of donor NK cells, which is largely governed by TGFβ signaling. We recently developed a novel platform for ex vivo expansion of healthy donor NK cells. We previously showed these cells to be safe in a dose-escalation study when given without cytokine support, with early evidence of response in pts with metastatic colorectal cancer (CRC) and in pts with hematologic malignancies. IL-2 has been well-established as an important activating cytokine supporting NK cells in humans, but can also induce regulatory T cells, which further suppress NK cells by producing TGFβ. We seek to improve upon the early activity we previously observed with NK cells alone by administering concurrently with IL-2 and by limiting the inhibitory tumor microenvironment and regulatory T cells with TGFβ receptor 1 inhibitor vactosertib. Methods: This phase Ib open-label study evaluates the safety and persistence (primary objectives), and the clinical and biological activity and trafficking (secondary objectives) of our novel NK cell therapy in combination with IL-2 (aldesleukin) and TGFβ receptor 1 inhibitor vactosertib. Up to 12 pts with metastatic CRC or relapsed/refractory hematologic malignancies will be enrolled. Pts will undergo low-dose lymphodepletion with fludarabine and cyclophosphamide followed by 2 infusions of NK cells, administered 14 days apart. Concurrently, pts will receive aldesleukin subcutaneously 3 times weekly and vactosertib orally 5 consecutive days/week x4 weeks total. Pts will undergo pre- and post-treatment biopsies for quantification of NK cell trafficking and exploration of immune cell profiling changes in the tumor microenvironment. The trial is currently open to enrollment, with 1 pt accrued at time of submission. Clinical trial information: NCT05400122 .

DNA methylation, catalyzed by DNA methyltransferase (DNMT), is a well-characterized epigenetic modification in cancer cells. In particular, promoter hypermethylation of

The administration of allogeneic natural killer (NK) cells following a lymphodepleting chemotherapy regimen is emerging as a well-tolerated therapeutic approach in the management of various malignancies. Contrary to the expected complications of allogeneic T cell therapy, there remains no evidence of graft-versus-host disease (GVHD) mediated by NK cells in numerous clinical trials. On the contrary, preclinical and clinical studies suggest that NK cells do not induce GVHD and in fact may prevent its development following allogeneic hematopoietic cell transplantation (HCT). In this study, we sought to determine the maximum tolerated dose of non-HLA-matched donor NK cells derived from peripheral blood and ex vivo expanded using a novel feeder cell platform. In a single-center Phase I clinical trial using a 3 × 3 design, 9 subjects each received 2 infusions of NK cells 2 weeks apart following a preparative regimen of cyclophosphamide (60 mg/kg i.v.) and fludarabine (25 mg/m(2)/day i.v for 5 days). No exogenous cytokines were administered. NK cells were administered at 3 dose levels: 1 × 10(7)/kg, 2.5 × 10(7)/kg, and 5 × 10(7)/kg. Three subjects had myelodysplastic syndrome (MDS) or acute myelogenous leukemia (AML), and the other 6 subjects had colorectal carcinoma. Recipients were monitored over a 4-week period for GVHD as well as other adverse events and for persistence of donor NK cells in systemic circulation. Disease assessment was started at 28 days following the first NK cell infusion and continued until postinfusion day 100 or disease progression. In all 9 study subjects, there was no occurrence of GVHD and no dose-limiting toxicities that would warrant cohort expansion at any of the 3 planned cell dose levels. Low-level donor NK cell persistence was observed up to 4 weeks after the first NK cell infusion at all dose levels. The best observed response was a complete response with incomplete platelet recovery in a MDS subject who experienced disease relapse after prior allogeneic HCT. Other responses were stable disease in 1 subject with MDS and 2 subjects with colorectal cancer up to postinfusion day 100. This off-the-shelf, third-party NK cell product can be administered safely without inducing GVHD and exhibits in vivo persistence promoted by preparative lymphodepletion alone. The observed clinical responses could be enhanced by administration of exogenous cytokine support, as well as complementary approaches that promote NK cell function in the tumor microenvironment.

