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Influenza, a respiratory disease mainly caused by influenza A and B, viruses of the Orthomyxoviridae, is still a burden on our society’s health and economic system. Influenza A viruses (IAV) circulate in mammalian and avian populations, causing seasonal outbreaks with high numbers of cases. Due to the high variability in seasonal IAV triggered by antigenic drift, annual vaccination is necessary, highlighting the need for a more broadly protective vaccine against IAV. The safety tested Modified Vaccinia virus Ankara (MVA) is licensed as a third-generation vaccine against smallpox and serves as a potent vector system for the development of new candidate vaccines against different pathogens. Here, we generated and characterized recombinant MVA candidate vaccines that deliver the highly conserved internal nucleoprotein (NP) of IAV under the transcriptional control of five newly designed chimeric poxviral promoters to further increase the immunogenic properties of the recombinant viruses (MVA-NP). Infections of avian cell cultures with the recombinant MVA-NPs demonstrated efficient synthesis of the IAV-NP which was expressed under the control of the five new promoters. Prime-boost or single shot immunizations in C57BL/6 mice readily induced circulating serum antibodies’ binding to recombinant IAV-NP and the robust activation of IAV-NP-specific CD8+ T cell responses. Moreover, the MVA-NP candidate vaccines protected C57BL/6 mice against lethal respiratory infection with mouse-adapted IAV (A/Puerto Rico/8/1934/H1N1). Thus, further studies are warranted to evaluate the immunogenicity and efficacy of these recombinant MVA-NP vaccines in other IAV challenge models in more detail.

Purpose In patients undergoing chemoradiation for esophageal squamous cell carcinoma (ESCC), the extent of elective nodal irradiation (ENI) is still discussed controversially. This study aimed to analyze patterns of lymph node metastases and their correlation with the primary tumor using 18F‑fludeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scans. Methods 102 ESCC patients with pre-treatment FDG-PET/CT scans were evaluated retrospectively. After exclusion of patients with low FDG uptake and patients without FDG-PET-positive lymph node metastases (LNM), 76 patients were included in the final analysis. All LNM were assigned to 16 pre-defined anatomical regions and classified according to their position relative to the primary tumor (above, at the same height, or below the primary tumor). In addition, the longitudinal distance to the primary tumor was measured for all LNM above or below the primary tumor. The craniocaudal extent (i.e., length) of the primary tumor was measured using FDG-PET imaging (LPET) and also based on all other available clinical and imaging data (endoscopy, computed tomography, biopsy results) except FDG-PET (LCT/EUS). Results Significantly more LNM were identified with 18F‑FDG-PET/CT (177 LNM) compared to CT alone (131 LNM, p CT/EUS (median 6 cm) and LPET (median 6 cm, p = 0.846) Conclusion 18F‑FDG-PET can help to identify subclinical lymph node metastases which are located outside of recommended radiation fields. PET-based involved-field irradiation might be the ideal compromise between small treatment volumes and decreasing the risk of undertreatment of subclinical metastatic lymph nodes and should be further evaluated.

The “opioid crisis” stemming from overprescribing of prescription opioids describes an iatrogenic situation which has resulted in a rise in opioid use disorder (OUD) and overdose deaths. Many of these patients suffer from chronic non-cancer pain syndromes (CNCP) who have been injudiciously treated with opioids. Some patients with CNCP are treated successfully with opioids in accordance with modern guidelines. There is a very complex, small group of patients with CNCP who require higher than recommended dosages of opioids when other modalities and treatments have failed. We describe such a patient and believe that there is a subset of patients with unremitting suffering from chronic pain which we have called end-stage chronic pain (ESCP). These patients, despite receiving expert chronic pain care, often require high doses of opioids and suffer a dramatic decline in quality of life (QOL), function and an increase in their suffering when their opioids are tapered or discontinued. We have responded to the treatment of this group of patients by critically examining our approach to the use of opioids for their pain and attempting to reconcile high dose opioids in the setting of the Center for Disease Control (CDC) guidelines. We describe a patient with severe chronic pain from congenital spinal disease who experienced increased pain and suffering when his opioids were tapered. We will discuss our approach to this patient and in doing so discuss the concept of ESCP and proposed criteria for the use of high dose opioids in such patients.

