CDC's Multiple Approaches to Safeguard the Health, Safety, and Resilience of Ebola Responders.

Over 27,000 people were sickened by Ebola and over 11,000 people died between March of 2014 and June of 2016. The US Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) was one of many public health organizations that sought to stop this outbreak. This agency deployed almost 2,000 individuals to West Africa during that timeframe. Deployment to these countries exposed these individuals to a wide variety of dangers, stressors, and risks.Being concerned about the at-risk populations in Africa, and also the well-being of its professionals who willingly deployed, the CDC did several things to help safeguard the health, safety, and resilience of these team members before, during, and after deployment.The accompanying special report highlights innovative pre-deployment training initiatives, customized screening processes, and post-deployment outreach efforts intended to protect and support the public health professionals fighting Ebola. Before deploying, the CDC team members were expected to participate in both internally-created and externally-provided trainings. These ranged from pre-deployment briefings, to Preparing for Work Overseas (PFWO) and Public Health Readiness Certificate Program (PHRCP) courses, to Incident Command System (ICS) 100, 200, and 400 courses.A small subset of non-clinical deployers also participated in a three-day training designed in collaboration with the Center for the Study of Traumatic Stress (CSTS; Bethesda, Maryland USA) to train individuals to assess and address the well-being and resilience of themselves and their teammates in the field during a deployment. Participants in this unique training were immersed in a Virtual Reality Environment (VRE) that simulated deployment to one of seven different types of emergencies.The CDC leadership also requested a pre-deployment screening process that helped professionals in the CDC's Occupational Health Clinic (OHC) determine whether or not individuals were at an increased risk of negative outcomes by participating in a rigorous deployment at that time.When deployers returned from the field, they received personalized invitations to participate in a voluntary, confidential, post-deployment operational debriefing one-on-one or in a group.Implementing these approaches provided more information to clinical decision makers about the readiness of deployers. It provided deployers with a greater awareness of the kinds of challenges they were likely to face in the field. The post-deployment outreach efforts reminded staff that their contributions were appreciated and there were resources available if they needed help processing any of the potentially-traumatizing things they may have experienced.

Improving breastfeeding medicine in undergraduate medical education: A student survey and extensive curriculum review with suggestions for improvement.

BACKGROUND: Breastfeeding education should be incorporated routinely into medical school curricula. Despite strong evidence supporting exclusive breastfeeding of infants, lack of physician education has continued to undermine the practice of breastfeeding. Protecting and supporting breastfeeding should be a public health priority as it has the potential to save billions of dollars in health care and also provide the most benefit to the newborn infant. The purpose of this article was to evaluate how the United States undergraduate medical institution incorporates breastfeeding medicine into its curriculum and to suggest modifications that will improve breastfeeding education at all undergraduate medical institutions. METHODS: The authors performed an in-depth review of the undergraduate medical curriculum at the United States medical institution. Course requirements and lectures were compared with the 12 knowledge-based and 12 skill-based competencies that the authors suggest all medical students should possess. In addition, the authors sent out an electronic survey to 600 medical students at the same institution to assess current students understanding and comfort with basic breastfeeding topics. RESULTS: Students in the preclinical years are only learning 3 of the 12 knowledge-based competencies and 1 of the 12 skill-based competencies. Students in the clinical years are learning 5 of the 12 knowledge-based competencies and 9 of the 12 skill-based competencies. Survey results showed that the majorities of medical students were not comfortable with basic breastfeeding medicine and guidance. DISCUSSION: The authors recommend several curriculum changes to advance breastfeeding education. A more targeted breastfeeding curriculum in medical education will help to improve physician knowledge, practice patterns, and confidence in breastfeeding management.

Coevolution of Peer-Reviewed Literature and Clinical Practice in High-Grade Glioma Resection.