Pediatric Acute Myeloid Leukemia (AML) with a FLT3 internal tandem duplication (FLT3-ITD) is a challenging disease due to poor outcomes in many patients. The 4-year progression-free survival is still only 31%. Current biomarkers are insufficient to predict why certain patients with FLT3-ITD AML relapse and others do not. The development of prognostic biomarkers in FLT3-ITD pediatric AML may help improve the outcomes and management of these patients. We acquired a panel of 37 diagnostic samples with 18 samples from FLT3-ITD pediatric AML patients with poor outcomes (relapse within 3 years) and 19 from favorable outcome patients that did not exhibit relapse for at least 5 years. Next, we performed FACS to isolate CD34+CD38dim and CD34+CD38+ cells. These two populations were then sequenced using 10x Genomics 3’ end single-cell RNA sequencing (scRNAseq). Using this scRNAseq dataset comprising over 250k single cells, we first investigated if the frequency of specific RNA clusters of AML cells may predict patient outcome. We found 5 clusters had significantly different frequencies between patients with favorable and poor outcomes (p < 0.05). Using these clusters, we performed CIBERSORTx deconvolution on publicly available FLT3-ITD AML bulk RNAseq samples from TCGA (n = 36), BeatAML (n = 47), and the TARGET project (ntrain = 72; ntest = 26) to identify the inferred cluster composition present in each AML patient from these datasets. Next we built LASSO prediction models using the inferred scRNAseq clusters by CIBERSORTx and incorporating clinical features including leukemic blast percentage, bone marrow leukemic blast percentage, and WBC at diagnosis. We found these prediction models to be highly specific as a prognostic biomarker for pediatric AML (p << 0.01). We were unable to train a model directly using genes from the publicly available bulk RNAseq data for pediatric FLT3-ITD AML, highlighting the relevance of using our deconvolution based biomarker. Between the high (> median) and low (< median) LASSO score groups, there was ~50% difference in the number of patients relapsing after 4 years. When we included this LASSO score in a multivariate cox regression (likelihood ratio p value = 0.007), the LASSO score (HR = 6.8, p = 0.026, CI = 1.26 - 37.28) showed additional predictive ability when including FLT3-ITD allelic ratio (HR = 1.83, p = 0.38, CI = 0.47 - 7.15) and MRD (HR = 3.95, p = 0.021 CI = 0.051 - 0.79). These results demonstrate that incorporating rare AML cell populations into a prognostic biomarker could add substantial clinical information to existing biomarkers. This indicates single-cell derived prognostic models can and should be explored further for pediatric FLT3-ITD AML and demonstrates a platform that could be used for other malignancies, including non-hematologic tumors, to create cell-type biomarkers. Citation Format: Robert Schauner, Zachary Jackson, Nethrie Idippily, Grace Lee, Sheela Karunanithi, Shivaprasaad Manjappa, Tae Hyun Hwang, David Wald. New platform for novel biomarker discovery using single-cell RNA sequencing on pediatric acute myeloid leukemia samples [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4080.

The mechanism of aging is not yet fully understood. It has been recognized that there are age-dependent changes in the DNA methylation pattern of the whole genome. To date, there are several DNA methylation-based estimators of the chronological age. A majority of the estimators use the DNA methylation data from a single tissue type, such as blood. In 2013, for the first time, Steve Horvath reported the DNA methylation-based age estimator (353 CpGs were used) that could be applied to multiple tissues. A refined, more sensitive version that uses 391 CpGs was subsequently developed and validated in human cells, including fibroblasts. In this review, the age predicted by DNA methylation-based age estimator is referred to as DNAmAge, and the biological process controlling the progression of DNAmAge is referred to as the epigenetic aging in this minireview. The concepts of DNAmAge and epigenetic aging provide us opportunities to discover previously unrecognized biological events controlling aging. In this article, we discuss the frequently asked questions regarding DNAmAge and the epigenetic aging by introducing recent studies of ours and others. We focus on addressing the following questions: (1) Is there any synchronization of DNAmAge between cells in a human body?, (2) Can we use in vitro (cell culture) systems to study the epigenetic aging?, (3) Is there an age limit of DNAmAge?, and (4) Is it possible to change the speed and direction of the epigenetic aging? We describe our current understandings to these questions and outline potential future directions. IMPACT STATEMENT: Aging is associated with DNA methylation (DNAm) changes. Recent advancement of the whole-genome DNAm analysis technology allowed scientists to develop DNAm-based age estimators. A majority of these estimators use DNAm data from a single tissue type such as blood. In 2013, a multi-tissue age estimator using DNAm pattern of 353 CpGs was developed by Steve Horvath. This estimator was named “epigenetic clock”, and the improved version using DNAm pattern of 391 CpGs was developed in 2018. The estimated age by epigenetic clock is named DNAmAge. DNAmAge can be used as a biomarker of aging predicting the risk of age-associated diseases and mortality. Although the DNAm-based age estimators were developed, the mechanism of epigenetic aging is still enigmatic. The biological significance of epigenetic aging is not well understood, either. This minireview discusses the current understanding of the mechanism of epigenetic aging and the future direction of aging research.