In cell culture infections with vaccinia virus the number of counted virus particles is substantially higher than the number of plaques obtained by titration. We found that standard vaccine preparations of recombinant Modified Vaccinia virus Ankara produce only about 20–30% plaque-forming virions in fully permissive cell cultures. To evaluate the biological activity of the non-plaque-forming particles, we generated recombinant viruses expressing fluorescent reporter proteins under transcriptional control of specific viral early and late promoters. Live cell imaging and automated counting by fluorescent microscopy indicated that virtually all virus particles can enter cells and switch on viral gene expression. Although most of the non-plaque-forming infections are arrested at the level of viral early gene expression, we detected activation of late viral transcription in 10–20% of single infected cells. Thus, non-plaque-forming particles are biologically active, and likely contribute to the immunogenicity of vaccinia virus vaccines., Highlights • Recombinant vaccinia virus MVA preparations contain >70% non-plaque-forming virions. • Non-plaque-forming particles can enter cells and switch on viral gene expression. • Non-plaque-forming virions are likely to contribute to vaccine immunogenicity.

Including target populations in the design and implementation of research trials has been one response to the growing health disparities endemic to our health care system, as well as an aid to study generalizability. One type of community-based participatory research is “Patient Centered-Research”, in which patient perspectives on the germane research questions and methodologies are incorporated into the study. The Patient-Centered Outcomes Research Institute (PCORI) has mandated that meaningful patient and stakeholder engagement be incorporated into all applications. As of March 2015, PCORI funded seven clinically-focused studies of patients with kidney disease. The goal of this paper is to synthesize the experiences of these studies to gain an understanding of how meaningful patient and stakeholder engagement can occur in clinical research of kidney diseases, and what the key barriers are to its implementation. Our collective experience suggests that successful implementation of a patient- and stakeholder-engaged research paradigm involves: (1) defining the roles and process for the incorporation of input; (2) identifying the particular patients and other stakeholders; (3) engaging patients and other stakeholders so they appreciate the value of their own participation and have personal investment in the research process; and (4) overcoming barriers and challenges that arise and threaten the productivity of the collaboration. It is our hope that the experiences of these studies will further interest and capacity for incorporating patient and stakeholder perspectives in research of kidney diseases.

Activation of CD8(+)T-cells is an essential part of immune responses elicited by recombinant modified vaccinia virus Ankara (MVA). Strategies to enhance T-cell responses to antigens may be particularly necessary for broadly protective immunization against influenza A virus infections or for candidate vaccines targeting chronic infections and cancer. Here, we tested recombinant MVAs that targeted a model antigen, GFP, to different localizations in infected cells. In vitro characterization demonstrated that GFP accumulated in the nucleus (MVA-nls-GFP), associated with cellular membranes (MVA-myr-GFP) or was equally distributed throughout the cell (MVA-GFP). On vaccination, we found significantly higher levels of GFP-specific CD8(+)T-cells in MVA-myr-GFP-vaccinated BALB/c mice than in those immunized with MVA-GFP or MVA-nls-GFP. Thus, myristoyl modification may be a useful strategy to enhance CD8(+)T-cell responses to MVA-delivered target antigens.

West Nile virus (WNV) cycles between insects and wild birds, and is transmitted via mosquito vectors to horses and humans, potentially causing severe neuroinvasive disease. Modified Vaccinia virus Ankara (MVA) is an advanced viral vector for developing new recombinant vaccines against infectious diseases and cancer. Here, we generated and evaluated recombinant MVA candidate vaccines that deliver WNV envelope (E) antigens and fulfil all the requirements to proceed to clinical testing in humans. Infections of human and equine cell cultures with recombinant MVA demonstrated efficient synthesis and secretion of WNV envelope proteins in mammalian cells non-permissive for MVA replication. Prime-boost immunizations in BALB/c mice readily induced circulating serum antibodies binding to recombinant WNV E protein and neutralizing WNV in tissue culture infections. Vaccinations in HLA-A2.1-/HLA-DR1-transgenic H-2 class I-/class II-knockout mice elicited WNV E-specific CD8+ T cell responses. Moreover, the MVA-WNV candidate vaccines protected C57BL/6 mice against lineage 1 and lineage 2 WNV infection and induced heterologous neutralizing antibodies. Thus, further studies are warranted to evaluate these recombinant MVA-WNV vaccines in other preclinical models and use them as candidate vaccine in humans.

