[Resilience against IT attacks in hospitals : Results from an exercise in a German university hospital]. / Resilienz gegen IT-Angriffe an Kliniken : Ergebnisse einer Stabsrahmenübung an einem Universitätsklinikum.

BACKGROUND: According to the legal definition healthcare systems and their components (e.g., hospitals) are part of the critical infrastructure of modern industrial nations. During the last few years hospitals increasingly became targets of cyber attacks causing severe impairment of their operability for weeks or even months. According to the German federal strategy for protection of critical infrastructures (KRITIS strategy), hospitals are obligated to take precautions against potential cyber attacks or other IT incidents. OBJECTIVE: This article describes the process of planning, execution and results of an advanced table-top exercise which took place in a university hospital in Germany and simulated the first 3 days after a cyber attack causing a total failure of highly critical IT systems. MATERIAL AND METHODS: During a first stage lasting about 8 months IT-dependent processes within the clinical routine were identified and analyzed. Then paper-based and off-line back-up processes and workarounds were developed and department-specific emergency plans were defined. Finally, selected central facilities such as pharmacy, laboratory, radiology, IT and the hospitals crisis management team took part in the actual disaster exercise. Afterwards the participants were asked to evaluate the exercise and the hospitals cyber security using a questionnaire. On this basis the authors visualized the hospital's resilience against cyber incidents and defined short-term, medium-term and long-term needs for action. RESULTS: Of the participants 85% assessed the exercise as beneficial, 97% indicated that they received adequate support during the preparations and 75% had received sufficient information; however, only 34% had the opinion that the hospital's and their own preparedness against critical IT failures were sufficient. Before the exercise took place, IT-specific emergency plans were present only in 1.7% of the hospital facilities but after the exercise in 86.7% of the clinical and technical departments. The highest resilience against cyber attacks was not surprisingly reported by facilities that still work routinely with paper-based or off-line processes, the IT department showed the lowest resilience as it would come to a complete shutdown in cases of a total IT failure. CONCLUSION: The authors concluded that the planning phase is the most important stage of developing the whole exercise, giving the best opportunity for working out fallback levels and workarounds and through this strengthen the hospitals resilience against cyber attacks and comparable incidents. A meticulous preparedness can minimize the severe effects a total IT failure can cause on patient care, staff and the hospital as a whole.

Perceived psychological stress and risk of herpes zoster: a nationwide population-based cohort study.

BACKGROUND: Psychological stress may reduce cellular immunity, but its role in triggering latent infections, including herpes zoster (HZ), is controversial. OBJECTIVES: To examine the association between perceived psychological stress and risk of HZ. METHODS: In a linked registry-based cohort study, we followed 77 310 persons aged 40 years or older who participated in the 2010 Danish National Health Survey from 1 May 2010 until HZ diagnosis, death, emigration or 1 July 2014, whichever occurred first. We computed hazard ratios (HRs) of HZ associated with Cohen's Perceived Stress Scale (PSS) score (range 0-40) using Cox regression with age as the timescale, adjusted for sex, immunosuppressive and selected chronic conditions, immunosuppressive drugs, and sociodemographic, lifestyle and anthropometric factors. The PSS measures chronic stress perceived by an individual in response to various demands of daily life. We modelled the PSS score using quintiles and a restricted cubic spline function. RESULTS: The unadjusted rate of HZ varied from 5·53 to 7·20 per 1000 person-years from the lowest to the highest PSS score quintile. Compared with the lowest PSS score quintile, the adjusted HR for HZ was 1·00 [95% confidence interval (CI) 0·86-1·16], 1·08 (95% CI 0·92-1·26), 1·05 (95% CI 0·90-1·23) and 1·14 (95% CI 0·97-1·34) for the second to the fifth quintile, respectively. In cubic spline analyses, PSS scores < 20 were not associated with increased HR of HZ, but thereafter the HR increased linearly from 1·10 (95% CI 0·85-1·41) to 2·22 (95% CI 1·32-3·75). CONCLUSIONS: Our study indicated that high levels of psychological stress are associated with increased risk of HZ.