Background: Chimeric antigen receptor T cell (CAR-T) therapy is known to produce durable remissions in the treatment of CD19 + relapsed/refractory B cell malignancies. Nonetheless, many patients receiving CAR-T cells will fail to respond for unknown reasons. Here, we employed single cell RNA sequencing and protein surface marker profiling of serial CAR-T cell samples from patients with non-Hodgkin's lymphoma (NHL) to reveal CAR-T cell evolution, identify biomarkers of response, and test for evidence of exhaustion in CAR-T cells of poor responders. Methods: To describe the evolution of CAR-T cells after infusion into NHL patients and to identify mechanisms and biomarkers of response, our study examined manufactured CAR-T cell products and FACS isolated CAR-T cells from post-infusion blood samples from patients treated for CD19 + relapsed/refractory NHL. Utilizing scRNA sequencing and flow cytometry, we investigated time points after infusion that are known from previous studies to be associated with peak expansion (day 14) and contraction (day 30) and represent key changes in CAR-T cell activity. Altogether, our datasets include 14 manufactured CAR-T cell products, 13 samples from day 14, and 12 samples from day 30. This sampling represents 10 patients with favorable response (complete or partial remission (CR; PR)) and 4 patients with poor response (stable or progressive disease (SD; PD)). To isolate CAR-T cells for scRNA sequencing, viable CD3 +CAR + cells were sorted from cryopreserved CAR-T cell products or PBMCs. Next, libraries were generated with the 10x Genomics Chromium single cell 3' platform with feature barcoding technology to allow simultaneous and paired quantification of transcriptional and cell surface protein expression in individual CAR-T cells. The libraries were sequenced and the data stringently filtered. Batch effect removal was applied to remove differences due to sample preparation or sequencing. Results: Post-filtering, our dataset contained 94,000 cells with an average of 3,917 cells per sample, 8,518 reads per cell, and 2263 unique detectable genes per cell. After dimension reduction and clustering, eleven high-frequency clusters were identified with cluster patterns corresponding with time point, cell cycle phase, cell type, or patient (Figure 1). At the transcriptional level, post-infusion CD8 CAR-T cells displayed significant upregulation of transcription factors (PRDM1, EOMES) and cytotoxic effector molecules (GZMB, PRF1, GZMK, CCL5) associated with differentiation into cytotoxic effector cells as well as transcription factors associated with exhaustion (TOX, TOX2, NR4A2, NR4A3) (p.adj < 0.05) (Figure 2). These data were corroborated by enrichment of effector and exhaustion gene set signatures after infusion as well as global increases in the protein expression of activation and exhaustion markers CD45RO, CD69, CD57, PD1 (CD279), and TIGIT. Contrasts of CAR-T cells between response groups displayed enrichment of an exhaustion profile in CD8 CAR-T cells of poor responders characterized by significant upregulation of the transcription factors FOS, JUNB, JUND, FOSB, JUN, NR4A2, NFKBIA, and PRDM1 and other markers of exhaustion at the RNA level (p.adj < 0.0001). At the protein level, the frequency of TIGIT expression was 20% greater on average in the CD8 CAR-T cells of poor responders compared to favorable responders (Figure 3). CD8 CAR-T cells expressing TIGIT compared to TIGIT negative CD8 CAR-T cells were enriched in an exhaustion transcriptional profile by gene set enrichment analysis and expressed consistently higher levels of exhaustion markers (PD1, CTLA4, LAG3, TIM3) by flow cytometry, regardless of response group or time point (Figure 4). Conclusions: At the transcriptional and protein levels, we note the evolution of CAR-T cells toward a non-proliferative, highly-differentiated, and exhausted state that is enriched in CAR-T cells of patients with poor response. Furthermore, we identified the checkpoint receptor TIGIT as a novel prognostic biomarker and potential driver of CAR-T cell exhaustion. Figure 1 Figure 1. Disclosures Dropulic: Lentigen: Ended employment in the past 24 months, Patents & Royalties. Caimi: Kite Pharmaceuticals: Consultancy; XaTek: Patents & Royalties: Royalties from patents (wife); Seattle Genetics: Consultancy; Genentech: Research Funding; ADC Theraputics: Consultancy, Research Funding; Verastem: Consultancy; Amgen Therapeutics.: Consultancy; TG Therapeutics: Honoraria. de Lima: Miltenyi Biotec: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Incyte: Membership on an entity's Board of Directors or advisory committees.