Background and objectives More than 90,000 patients with ESRD die annually in the United States, yet advance care planning (ACP) is underutilized. Understanding patients’ and families’ diverse needs can strengthen systematic efforts to improve ACP. Design, setting, participants, & measurements In-depth interviews were conducted with a purposive sample of patients and family/friends from dialysis units at two study sites. Applying grounded theory, interviews were audiotaped, professionally transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized into major themes and subthemes. Results Thirteen patients and nine family/friends participated in interviews. The mean patient age was 63 years (SD 14) and five patients were women. Participants identified as black ( n =1), Hispanic ( n =4), Native American ( n =4), Pacific Islander ( n =1), white ( n =11), and mixed ( n =1). Three major themes with associated subthemes were identified. The first theme, “Prior experiences with ACP,” revealed that these discussions rarely occur, yet most patients desire them. A potential role for the primary care physician was broached. The second theme, “Factors that may affect perspectives on ACP,” included a desire for more of a connection with the nephrologist, positive and negative experiences with the dialysis team, disenfranchisement, life experiences, personality traits, patient-family/friend relationships, and power differentials. The third theme, “Recommendations for discussing ACP,” included thoughts on who should lead discussions, where and when discussions should take place, what should be discussed and how. Conclusions Many participants desired better communication with their nephrologist and/or their dialysis team. A number expressed feelings of disenfranchisement that could negatively impact ACP discussions through diminished trust. Life experiences, personality traits, and relationships with family and friends may affect patient perspectives regarding ACP. This study’s findings may inform clinical practice and will be useful in designing prospective intervention studies to improve patient and family experiences at the end of life.

We examined the benefits of a collaboration between the Indian Health Service and an academic medical center to address the high rates of unintentional drug overdose in American Indians/Alaska Natives. In January 2015, the Indian Health Service became the first federal agency to mandate training in pain and opioid substance use disorder for all prescribing clinicians. More than 1300 Indian Health Service clinicians were trained in 7 possible 5-hour courses specific to pain and addiction. We noted positive changes in pre- and postcourse knowledge, self-efficacy, and attitudes as well as thematic responses showing the trainings to be comprehensive, interactive, and convenient.

Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico’s 2012–2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.