BACKGROUND: The paradigm of evidence-based medicine dictates that clinical practice should reflect the shifting landscape of the peer-reviewed literature. Here, we examined the extent to which this premise is fulfilled as it pertains to the surgical resection of high-grade gliomas (HGGs). OBJECTIVE: We assessed trends in published literature regarding HGG survival after resection in conjunction with trends in clinical practice patterns of HGG resection. METHODS: We performed a comprehensive PubMed search to identify articles that examined whether gross total resection (GTR) improves HGG survival. Temporal trends in the literature were compared with rates of GTR in the Surveillance Epidemiology and End Results (SEER) database, the Veterans Health Administration database, and published data series from academic neuro-oncology centers. RESULTS: Before 2000, the ratio of articles supporting survival benefit of GTR relative to those not supporting it ranged from approximately 1:5 to 1:1. Since 2000, this ratio has steadily increased such that by the post-2013 period, 32 of the 33 published articles (>30:1) supported the survival benefit of GTR. Although the frequency of GTR increased during the 2000-2004 period in the SEER and Veterans Health Administration database, no further increase in the frequency of GTR was observed thereafter. In contrast, resection rates in academic neuro-oncology centers continued to increase subsequent to 2004. CONCLUSIONS: Our results indicate that clinical practice patterns mirror publication patterns for HGG resection, suggesting that neurosurgical oncology is a field in which clinical practice is informed by the peer-reviewed literature.

'Journal Bias' in peer-reviewed literature: an analysis of the surgical high-grade glioma literature.

The core premise of evidence-based medicine is that clinical decisions are informed by the peer-reviewed literature. To extract meaningful conclusions from this literature, one must first understand the various forms of biases inherent within the process of peer review. We performed an exhaustive search that identified articles exploring the question of whether survival benefit was associated with maximal high-grade glioma (HGG) resection and analysed this literature for patterns of publication. We found that the distribution of these 108 articles among the 26 journals to be non-random (p<0.01), with 75 of the 108 published articles (69%) appearing in 6 of the 26 journals (25%). Moreover, certain journals were likely to publish a large number of articles from the same medical academic genealogy (authors with shared training history and/or mentor). We term the tendency of certain types of articles to be published in select journals 'journal bias' and discuss the implication of this form of bias as it pertains to evidence-based medicine.

Impact of medical academic genealogy on publication patterns: An analysis of the literature for surgical resection in brain tumor patients.

"Academic genealogy" refers to the linking of scientists and scholars based on their dissertation supervisors. We propose that this concept can be applied to medical training and that this "medical academic genealogy" may influence the landscape of the peer-reviewed literature. We performed a comprehensive PubMed search to identify US authors who have contributed peer-reviewed articles on a neurosurgery topic that remains controversial: the value of maximal resection for high-grade gliomas (HGGs). Training information for each key author (defined as the first or last author of an article) was collected (eg, author's medical school, residency, and fellowship training). Authors were recursively linked to faculty mentors to form genealogies. Correlations between genealogy and publication result were examined. Our search identified 108 articles with 160 unique key authors. Authors who were members of 2 genealogies (14% of key authors) contributed to 38% of all articles. If an article contained an authorship contribution from the first genealogy, its results were more likely to support maximal resection (log odds ratio = 2.74, p < 0.028) relative to articles without such contribution. In contrast, if an article contained an authorship contribution from the second genealogy, it was less likely to support maximal resection (log odds ratio = -1.74, p < 0.026). We conclude that the literature on surgical resection for HGGs is influenced by medical academic genealogies, and that articles contributed by authors of select genealogies share common results. These findings have important implications for the interpretation of scientific literature, design of medical training, and health care policy.

Development of PCR assays for detection of Trichomonas vaginalis in urine specimens.

Trichomonas vaginalis infections are usually asymptomatic or can result in nonspecific clinical symptoms, which makes laboratory-based detection of this protozoan parasite essential for diagnosis and treatment. We report the development of a battery of highly sensitive and specific PCR assays for detection of T. vaginalis in urine, a noninvasive specimen, and development of a protocol for differentiating among Trichomonas species that commonly infect humans.

Cation exchange surface-mediated denaturation of an aglycosylated immunoglobulin (IgG1).

Cation exchange chromatography of an aglycosylated IgG1 resulted in two distinct peaks during gradient elution. The early eluting peak contained <1% high molecular weight (HMW) species, while the later peak contained 23% HMW species. Analysis by hydrogen-deuterium exchange and Fourier transform infrared spectroscopy (FTIR) indicated that aggregate formation and generation of the second peak were caused by antibody denaturation on the resin surface. Denaturation and HMW generation was increased by the use of strong cation exchange media, by increasing antibody residence time on the exchanger, or increasing temperature. Denaturation and HMW generation was reduced by increasing pH or ionic strength, by the use of preferentially excluded solutes such as citrate or glycine and controlled entirely by addition of 125 mM arginine to the process buffers. This leads to the hypothesis that denaturation and HMW generation of this antibody can be managed by reducing the strength of binding, by increasing its conformational stability, or by suppressing non-native protein-protein interactions. The glycosylated version of this antibody exhibited less than 2% denatured form, suggesting that glycosylation contributes significantly to the stability of this antibody. These findings may be helpful in managing aggregation in other antibodies, and particularly useful in developing purification processes for aglycosylated antibodies.