Normal human hematopoietic stem and progenitor cells (HPC) lose expression of MLH1, an important mismatch repair (MMR) pathway gene, with age. Loss of MMR leads to replication dependent mutational events and microsatellite instability observed in secondary acute myelogenous leukemia and other hematologic malignancies. Epigenetic CpG methylation upstream of the MLH1 promoter is a contributing factor to acquired loss of MLH1 expression in tumors of the epithelia and proximal mucosa. Using single molecule high-throughput bisulfite sequencing we have characterized the CpG methylation landscape from −938 to −337 bp upstream of the MLH1 transcriptional start site (position +0), from 30 hematopoietic colony forming cell clones (CFC) either expressing or not expressing MLH1. We identify a correlation between MLH1 promoter methylation and loss of MLH1 expression. Additionally, using the CpG site methylation frequencies obtained in this study we were able to generate a classification algorithm capable of sorting the expressing and non-expressing CFC. Thus, as has been previously described for many tumor cell types, we report for the first time a correlation between the loss of MLH1 expression and increased MLH1 promoter methylation in CFC derived from CD34+ selected hematopoietic stem and progenitor cells.

Handheld multi-gas meters (MGMs) are equipped with sensors to monitor oxygen (O2) levels and additional sensors to detect the presence of combustible or toxic gases in the environment. This report is limited to operational response-type MGMs that include at least four different sensors. These sensors can vary by type and by the chemical monitored. In real time, the sensors report the concentration of monitored gases in the atmosphere near the MGM. To provide emergency responders with information on handheld multi-gas meters, the System Assessment and Validation for Emergency Responders (SAVER) Program conducted a market survey. This market survey report is based on information gathered between November 2015 and February 2016 from vendors, Internet research, industry publications, an emergency responder focus group, and a government issued Request for Information (RFI) that was posted on the Federal Business Opportunities website.

Context.—Despite the widespread practice of pathologist review of blood and body fluid smears, little is known about its impact on improving patient care. Objective.—To assess the clinical usefulness of pathologist review of blood and body fluid smears. Design.—Survey study. Pathology residents contacted the ordering physician after pathologist reviews were reported to assess their clinical impact. Results.—Ninety-six pathologist reviews met criteria for study inclusion, and 64 ordering physicians were successfully contacted during the 2-month study period. Of the 64 cases, 19 reviews (30%) had been seen by the physician within 24 to 48 hours after the report was issued and 33 (51%) had not been seen; in 4 (6%) instances, physicians did not remember whether they had seen the review. Eight reviews (13%) were considered urgent enough to warrant immediate communication by the pathologist. Of the 27 reviews that were seen or directly communicated, 23 (85%) contributed to clinical diagnosis and/or patient management. Conclusions.—This study demonstrates the contribution of pathologist reviews of blood and body fluids to clinical diagnosis and patient management. The results also highlight the problem of a lack of physician awareness of clinical pathology results.

