IT infrastructure components to support clinical care and translational research projects in a comprehensive cancer center.

This paper presents the concept of an integrated IT infrastructure framework established at the comprehensive cancer center at the University Hospital Erlangen. The framework is based on the single source concept where data from the electronic medical record are reused for clinical and translational research projects. The applicability of the approach is illustrated by two case studies from colon cancer and prostate cancer research projects.

Interpreter services in emergency medicine.

Emergency physicians are routinely confronted with problems associated with language barriers. It is important for emergency health care providers and the health system to strive for cultural competency when communicating with members of an increasingly diverse society. Possible solutions that can be implemented include appropriate staffing, use of new technology, and efforts to develop new kinds of ties to the community served. Linguistically specific solutions include professional interpretation, telephone interpretation, the use of multilingual staff members, the use of ad hoc interpreters, and, more recently, the use of mobile computer technology at the bedside. Each of these methods carries a specific set of advantages and disadvantages. Although professionally trained medical interpreters offer improved communication, improved patient satisfaction, and overall cost savings, they are often underutilized due to their perceived inefficiency and the inconclusive results of their effect on patient care outcomes. Ultimately, the best solution for each emergency department will vary depending on the population served and available resources. Access to the multiple interpretation options outlined above and solid support and commitment from hospital institutions are necessary to provide proper and culturally competent care for patients. Appropriate communications inclusive of interpreter services are essential for culturally and linguistically competent provider/health systems and overall improved patient care and satisfaction.

Immunogenicity and Efficacy of a Novel Multi-Antigenic Peptide Vaccine Based on Cross-Reactivity between Feline and Human Immunodeficiency Viruses.

For the development of an effective HIV-1 vaccine, evolutionarily conserved epitopes between feline and human immunodeficiency viruses (FIV and HIV-1) were determined by analyzing overlapping peptides from retroviral genomes that induced both anti-FIV/HIV T cell-immunity in the peripheral blood mononuclear cells from the FIV-vaccinated cats and the HIV-infected humans. The conserved T-cell epitopes on p24 and reverse transcriptase were selected based on their robust FIV/HIV-specific CD8⁺ cytotoxic T lymphocyte (CTL), CD4⁺ CTL, and polyfunctional T-cell activities. Four such evolutionarily conserved epitopes were formulated into four multiple antigen peptides (MAPs), mixed with an adjuvant, to be tested as FIV vaccine in cats. The immunogenicity and protective efficacy were evaluated against a pathogenic FIV. More MAP/peptide-specific CD4⁺ than CD8⁺ T-cell responses were initially observed. By post-third vaccination, half of the MAP/peptide-specific CD8⁺ T-cell responses were higher or equivalent to those of CD4⁺ T-cell responses. Upon challenge, 15/19 (78.9%) vaccinated cats were protected, whereas 6/16 (37.5%) control cats remained uninfected, resulting in a protection rate of 66.3% preventable fraction (p = 0.0180). Thus, the selection method used to identify the protective FIV peptides should be useful in identifying protective HIV-1 peptides needed for a highly protective HIV-1 vaccine in humans.

Studies of the thermodynamic properties of hydrogen gas in bulk water.

The thermodynamic properties of hydrogen gas in liquid water are investigated using Monte Carlo molecular simulation and the quasichemical theory of liquids. The free energy of hydrogen hydration obtained by Monte Carlo simulations agrees well with the experimental result, indicating that the classical force fields used in this work provide an adequate description of intermolecular interactions in the aqueous hydrogen system. Two estimates of the hydration free energy for hydrogen made within the framework of the quasichemical theory also agree reasonably well with experiment provided local anharmonic motions and distant interactions with explicit solvent are treated. Both quasichemical estimates indicate that the hydration free energy results from a balance between chemical association and molecular packing. Additionally, the results suggest that the molecular packing term is almost equally driven by unfavorable enthalpic and entropic components.

Advances in FIV vaccine technology.

