Data standards for interoperability of care team information to support care coordination of complex pediatric patients.

OBJECTIVE: Seamless access to information about the individuals and organizations involved in the care of a specific patient ("care teams") is crucial to effective and efficient care coordination. This is especially true for vulnerable and complex patient populations such as pediatric patients with special needs. Despite wide adoption of electronic health records (EHR), current EHR systems do not adequately support the visualization and management of care teams within and across health care organizations. Electronic health information exchange has the potential to address this issue. In the present study, we assessed the adequacy of available health information exchange data standards to support the information needs related to care coordination of complex pediatric patients. METHODS: We derived data elements from the information needs of clinicians and parents to support patient care teams; and mapped them to data elements in the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) standard and in the HL7 Fast Healthcare Interoperability Resources (FHIR) standard. We also identified additional C-CDA data elements and FHIR resources that include patients' care team members. RESULTS: Information about care team members involved in patient care is generally well-represented in the C-CDA and FHIR specifications. However, there are gaps related to patients' non-clinical events and care team actions. In addition, there is no single place to find information about care team members; rather, information about practitioners and organizations may be available in several different types of C-CDA data elements and FHIR resources. CONCLUSION: Through standards-based electronic health information exchange, it appears to be feasible to build patient care team representations irrespective of the location of patient care. In order to gather care team information across disparate systems, exchange of multiple C-CDA documents and/or execution of multiple FHIR queries will be necessary. This approach has the potential to enable comprehensive patient care team views that may help improve care coordination.

Stabilizing endothelium of donor hearts with fusogenic liposomes reduces myocardial injury and dysfunction.

BACKGROUND: Myocardial injury after heart transplantation is a consequence of pathophysiologic events initiated by local ischemia/reperfusion injury that is further aggravated by the inflammatory response due to blood exposure to the pump's artificial surfaces during cardiopulmonary bypass. The purpose of the present study was to determine the effectiveness of fusogenic lipid vesicles (FLVs) in enhancing the cardioprotective effect of St. Thomas organ preservation solution (ST). We hypothesized that donor hearts preserved with ST+FLVs will stabilize the endothelium during reperfusion, which, in turn, will reduce both endothelial barrier dysfunction and myocardial damage. METHODS: To examine the effect of ST+FLVs therapy in vitro, C3b deposition and adhesion molecule expression studies were performed on human umbilical vein endothelial cells challenged with plastic contact-activated plasma. To assess the therapy in vivo, a cervical heterotopic working heart transplantation model in rats was used. Donor hearts were preserved for 1 h at 27°C (15 min) and 4°C (45 min) and, after transplantation, were followed up for 2 h. Left ventricular function and the blood cardiac troponin I levels were quantified. RESULTS: Human umbilical vein endothelial cells treated with ST+FLVs had reduced C3b deposition and expression of adhesion molecules compared with ST alone (P < 0.05). Donor hearts receiving ST+FLVs therapy had reduced left ventricular dysfunction and cardiac troponin I compared with ST alone. CONCLUSIONS: We concluded that FLVs enhanced the cardioprotective effect of ST and reduced postischemic left ventricular dysfunction and myocardial damage. The mechanism of protection appears to be associated with the stabilization of endothelial cell membranes owing to incorporation of FLV-derived lipids.

Randomized, Double-Blind Placebo-Controlled Trial to Assess the Effect of Probiotics on Irritable Bowel Syndrome in Veterans With Gulf War Illness.

Background: Many veterans who served in Operation Desert Storm (August 1990 to March 1991) experienced a complex of symptoms of unknown etiology called Gulf War illness (GWI), which significantly impacts the health and quality of life (QOL) and may have contributed to irritable bowel syndrome (IBS). Methods: We performed a prospective, double-blind placebocontrolled study to determine the efficacy of the multistrain De Simone Formulation probiotic containing 8 strains of bacteria on symptoms of IBS and GWI. Veterans of Operation Desert Storm who had IBS and ≥ 2 nonintestinal symptoms of GWI were included. The primary study endpoint was change in bowel symptom score. The secondary endpoints were mean change in symptoms, QOL, and extra-intestinal and posttraumatic stress disorder (PTSD) symptoms. Results: A total of 101 Gulf War veterans with IBS and GWI were screened at the Veteran Affairs Medical Center in Salt Lake City, Utah. The study was completed by 53 veterans; 47 (89%) were male with a mean (SD) age of 55 (8) years. The probiotic did not improve IBS symptoms or other extra-intestinal symptoms common to IBS and GWI. Conclusions: Our study did not demonstrate statistically significant improvement in IBS symptoms or QOL after treatment with the probiotic. We also did not find any improvement in symptoms of GWI or PTSD.

Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.

OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Antioxidant Activity of Yichun Blue Honeysuckle (YBHS) Berry Counteracts CCl4-Induced Toxicity in Liver Injury Model of Mice.