[Success, satisfaction and improvement of informed consents for computed tomography : A survey among patients and physicians]. / Aufklärungserfolg, Zufriedenheit und Verbesserungsmöglichkeiten bei Computertomographie-Aufklärungen : Eine Befragung von Patienten und Ärzten.

BACKGROUND: Providing informed consent before a computed tomography (CT) is important for the physicians and the patients. A personal interview about the procedure, risks, and possible alternatives is mandatory before a CT examination. METHODS: A survey was carried out on patient satisfaction with regard to the duration and content of informed consents of CT examinations. Physicians were also interviewed about the duration and content of CT informed consents. Another part of the survey dealt with the acceptance of technical innovations, such as information videos or tablets/PCs. RESULTS: A total of 512 patients and 106 physicians took part in the survey. The duration of the informed consent was estimated by the patients to be 4.08 min on average and 4.7 min by the physicians. The most detailed information given by the physicians regards side effects associated with contrast agents. Less information was given on possible diagnostic alternatives and the need for an examination. According to this, about 92% of all patients did not remember having received information about alternative examinations. Furthermore, 88.7% of the patients and 95.3% of the physicians recommended informed consent using interactive videos and animations, and 74% of the patients and 98.8% of the physicians recommended answering questions on tablet/PC. CONCLUSION: Patients estimated the duration of a CT informed consent to be a little bit shorter, although some patients did not remember the content very well. The acceptance of technical innovations was very high among the participants. The use of information videos and tablets/PCs could increase the success of providing informed consent.

[Hepatolienal candidosis as a rare differential diagnosis of disseminated small parenchym lesions]. / Hepatolienale Candidose als seltene Differenzialdiagnose disseminierter kleinherdiger Parenchymveränderungen.

HISTORY: We report about a 17-year-old patient with the secondary malignancy of acute myeloid leukemia (AML). He developed fever of unclear origin during the hematopoietic stem cell transplantation.History We report about a 17-year-old patient with the secondary malignancy of acute myeloid leukemia (AML). He developed fever of unclear origin during the hematopoietic stem cell transplantation. EXAMINATIONS: In the focus search, the routine sonography of the abdomen showed disseminated hypoechoic small- parenchymal lesions of the liver. In the complementary MRI, disseminated small lesions of the liver parenchyma and the spleen were demarked after contrast agent administration. DIAGNOSIS: Imaging revealed suspicion of hepatolienal candiasis.Diagnosis Imaging revealed suspicion of hepatolienal candiasis. THERAPY: Empirical therapy with amphotericin B was used. A sonographic punch biopsy of the liver was performed. The pathological examination showed oval particles in the PAS staining in the sense of an opportunistic mycosis of the Candida infection type. CONCLUSION: The case shows that in immunosuppressed patients, candidiasis must always be considered as a differential diagnosis with simultaneous parenchymal changes in the liver and/or spleen. In addition, in the screening situation, a suitable linear transducer should be used when asking about fungal lesions in the liver and spleen. Alternatively, if suspected hepato-lienal candidiasis could be diagnosed by a contrast-enhanced MRI of the upper abdomen/abdomen.

The association between partner bereavement and melanoma: cohort studies in the U.K. and Denmark.