Advances in vaccine technology are occurring in the molecular techniques used to develop vaccines and in the assessment of vaccine efficacy, allowing more complete characterization of vaccine-induced immunity correlating to protection. FIV vaccine development has closely mirrored and occasionally surpassed the development of HIV-1 vaccine, leading to first licensed technology. This review will discuss technological advances in vaccine designs, challenge infection assessment, and characterization of vaccine immunity in the context of the protection detected with prototype and commercial dual-subtype FIV vaccines and in relation to HIV-1.

Effects of staff training and electronic event monitoring on long-term adherence to lung-protective ventilation recommendations.

PURPOSE: To investigate long-term effects of staff training and electronic clinical decision support (CDS) on adherence to lung-protective ventilation recommendations. MATERIALS AND METHODS: In 2012, group instructions and workshops at two surgical intensive care units (ICUs) started, focusing on standardized protocols for mechanical ventilation and volutrauma prevention. Subsequently implemented CDS functions continuously monitor ventilation parameters, and from 2015 triggered graphical notifications when tidal volume (VT) violated individual thresholds. To estimate the effects of these educational and technical interventions, we retrospectively analyzed nine years of VT records from routine care. As outcome measures, we calculated relative frequencies of settings that conform to recommendations, case-specific mean excess VT, and total ICU survival. RESULTS: Assessing 571,478 VT records from 10,241 ICU cases indicated that adherence during pressure-controlled ventilation improved significantly after both interventions; the share of conforming VT records increased from 61.6% to 83.0% and then 86.0%. Despite increasing case severity, ICU survival remained nearly constant over time. CONCLUSIONS: Staff training effectively improves adherence to lung-protective ventilation strategies. The observed CDS effect seemed less pronounced, although it can easily be adapted to new recommendations. Both interventions, which futures studies could deploy in combination, promise to improve the precision of mechanical ventilation.

The effect of performance incentives on resident documentation in an emergency medicine residency program.

We sought to improve resident chart documentation in an academic emergency department using an incentive. A stipend for educational expenses was offered to residents for documenting charts above specific threshold Evaluation & Management (E&M) levels. Comparisons were made with historical levels. Twenty-two residents participated over 4 months (70% received the stipend). Documentation levels increased significantly from 2.86 and 3.04 during historical controls to 3.31 during the study period (p < 0.05). Fifty-six percent of charts were documented at 99284 or 99285 during the study period compared to 39% and 23% in the control periods (p < 0.05). Three months after the plan (with no incentives), documentation continued to improve, with 59% documented at 99284 or 99285. Mean collection per patient was $48.05 for the study period and $42.36 and $35.86 for the historical periods (p < 0.05). Implementation of a resident incentive program to enhance chart documentation may considerably improve documentation and resident education in proper chart documentation.

Racial and Ethnic Disparities in Health and Health Care: an Assessment and Analysis of the Awareness and Perceptions of Public Health Workers Implementing a Statewide Community Transformation Grant in Texas.

INTRODUCTION: Little is known about the awareness of public health professionals regarding racial and ethnic disparities in health in the United States of America (USA). Our study objective was to assess the awareness and perceptions of a group of public health workers in Texas regarding racial health disparities and their chief contributing causes. METHODS: We surveyed public health professionals working on a statewide grant in Texas, who were participants at health disparities' training workshops. Multivariable logistic regression was employed in examining the association between the participants' characteristics and their perceptions of the social determinants of health as principal causes of health disparities. RESULTS: There were 106 respondents, of whom 38 and 35 % worked in health departments and non-profit organizations, respectively. The racial/ethnic groups with the highest incidence of HIV/AIDS and hypertension were correctly identified by 63 and 50 % of respondents, respectively, but only 17, and 32 % were knowledgeable regarding diabetes and cancer, respectively. Seventy-one percent of respondents perceived that health disparities are driven by the major axes of the social determinants of health. Exposure to information about racial/ethnic health disparities within the prior year was associated with a higher odds of perceiving that social determinants of health were causes of health disparities (OR 9.62; 95 % CI 2.77, 33.41). CONCLUSION: Among public health workers, recent exposure to information regarding health disparities may be associated with their perceptions of health disparities. Further research is needed to investigate the impact of such exposure on their long-term perception of disparities, as well as the equity of services and programs they administer.