Yichun Blue Honeysuckle (YBHS) is reported to have a broad range of health benefits including protection against a number of chronic diseases. The objective of our study was to determine whether YBHS exhibits antioxidant activity, and if so, determine how it provides protection against oxidative stress. Eight-week old mice (25 male and 25 female) were randomized into five groups (n = 10 per group). YBHS extract (at 6.25%, 12.5%, or 25%) was administrated via intra-gastric tube to mice at 0.1 mL/10 g body weight once daily for 7 days. On the 8th day, all animals except for the controls received 250 mg/kg of CCl4 through an intra-gastric tube. The animals were sacrificed 6 h after CCl4 administration. Liver samples obtained from these mice were analyzed for the levels of Thiobarbituric Acid Reactive Substances (TBARS) and glutathione and the activities of Superoxide Dismutase (SOD), Catalase (CAT), and Glutathione Peroxidase (GPx), using biochemical assay kits. Our results showed that YBHS indeed reduces lipid peroxidation, suggesting that YBHS decreases the Reactive Oxygen Species (ROS) levels. We also found that YBHS activated the endogenous antioxidant enzymes including superoxide dismutase, catalase, and glutathione peroxidase and its co-enzyme glutathione reductase. In addition, we showed that glutathione levels were increased by YBHS treatment. Furthermore, the 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay revealed that YBHS has potent free radical scavenging activity. Based on the results from our study, we conclude that YBHS scavenges ROS by enhancing the activity of the endogenous antioxidant defense system activity for conferring liver protective effects.

Migration of Caenorhabditis elegans to manure and manure compost and potential for transport of Salmonella newport to fruits and vegetables.

A study was done to determine if a free-living, bacterivorous nematode, Caenorhabditis elegans, migrates to bovine manure, turkey manure, composted bovine manure, composted turkey manure, and manure-amended soil inoculated with Salmonella Newport. Movement of the worm to lettuce, strawberries, and carrots was also studied. C. elegans moved most rapidly to turkey manure and strawberries, with 35% and 60% of worms, respectively, associating with samples within 30 min. Survival and reproduction of C. elegans in test materials were not affected by the presence of S. newport. Bovine manure and bovine manure compost inoculated with S. newport (8.6 log10 CFU/g) were separately placed in the bottom of a glass jar and covered with a layer of soil (5 cm) inoculated (50 worms/g) or not inoculated with C. elegans. A piece of lettuce, strawberry, or carrot was placed on top of the soil before jars were sealed and held at 20 degrees C for up to 10 days. In the system using soil inoculated with C. elegans, S. newport initially in bovine manure was detected on the surface of lettuce, strawberry, and carrot samples within 3, 1, and 1 days, respectively. The pathogen was detected on lettuce, strawberry, and carrot within 1, 7, and 1 days, respectively, when initially present in bovine manure compost. With one exception, the pathogen was not detected on the produce over the 10-day incubation period when C. elegans was not present in the soil. Results indicate that C. elegans has the potential for transporting S. newport in soil to the surface of preharvest fruits and vegetables in contact with soil.

Diethylene glycol monomethyl ether, ethylene glycol monomethyl ether and the metabolite, 2-methoxyacetic acid affect in vitro chondrogenesis.

Diethylene glycol monomethyl ether (DEGME), ethylene glycol monomethyl ether (EGME) and their common metabolite, methoxyacetic acid (MAA) have been associated with adverse reproductive effects. The objective of this research is to investigate the effects of DEGME, EGME and MAA on in vitro chondrogenesis and the mechanisms by which these effects occur. Micromass cultures were exposed to DEGME, EGME or MAA for 5 days and proteoglycan abundance and cell proliferation determined. Longer-term 9- and 14-day cultures were exposed to MAA and apoptosis analyzed. All three chemicals decreased proteoglycan abundance and cell proliferation at the highest dose tested (100 microL/mL). However, only MAA showed a dose-dependent effect for both parameters at 0.01, 10, and 100 microL/mL. Furthermore, micromass cultures show an increase in apoptotic cells which when treated with MAA suggest that cell death could result from induced apoptosis. These results suggest that effects of DEGME and EGME are the result of generalized toxicity, but their metabolite MAA induces mitochondrial-mediated apoptosis during in vitro chondrogenesis.

Persistence of Escherichia coli O157:H7, Salmonella Newport, and Salmonella Poona in the gut of a free-living nematode, Caenorhabditis elegans, and transmission to progeny and uninfected nematodes.