BACKGROUND: Psychological stress is commonly cited as a risk factor for melanoma, but clinical evidence is limited. OBJECTIVES: This study aimed to evaluate the association between partner bereavement and (i) first-time melanoma diagnosis and (ii) mortality in patients with melanoma. METHODS: We conducted two cohort studies using data from the U.K. Clinical Practice Research Datalink (1997-2017) and Danish nationwide registries (1997-2016). In study 1, we compared the risk of first melanoma diagnosis in bereaved vs. matched nonbereaved people using stratified Cox regression. In study 2 we estimated hazard ratios (HRs) for death from melanoma in bereaved compared with nonbereaved individuals with melanoma using Cox regression. We estimated HRs separately for the U.K. and for Denmark, and then pooled the data to perform a random-effects meta-analysis. RESULTS: In study 1, the pooled adjusted HR for the association between partner bereavement and melanoma diagnosis was 0·88 [95% confidence interval (CI) 0·84-0·92] across the entire follow-up period. In study 2, we observed increased melanoma-specific mortality in people experiencing partner bereavement across the entire follow-up period (HR 1·17, 95% CI 1·06-1·30), with the peak occurring during the first year of follow-up (HR 1·31, 95% CI 1·07-1·60). CONCLUSIONS: We found decreased risk of melanoma diagnosis, but increased mortality associated with partner bereavement. These findings may be partly explained by delayed detection resulting from the loss of a partner who could notice skin changes. Stress may play a role in melanoma progression. Our findings indicate the need for a low threshold for skin examination in individuals whose partners have died. What is already known about this topic? Psychological stress has been proposed as a risk factor for the development and progression of cancer, including melanoma, but evidence is conflicting. Clinical evidence is limited by small sample sizes, potential recall bias associated with self-report, and heterogeneous stress definitions. What does this study add? We found a decreased risk of melanoma diagnosis, but increased mortality associated with partner bereavement. While stress might play a role in the progression of melanoma, an alternative explanation is that bereaved people no longer have a close person to help notice skin changes, leading to delayed melanoma detection. Linked Comment: Talaganis et al. Br J Dermatol 2020; 183:607-608.

[Analysis of documented informed consent forms for computed tomography : Completeness and data quality in four clinics]. / Analyse von dokumentierten Computertomographie-Aufklärungen : Vollständigkeit und Datenqualität in vier Kliniken.

BACKGROUND: Before performing a medical procedure, such as a computed tomography, an obligatory informed consent of the patient and its detailed documentation is necessary. METHODS: A total of 1424 informed consent forms for contrast-enhanced computed tomography from four clinics with different healthcare levels were analyzed. Informed consent forms were evaluated related to completeness, legibility and quality. RESULTS: In all, 1110 (77.9%) informed consent forms were sufficiently completed, 267 patients (18.8%) answered the form incompletely and 47 patients (3.3%) returned it without answering a question. Handwritten comments were found in 1391 (97.7%) cases. Thereof, 1329 (93.3%) were graded as detailed comments and 62 (4.4%) as less detailed comments. These comments were well legible in 675 (47.4%) cases, 558 (39.2%) informed consents showed limited legibility and in 158 (11.1%) more than 50% of the comments were unreadable. Signatures were complete in 1374 (96.5%) informed consent forms. CONCLUSION: The results show a better quality and documentation of informed consent forms for computed tomography obtained by radiology residents compared to radiological specialists. Compared to the radiologists, the non-radiologists performed significantly worse. The establishment of videos and use of digital informed consent forms could provide a possible solution.

Partner bereavement and risk of psoriasis and atopic eczema: cohort studies in the U.K. and Denmark.