HIV-1 p24 vaccine protects cats against feline immunodeficiency virus infection.

BACKGROUND: Based on previous analysis of feline immunodeficiency virus (FIV)-specific cross-reactive antibodies to HIV-1 p24, cats vaccinated with HIV-1 p24 were evaluated for cross-reactive immunity to FIV. OBJECTIVE: : To determine the level of cross-reactivity that exists between HIV-1 and FIV p24 and its implications for vaccine prophylaxis. METHODS: Specific-pathogen-free cats were immunized three times with HIV-1 p24 in Ribi adjuvant, with (n = 18) or without cytokine (n = 6). Control cats were immunized three times with adjuvant (n = 10) or phosphate-buffered saline (PBS; n = 5). All immunized cats were challenged with either subtypes B or A/B FIV, and monitored by virus isolation, proviral PCR, FIV-specific antibodies, and feline interferon-gamma ELISpot for T-cell activities. RESULTS: Of 18 cats vaccinated with subtype B HIV-1 (HIV-1LAI/LAV, HIV-1UCD1) p24 in Ribi/cytokine adjuvant 14 (78%) were protected against FIV challenges (subtype Agag and Bgag) that infected all 15 adjuvant- or PBS-immunized cats. Furthermore, only three of six (50%) cats vaccinated with FIV p24 in Ribi/cytokine adjuvant were protected against similar FIV challenge. HIV-1 p24 vaccination induced weak cross-reactive antibodies to FIV p24, which did not correlate with vaccine efficacy. However, the peripheral blood mononuclear cells from HIV-1 p24-vaccinated/protected cats at 33-34 weeks post-FIV challenge responded to three T-cell responsive peptides at the carboxyl-terminus of the FIV p24, whereas those cells from the infected control cats had minimal to no responses to the same peptides. CONCLUSIONS: These results suggest the importance of including lentiviral p24 as vaccine immunogen for human AIDS vaccine. Moreover, these results suggest the potential importance of evolutionarily conserved, cross-protective epitopes in vaccine protection.

Vaccine information statements. Revolutionary but neglected educational advances in healthcare in the United States.

The purpose of this report is to provide further information about vaccine information statements (VISs) that are revolutionary but neglected educational advances in the United States. Because the use of VISs is mandated by the Federal Government in every individual being immunized, it is the goal of this report to further awaken health professionals and society to the mandatory use of these superb educational statements. With the passage of the National Childhood Vaccine Injury Act of 1986, the Federal Government required that VISs would be given to all vaccine recipients. As of September 2001, the VISs that must be used are diphtheria, tetanus, pertussis, (DTaP); diphtheria, tetanus (Td); measles, mumps, rubella (MMR); polio (IPV); hepatitis B; Haemophilus influenzae type b (Hib); varicella; and pneumococcal conjugate. Copies of the VISs are available at www.cdc.gov/nip/publications/VIS. The National Childhood Vaccine Injury Act of 1986 mandated that all health care providers report certain adverse events that occur following vaccination. As a result, the Vaccine Adverse Events Reporting System (VAERS) was established by the FDA and the Centers for Disease Control and Prevention (CDC) in 1990. In order to reduce the liability of manufacturers and healthcare providers, the National Childhood Vaccine Injury Act of 1986 established the National Vaccine Injury Compensation Program (NVICP). This program is intended to compensate those individuals who have been injured by vaccines on a no-fault basis. While the use of VISs has been mandated since 1996, a national survey of private practice office settings has revealed that many immunized patients do not receive the VISs. When these forms were used, physicians rarely initiated discussions regarding contraindications to immunizations or the National Vaccine Injury Compensation Program. Fortunately, the state boards of medical examiners, like the one in Oregon, are taking a strong stand for the use of VISs, with the warning that failure to use a VIS may result in disciplinary action. Our nation and practicing physicians must be awakened to the importance of the use of VISs to ensure that every vaccinated individual receives this statement at the time of vaccination.