Characterization of a unique IgG1 mAb CEX profile by limited Lys-C proteolysis/CEX separation coupled with mass spectrometry and structural analysis.

The unique cation exchange chromatography (CEX) charge variant profile of mAb1 is characterized by a combination of mass spectrometry, limited Lys-C digestion followed by CEX separation and structural analysis. During CEX method development, mAb1 showed several unexpected phenomena, including a unique profile containing two main species (acidic 2 and main) and significant instability during stability studies of the main species. Reduced Lys-C peptide mapping identified a small difference in one of the heavy chain peptides (H4) in acidic 2 and further mass analysis identified this difference as Asn55 deamidation. However, the amount of Asn55 deamidation in acidic 2 could account for only half of the species present in this peak. Lys-C limited digest followed by CEX separated several unique peaks in the acidic peak 2 including two pre Fab peaks (LCC1 and LCC2). Whole protein mass analysis suggested that both LCC1 and LCC2 were potentially deamidated species. Subsequent peptide mapping with MS/MS determined that LCC1 contained isoAsp55 and LCC2 contained Asp55. Combining LCC1 and LCC2 CEX peak areas could account for nearly all of the species present in acidic peak 2. Subsequent detailed sequence analysis combined with molecular modeling identified Asn55 and its surrounding residues are responsible for the different CEX behavior and instability of mAb1 following forced degradation at high pH. Overall, the combinatorial approach used in this study proved to be a powerful tool to understand the unique charge variant and stability profile of a monoclonal antibody.

Development and characterization of the NanoOrange protein quantitation assay: a fluorescence-based assay of proteins in solution.

We developed a sensitive fluorescence assay for the quantitation of proteins in solution using the NanoOrange reagent, a merocyanine dye that produces a large increase in fluorescence quantum yield upon interaction with detergent-coated proteins. The NanoOrange assay allowed for the detection of 10 ng/mL to 10 micrograms/mL protein with a standard fluorometer, offering a broad, dynamic quantitation range and improved sensitivity relative to absorption-based protein solution assays. The protein-to-protein variability of the NanoOrange assay was comparable to those of standard assays, including Lowry, bicinchoninic acid, and Bradford procedures. We also found that the NanoOrange assay is useful for detecting relatively small proteins or large peptides, such as aprotinin and insulin. The assay was somewhat sensitive to the presence of several common contaminants found in protein preparations such as salts and detergents; however, it was insensitive to the presence of reducing agents, nucleic acids, and free amino acids. The simple assay protocol is suitable for automation. Samples are briefly heated in the presence of dye in a detergent-containing diluent, allowed to cool to room temperature, and fluorescence is measured using 485-nm excitation and 590-nm emission wavelengths. Therefore, the NanoOrange assay is well suited for use with standard fluorescence microplate readers, fluorometers, and some laser scanners.

Simultaneous red/green dual fluorescence detection on electroblots using BODIPY TR-X succinimidyl ester and ELF 39 phosphate.

A two-color fluorescence detection method is described based upon covalently coupling the succinimidyl ester of BODIPY TR-X dye to proteins immobilized on polyvinylidene difluoride membranes, followed by detection of target proteins using the fluorogenic, precipitating substrate ELF 39-phosphate in combination with alkaline phosphatase conjugated reporter molecules. This results in all proteins in the profile being visualized as fluorescent red signal while those detected specifically with the alkaline phosphatase conjugate appear as fluorescent green signal. The dichromatic detection system is broadly compatible with ultraviolet epi- or trans-illuminators combined with photographic or charge-coupled device cameras, and xenon-arc sources equipped with appropriate excitation/emission filters. The dichromatic method permits detection of low nanogram amounts of protein and allows for unambiguous identification of target proteins relative to the entire protein profile on a single electroblot, obviating the need to run replicate gels that would otherwise require visualization of total proteins by silver staining and subsequent alignment with chemiluminescent or colorimetric signals generated on electroblots. Combining the detection approach with an Alexa Fluor 350 dye conjugated monoclonal antibody permits simultaneous fluorescence detection of two antigens and the total protein profile on the same electroblot.