The purpose of this research is to explore earthquake risk perceptions in California. Specifically, we examine the risk beliefs, feelings, and experiences of lay, professional, and expert individuals to explore how risk is perceived and how risk perceptions are formed relative to earthquakes. Our results indicate that individuals tend to perceptually underestimate the degree that earthquake (EQ) events may affect them. This occurs in large part because individuals’ personal felt experience of EQ events are generally overestimated relative to experienced magnitudes. An important finding is that individuals engage in a process of “cognitive anchoring” of their felt EQ experience towards the reported earthquake magnitude size. The anchoring effect is moderated by the degree that individuals comprehend EQ magnitude measurement and EQ attenuation. Overall, the results of this research provide us with a deeper understanding of EQ risk perceptions, especially as they relate to individuals’ understanding of EQ measurement and attenuation concepts.

Though the majority of antibody-mediated renal transplant rejections are thought to be due to HLA antibodies, there is increasing evidence that non-HLA antibodies also can mediate rejection. For example, antibodies directed against the Angiotensin II type 1 receptor (AT1R) have been implicated in humoral renal transplant rejection episodes and impaired graft survival. While many cases of acute rejection potentially due to AT1R antibodies have been reported, there is little published evidence relating to AT1R antibodies causing hyperacute rejection. We report the case of a patient with pre-existing AT1R antibodies and no donor-specific HLA antibodies who experienced an episode of hyperacute rejection. The patient is a 47 year old female with a longstanding history of type 1 diabetes and end stage renal disease secondary to diabetic nephropathy. She had received 2 previous renal transplants approximately 21 and 22 years ago. Pre-transplant she was highly sensitized with a T-cell flow PRA of 99% and B-cell flow PRA of 100%, but did not demonstrate any donor- specific HLA antibody. The T- and B-cell flow and T-cell CDC crossmatches performed between the patient and donor were negative. She had a pre-transplant AT1R antibody level of 18.5 Units/ml measured 8 days before transplant. During the surgical procedure the patient experienced a hyperacute rejection episode. Biopsy of the organ demonstrated possible antibody-mediated rejection. The patient was treated with plasmapheresis and IVIG and her renal function stabilized over the following 6 weeks. The patient has also been maintained on Losartan, an AT1R inhibitor. The patient has now continued to demonstrate stable renal function for the previous 2 years. Our case highlights the importance of appreciating the possible peri-transplant risks of AT1R antibody particularly as treatment with the AT1R inhibitor, Losartan, has been shown by others to provide therapeutic benefits.

ObjectivesOn March 11, 2011, Japan experienced the largest earthquake in its history. The undersea earthquake launched a tsunami that inundated much of Japan's eastern coastline and damaged nuclear power plants, precipitating multiple reactor meltdowns. We examined open-source disaster situation reports, news accounts, and disaster-monitoring websites to gather event-specific data to conduct a trauma signature analysis of the event.MethodsThe trauma signature analysis included a review of disaster situation reports; the construction of a hazard profile for the earthquake, tsunami, and radiation threats; enumeration of disaster stressors by disaster phase; identification of salient evidence-based psychological risk factors; summation of the trauma signature based on exposure to hazards, loss, and change; and review of the mental health and psychosocial support responses in relation to the analysis.ResultsExposure to this triple-hazard event resulted in extensive damage, significant loss of life, and massive population displacement. Many citizens were exposed to multiple hazards. The extremity of these exposures was partially mitigated by Japan's timely, expert-coordinated, and unified activation of an evidence-based mental health response.ConclusionsThe eastern Japan disaster was notable for its unique constellation of compounding exposures. Examination of the trauma signature of this event provided insights and guidance regarding optimal mental health and psychosocial responses. Japan orchestrated a model response that reinforced community resilience. (Disaster Med Public Health Preparedness. 2013;0:1-14)