Scientific basis for the selection of emergency medical examination gloves for emergency medical technicians, paramedics, firefighters, and emergency department personnel. An update.

The use of powder-free natural rubber or latex-free emergency medical examination gloves is especially important to emergency medical technicians, paramedics, firefighters, and emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics, and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent codes and standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA-approved gloves. There are four well-defined goals of this report that will assist emergency medical services, fire departments, and hospitals in the selection and purchase of emergency medical examination gloves. First, we will review again the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. As of September 2003, the emergency medical examination glove must meet the new design and performance requirements of emergency medical examination gloves discussed in NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 2003 Edition.

Ontology-based data integration between clinical and research systems.

Data from the electronic medical record comprise numerous structured but uncoded elements, which are not linked to standard terminologies. Reuse of such data for secondary research purposes has gained in importance recently. However, the identification of relevant data elements and the creation of database jobs for extraction, transformation and loading (ETL) are challenging: With current methods such as data warehousing, it is not feasible to efficiently maintain and reuse semantically complex data extraction and trans-formation routines. We present an ontology-supported approach to overcome this challenge by making use of abstraction: Instead of defining ETL procedures at the database level, we use ontologies to organize and describe the medical concepts of both the source system and the target system. Instead of using unique, specifically developed SQL statements or ETL jobs, we define declarative transformation rules within ontologies and illustrate how these constructs can then be used to automatically generate SQL code to perform the desired ETL procedures. This demonstrates how a suitable level of abstraction may not only aid the interpretation of clinical data, but can also foster the reutilization of methods for un-locking it.

Society for Academic Emergency Medicine survey of the Association of American Medical Colleges Council of Academic Societies.

The Society for Academic Emergency Medicine (SAEM) surveyed the Council of Academic Societies (CAS) organizations to obtain useful information to project SAEM goals into the year 2010. The objective of this work was to understand common and varying organizational operations and identify opportunities. The authors reviewed CAS organizations' mission statements, operating budgets, modes of communications, products, meeting formats, foundations, endowment funds, staff structures, headquarters, advocacy activities (services), top challenges, and most significant changes anticipated the next ten years. The survey methodology was used to gain insight into modes of operation of CAS organizations and enable SAEM to review its own operations and identify potential organizational changes based on the experiences of others. Individual CAS organizations might similarly benefit by reviewing the results of the survey and comparing themselves with others.

Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States.

There is a global epidemic of hepatitis B virus (HBV) infections affecting more than 350 million people worldwide. This collective review provides the rationale for a comprehensive strategy to eliminate transmission of HBV in the United States. The virologic characteristics of HBV include three forms of HBV surface antigen (HBsAg), HBV core antigen (HbcAg), as well as a circulating peptide, the HBV e antigen (HBeAg). The year 2002 was the 20th anniversary of the use in the United States of the world's first vaccine against HBV. Our prevention strategy involves making HBV vaccine a part of the routine vaccination schedules for all infants in the United States. Hepatitis B immune globulin (HBIG) is another useful adjunct for prophylaxis that provides temporary protection (i.e., 3-6 months) and is recommended in only certain postexposure settings. The routes for administration of HBV vaccine and HBIG are intramuscular sites that differ according to the age of the individual. Following routine HBV vaccination in adults and children, prevaccination and postvaccination serologic testing is not recommended because of the relatively low rate of HBV infection and the low cost of the vaccine. Postexposure prophylaxis for HBV with serologic testing is, however, necessary for all hospital personnel exposed to blood or body fluids. In addition, infants born from mothers not immunized to HBV or those who are infected with HBV also require comprehensive postexposure prophylaxis with serologic testing. Comprehensive immunization strategies with serologic testing must be implemented for all groups that have a high risk of HBV infection. Finally, vaccine information statements (VIS) must be carefully integrated in this comprehensive disease prevention strategy, which is designed to prevent the transmission of HBV in the United States.

Scientific basis for selection of emergency medical examination gloves for emergency medical technicians, paramedics, firefighters, and emergency department personnel.