A study was undertaken to determine the persistence of Escherichia coli O157:H7 and salmonellae in the gut of a free-living nematode, Caenorhabditis elegans, as affected by temperature and relative humidity and to determine if infected worms transmit Salmonella enterica serotype Newport to progeny and uninfected worms. Worms were fed cells of a non-pathogenic strain of E. coli (OP50), E. coli O157:H7, S. enterica serotype Newport, and S. enterica serotype Poona, followed by incubating at 4, 20, or 37 degrees C for up to 5 days. Initial populations of ingested pathogens significantly increased by up to 2.93 log(10) cfu/worm within 1 day at 20 degrees C on K agar and remained constant for an additional 4 days. When worms were placed on Bacto agar, populations of ingested pathogens remained constant at 4 degrees C, decreased significantly at 20 degrees C, and increased significantly at 37 degrees C within 3 days. Worms fed E. coli OP50 or S. Newport were incubated at 4 or 20 degrees C at relative humidities of 33%, 75%, or 98% to determine survival characteristics of ingested bacteria. Fewer cells of the pathogens survived incubation at 33% relative humidity compared to higher relative humidities. Populations of ingested E. coli OP50 and S. Newport decreased by up to 1.65 and 3.44 log(10) cfu/worm, respectively, in worms incubated at 20 degrees C and 33% relative humidity. Placement together on K agar of adult worms, labeled with green fluorescent protein (gfp) in the pharynx area, that had ingested gfp-labeled S. Newport and uninfected wild type worms resulted in transfer of the pathogen to gut of wild type worms. S. Newport was isolated from C. elegans two generations removed from exposure to the pathogen. Results of these studies show that C. elegans may serve as a temporary reservoir of foodborne pathogens, and could perhaps be a vector for contaminating preharvest fruits and vegetables, thus potentially increasing the risk of enteric infections associated with consumption of raw produce.

Composite tissue allotransplantation in chimeric hosts part II. A clinically relevant protocol to induce tolerance in a rat model.

BACKGROUND: We and others have shown that mixed allogeneic chimerism induces donor-specific tolerance to composite tissue allografts across major histocompatibility complex barriers without the need for immunosuppression. However, a delay period between bone marrow transplantation and limb allotransplantation is required, making such protocols impractical for clinical application. This study eliminates this delay period in a rat hind limb allotransplantation model by performing mixed allogeneic chimerism induction and transplantation "simultaneously." METHODS: Group 1 included controls in which naïve Wistar Furth (WF) hosts received ACI hind limbs. Group 2 included (ACI-->WF) chimeras that received limbs from third-party donors (Fisher), and group 3 included chimeras that received irradiated (1,050 cGy) ACI limbs. In group 4, WF hosts conditioned with 950 cGy received irradiated (1,050 cGy) ACI limbs followed by infusion of 100 x 10(6) ACI T-cell-depleted bone marrow cells and immunotherapy (tacrolimus and mycophenolate mofetil) for 28 days. Group 5 animals received the same treatment as group 4 animals without immunotherapy. RESULTS: The rats in groups 1 and 2 rejected their limbs within 10 days. Only one rat in group 4 survived to the end of the study. Groups 3 and 5 demonstrated long-term limb survival without rejection or graft-versus-host disease. High levels of donor chimerism (>80%) were achieved and maintained throughout the study. Mixed lymphocyte reaction assays in both groups revealed donor-specific hyporesponsiveness with vigorous third-party reactivity. CONCLUSIONS: This study demonstrated that infusion of donor bone marrow cells into conditioned hosts immediately after limb transplantation results in stable mixed chimerism, robust tolerance, and reliable limb allograft survival.

Composite tissue allotransplantation in chimeric hosts: part I. Prevention of graft-versus-host disease.

BACKGROUND: Mixed allogeneic chimerism (MAC) has been shown to induce tolerance to composite tissue allografts (CTA). However, transplantation of unmanipulated donor-specific limbs results in severe graft-versus-host disease (GVHD). This suggests that nontolerant mature donor-derived cells in the CTA may affect the stability of chimerism, potentially resulting in GVHD. The aim of this study was to develop an approach to study and prevent GVHD in a mixed chimeric-rat hind-limb transplantation model. METHODS: [ACI-->WF] chimeras received a limb from Wistar Furth (WF) (syngeneic), Fisher (third-party), or ACI (irradiated [1,050 cGy] or nonirradiated) rats. In vitro tolerance was assessed using mixed lymphocyte reactivity (MLR) assays at the time the animals were killed. RESULTS: [ACI-->WF] chimeras with greater than 85% chimerism exhibited rejection-free survival of donor-specific hind limbs. However, 100% of these animals developed lethal GVHD 22.4+/-2.8 days after limb transplantation. [ACI-->WF] chimeras that underwent transplantation with irradiated ACI or syngeneic WF limbs showed no signs of rejection or GVHD at 5 months. Nonchimeric and third-party controls rejected limbs within 10 days. CONCLUSIONS: Conditioning of the host WF rats with 950 cGy of irradiation (sublethal, myeloablative) led to high levels of MAC without GVHD. The mature T-cell content of nonirradiated donor (ACI) limbs was sufficient to induce lethal GVHD in 100% of tolerant mixed chimeric [ACI-->WF] hosts. Irradiation of donor limbs before transplantation resulted in long-term donor-specific tolerance and prevented GVHD. These data demonstrate that (1) established chimeras could be susceptible to GVHD caused by immunocompetent donor cells transferred with the hind limb, and (2) inactivating these cells with irradiation prevents GVHD and destabilization of chimerism, and permits rejection-free graft acceptance.