BACKGROUND: Stress is commonly cited as a risk factor for psoriasis and atopic eczema, but such evidence is limited. OBJECTIVES: To investigate the association between partner bereavement (an extreme life stressor) and psoriasis or atopic eczema. METHODS: We conducted cohort studies using data from the U.K. Clinical Practice Research Datalink (1997-2017) and Danish nationwide registries (1997-2016). The exposed cohort was partners who experienced partner bereavement. The comparison cohort was up to 10 nonbereaved partners, matched to each bereaved partner by age, sex, county of residence (Denmark) and general practice (U.K.). Outcomes were the first recorded diagnosis of psoriasis or atopic eczema. We estimated hazard ratios (HRs) and confidence intervals (CIs) using a stratified Cox proportional hazards model in both settings, which were then pooled in a meta-analysis. RESULTS: The pooled adjusted HR for the association between bereavement and psoriasis was 1·01 (95% CI 0·98-1·04) across the entire follow-up. Similar results were found in other shorter follow-up periods. Pooled adjusted HRs for the association between bereavement and atopic eczema were 0·97 (95% CI 0·84-1·12) across the entire follow-up, 1·09 (95% CI 0·86-1·38) within 0-30 days, 1·18 (95% CI 1·04-1·35) within 0-90 days, 1·14 (95% CI 1·06-1·22) within 0-365 days and 1·07 (95% CI 1·02-1·12) within 0-1095 days. CONCLUSIONS: We found a modest increase in the risk of atopic eczema within 3 years following bereavement, which peaked in the first 3 months. Acute stress may play a role in triggering onset of new atopic eczema or relapse of atopic eczema previously in remission. We observed no evidence for increased long-term risk of psoriasis and atopic eczema following bereavement.

Genotyping of circulating tumor DNA in cholangiocarcinoma reveals diagnostic and prognostic information.

Diagnosis of Cholangiocarcinoma (CCA) is difficult, thus a noninvasive approach towards (i) assessing and (ii) monitoring the tumor-specific mutational profile is desirable to improve diagnosis and tailor treatment. Tumor tissue and corresponding ctDNA samples were collected from patients with CCA prior to and during chemotherapy and were subjected to deep sequencing of 15 genes frequently mutated in CCA. A set of ctDNA samples was also submitted for 710 gene oncopanel sequencing to identify progression signatures. The blood/tissue concordance was 74% overall and 92% for intrahepatic tumors only. Variant allele frequency (VAF) in ctDNA correlated with tumor load and in the group of intrahepatic CCA with PFS. 63% of therapy naive patients had their mutational profile changed during chemotherapy. A set of 76 potential progression driver genes was identified among 710 candidates. The molecular landscape of CCA is accessible via ctDNA. This could be helpful to facilitate diagnosis and personalize and adapt therapeutic strategies.

Report from the first European Dermato-Epidemiology Network forum.

The first European Dermato-Epidemiology Network (EDEN) forum was held on 30-31 March 2017 in Madrid, Spain. Dermatoepidemiology describes the study of causes, prevention, health services research and evaluation of interventions of skin diseases. EDEN aims to promote high-quality research, share expertise and facilitate collaboration. These aims were achieved during the EDEN forum by including a preconference course on skin cancer epidemiology; having excellent world-leading guest speakers on causality, quality of care, pharmacoepidemiology and missing data analysis; and including delegates who presented and discussed innovative research findings. The meeting brought together delegates from 11 different countries. We welcome everyone with an interest in clinical research and epidemiology related to skin disease to attend next year's meeting in March 2018 in Berlin.

Herpes zoster as a marker of occult cancer: A systematic review and meta-analysis.

OBJECTIVES: Researchers have advocated for an increased awareness of occult cancer among herpes zoster patients, but there are no systematic reviews to support these claims. We therefore conducted a systematic review and meta-analysis of evidence on zoster and risk of occult cancer. METHODS: Through February 18, 2016, we searched PubMed, EMBASE and references of relevant papers for studies on zoster and risk of any cancer. One author screened retrieved papers by title and abstract; included papers were reviewed by two authors for eligibility, data extraction, and potential biases. Despite statistical heterogeneity, associations were consistently in the same direction and we therefore computed pooled relative risks using random-effects models. RESULTS: We identified 46 eligible studies, 10 of which considered all cancer types combined. The pooled relative risk for any cancer was 1.42 (95% confidence interval: 1.18, 1.71) overall and 1.83 (95% confidence interval: 1.17, 2.87) at one year after zoster. Considering cancer subtypes, the highest estimates were generally reported for occult hematological cancer. The absolute risk of any cancer at one year after presentation with zoster was 0.7-1.8%. CONCLUSION: This study supports an association between zoster and occult cancer, but the low absolute risk of cancer limits the clinical implications.