Dusting powders were first applied to gloves to facilitate donning. After 1980, manufacturers devised innovative techniques to manufacture gloves without dusting powders. It has been well documented that the powders on gloves present a health hazard to patients, as well as healthcare workers. First, these powders elicit tissue toxicity in every tissue in the body. Second, these powders serve as carriers of latex allergen and may precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powders have caused a growing number of emergency medical technicians, paramedics, firelighters, and hospitals to abandon the use of powdered emergency medical examination gloves, using only powder-free gloves. Powder-free latex as well as non-latex gloves are now available to emergency medical technicians, paramedics, firefighters, and emergency department personnel. The use of powder-free natural rubber latex-free gloves is especially important to emergency medical technicians, paramedics, firefighters, as well as emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent Codes and Standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA approved gloves. It is the purpose of this report to review the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance Standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. In September 2003, the emergency medical examination glove must meet the new design and performance requirements of emergency medical examination gloves discussed

Management and prevention of tetanus.

The World Health Organization was committed to eliminating neonatal tetanus by 1995. Three years after this date, the infection killed over 400,000 babies a year, even though a safe, effective vaccine had been available for most of this century. The frequency of tetanus in the developing world epitomizes the healthcare disparity between the developed and the developing world. Consequently, the priority of the medical profession must be prevention, with the development of simpler immunization schedules with longer protection. Consequently, the purpose of this collective review is to provide an overview to the management of tetanus as well as to review the immunization strategy that will prevent this potentially deadly illness. Tetanus is caused by Cloistridium tetani, which is an obligate anaerobic, gram-positive rod that is motile and readily forms endospores. Although C. tetani is located everywhere, the disease is encountered largely in underdeveloped, overcrowded, and economically disadvantaged countries. C. tetani is widespread in the feces of domestic animals and humans, while spores of C. tetani are abundant in soil and in the environment surrounding the habitation of humans and animals. Tetanus usually follows deep penetrating wounds where anaerobic bacterial growth is facilitated. Three basic forms of tetanus may be distinguished: local, cephalic, and generalized. At least 80% of the cases are the generalized form. In the adult patient, the most characteristic sign of generalized tetanus is lockjaw, or trismus. The diagnosis of tetanus is most frequently made on clinical manifestations, rather than on bacteriologic findings. The three objectives of management of tetanus are: (1) to provide supportive care until the tetanospasmin that is fixed in tissue has been metabolized; (2) to neutralize circulating toxin; and (3) to remove the source of tetanospasmin. Because there is essentially no immunity to tetanus toxoid, the only effective way to control tetanus is by prophylactic immunization.

Feline immunodeficiency virus (FIV) vaccine efficacy and FIV neutralizing antibodies.

A HIV-1 tier system has been developed to categorize the various subtype viruses based on their sensitivity to vaccine-induced neutralizing antibodies (NAbs): tier 1 with greatest sensitivity, tier 2 being moderately sensitive, and tier 3 being the least sensitive to NAbs (Mascola et al., J Virol 2005; 79:10103-7). Here, we define an FIV tier system using two related FIV dual-subtype (A+D) vaccines: the commercially available inactivated infected-cell vaccine (Fel-O-Vax(®) FIV) and its prototype vaccine solely composed of inactivated whole viruses. Both vaccines afforded combined protection rates of 100% against subtype-A tier-1 FIVPet, 89% against subtype-B tier-3 FIVFC1, 61% against recombinant subtype-A/B tier-2 FIVBang, 62% against recombinant subtype-F'/C tier-3 FIVNZ1, and 40% against subtype-A tier-2 FIVUK8 in short-duration (37-41 weeks) studies. In long-duration (76-80 weeks) studies, the commercial vaccine afforded a combined protection rate of at least 46% against the tier-2 and tier-3 viruses. Notably, protection rates observed here are far better than recently reported HIV-1 vaccine trials (Sanou et al., The Open AIDS J 2012; 6:246-60). Prototype vaccine protection against two tier-3 and one tier-2 viruses was more effective than commercial vaccine. Such protection did not correlate with the presence of vaccine-induced NAbs to challenge viruses. This is the first large-scale (228 laboratory cats) study characterizing short- and long-duration efficacies of dual-subtype FIV vaccines against heterologous subtype and recombinant viruses, as well as FIV tiers based on in vitro NAb analysis and in vivo passive-transfer studies. These studies demonstrate that not all vaccine protection is mediated by vaccine-induced NAbs.

Workflows in cancer treatment and their influence upon clinical documentation.

To establish single source cancer documentation for a complete comprehensive cancer center CCC we performed a systematic analysis of diagnostic, therapeutic and documentation workflows for 13 cancer entities. Results suggest that we will need three types of clinical documentation to cover all cancer entities of the Erlangen CCC. We expect to have a workflow for solid entities with inpatient treatment, one for solid entities treated ambulatory and one for non solid cancer entities.

Simvastatin ameliorates cauda equina compression injury in a rat model of lumbar spinal stenosis.

Lumbar spinal stenosis (LSS) is the leading cause of morbidity and mortality worldwide. LSS pathology is associated with secondary injury caused by inflammation, oxidative damage and cell death. Apart from laminectomy, pharmacological therapy targeting secondary injury is limited. Statins are FDA-approved cholesterol-lowering drug. They also show pleiotropic anti-inflammatory, antioxidant and neuroprotective effects. To investigate the therapeutic efficacy of simvastatin in restoring normal locomotor function after cauda equina compression (CEC) in a rat model of LSS, CEC injury was induced in rats by implanting silicone gels into the epidural spaces of L4 and L6. Experimental group was treated with simvastatin (5 mg/kg body weight), while the injured (vehicle) and sham operated (sham) groups received vehicle solution. Locomotor function in terms of latency on rotarod was measured for 49 days and the threshold of pain was determined for 14 days. Rats were sacrificed on day 3 and 14 and the spinal cord and cauda equina fibers were extracted and studied by histology, immunofluorescence, electron microscopy (EM) and TUNEL assay. Simvastatin aided locomotor functional recovery and enhanced the threshold of pain after the CEC. Cellular Infiltration and demyelination decreased in the spinal cord from the simvastatin group. EM revealed enhanced myelination of cauda equina in the simvastatin group. TUNEL assay showed significantly decreased number of apoptotic neurons in spinal cord from the simvastatin group compared to the vehicle group. Simvastatin hastens the locomotor functional recovery and reduces pain after CEC. These outcomes are mediated through the neuroprotective and anti-inflammatory properties of simvastatin. The data indicate that simvastatin may be a promising drug candidate for LSS treatment in humans.

S-Nitrosoglutathione administration ameliorates cauda equina compression injury in rats.

Lumbar spinal stenosis (LSS) causes ischemia, inflammation, demyelination and results in dysfunction of the cauda equina (CE), leading to pain and locomotor functional deficits. We investigated whether exogenous administration of S-nitrosoglutathione (GSNO), an endogenous redox modulating anti-neuroinflammatory agent, hastens functional recovery in a CE compression (CEC) rat model. CEC was induced in adult female rats by the surgical implantation of two silicone blocks within the epidural spaces of L4-L6 vertebrae. GSNO (50 µg/kg body weight) was administered by gavage 1 h after the injury, and the treatment was continued daily thereafter. GSNO induced change in the pain threshold was evaluated for four days after the compression. Tissue analyses and locomotor function evaluation were carried out at two weeks and four weeks after the CEC respectively. GSNO significantly improved motor function in CEC rats as evidenced by an increased latency on rotarod compared with vehicle-treated CEC rats. CEC induced hyperalgesia was decreased by GSNO. GSNO also increased the expression of VEGF, reduced cellular infiltration (H&E staining) and apoptotic cell death (TUNEL assay), and hampered demyelination (LFB staining and g-ratio). These data demonstrate that administration of GSNO after CEC decreased inflammation, hyperalgesia and cell death leading to improved locomotor function of CEC rats. The therapeutic potential of GSNO observed in the present study with CEC rats suggests that GSNO is a candidate drug to test in LSS patients.