Patients’ understanding of their terminal illness plays an important role in determining the medical care patients receive near the end of life (EOL). Advanced cancer patients who have more accurate illness understanding tend to receive less aggressive care and have better quality of life at the EOL.1-5 Although oncologist-patient communication and receive less aggressive care and have better quality of life at the EOL.1-5 Although oncologist-patient communication and shared decision-making are increasingly recognized as important influences on EOL care, many advanced cancer patients do not accurately understand the severity of their illness. It is common and understandable for patients to misinterpret or retain very little information about their illness at the time of initial diagnosis.6 Many patients are in a state of shock or made emotionally numb by discussion of a terminal prognosis,7 which may inhibit their ability to comprehend the gravity of their condition. We have reported that among cancer patients with incurable metastatic disease only 38% acknowledged being terminally ill a median of 4 months prior to death.5 Additionally, recent findings indicate that advanced cancer patients’ understanding of their disease improves little over time as death nears. In a longitudinal study, Craft et al found that when patients with advanced malignant disease were initially asked about the purpose of their treatment, only 47.3% correctly noted that their treatment was not intended to cure their disease whereas 52.7% either thought the intent of their treatment was to cure their disease or did not know what the goal of their treatment was.8 Twelve weeks later, patient understanding of treatment goals remained unchanged, with 47.9% of these patients recognizing that their treatment was not to cure their disease and 52.1% of these patients who either thought the goal of their treatment was to cure their disease or did not know what the goal of treatment was.8 In another more recent longitudinal investigation, Temel et al found that 32% of patients with newly diagnosed metastatic nonsmall-cell lung cancer believed their cancer to be curable and 69% incorrectly thought that the goal of their treatment was to get rid of all cancer.9 Over time, 25% of the surviving patients thought their cancer was curable and 57.9% incorrectly thought that the goal of their treatment was to get rid of all cancer. Evidently, many advanced cancer patients approaching death have misconceptions about the severity of their illness, which undermines their ability to make informed decisions regarding their EOL care. Gender plays a significant role in the way patients with advanced cancer communicate with their oncologists and how they desire to receive information about their disease. Female cancer patients are more likely to play an active role in decision making and desire more emotional support from their oncologists, whereas male cancer patients tend to play a passive role and desire more medical information from oncology providers.10-12 Gender also plays a significant role in the way advanced cancer patients’ family caregivers understand treatment intent. Female family caregivers of advanced cancer patients have a more accurate understanding of treatment intent than their male counterparts. Male family caregivers’ understanding of treatment intent does not change over time.13 Patient and family caregiver gender influences treatment goal awareness within patient-caregiver dyads.14 These studies suggest that gender may play a significant role in determining illness understanding among patients with advanced cancer. In the present study, we examine gender differences in advanced cancer patients’ understanding of their illness, as measured by their terminal illness acknowledgment, recognition that their illness is incurable, and knowledge of the advanced stage of their cancer. We assessed patients’ illness understanding in these terms before and after appointments, where oncology providers discuss restaging scan results with their patients. This allowed us to determine whether a gender difference exists in the evolution of advanced cancer patients’ illness understanding. We also examine gender differences in patients’ reports of discussing life expectancy with their oncologists; and whether and to what extent such differences explain gender differences in advanced cancer patients’ illness understanding.

Little is known about optimal palliative and end-of-life care for American Indians and Alaska Natives (AIs/ANs).We searched MEDLINE, the Cochrane library, EBSCOhost, (PsycINFO, CINAHL Complete), and the University of New Mexico (UNM) Health Sciences Library and Informatics Center Native Health Database for search terms related to palliative care and AIs/ANs as of December 1, 2015. We included English language, peer-reviewed articles describing palliative care projects, programs, or studies in AI/AN populations or communities. We excluded case series, opinion or reflection pieces, and dissertations and articles addressing Pacific Islanders.Our search strategy yielded 294 references, of which we included 10 publications. Study methods and outcome measures were heterogeneous, and many studies were small and/or subject to multiple biases. Common themes included the importance of culturally appropriate communication, multiple barriers to treatment, and less frequent use of advance directives than other populations.Heterogeneity of study types, population, and small sample sizes makes it hard to draw broad conclusions regarding the best way to care for AIs/ANs. More studies are needed to assess this important topic.

Recent end-of-life (EOL) care literature in non-Native American (NA) populations has demonstrated the benefits of EOL discussions. EOL discussions are associated with less aggressive care at EOL, better patient self-assessed quality of life, and less caregiver depression after the patient is deceased. There is no literature assessing these issues in NA populations. However, common myths that may affect care include: 1) NA patients will not discuss death and dying, 2) severely ill NA patients and families will not choose do not resuscitate (DNR) status, and 3) NA patients and families will not utilize hospice services if offered.Our study explored these issues utilizing a consultation database from the Palliative Care Consultation Service at University of New Mexico Hospital (UNMH). Statistical analyses were conducted using nonparametric Wilcoxon tests for continuous variables and Fisher's exact test for categorical variables.Study results demonstrate that health care providers can hold EOL care discussions with NA patients and NA patients' care preferences are affected by these discussions. The result do not support our hypothesis that there would be a lower rate of post-consult DNR status in NA patients (compared with non-NA). NA and non-NA patients and families participated in family meetings and their code status was affected to a similar degree. Furthermore, NA patients and their families choose hospice services at rates similar to non-NA patients seen by the palliative care consultation service.

Cancer communication near the end of life has a growing evidence base, and requires clinicians to draw on a distinct set of communication skills. Patients with advanced and incurable cancers are dealing with the emotional impact of a life-limiting illness, treatment decisions that are complex and frequently involve consideration of clinical trials, and the challenges of sustaining hope while also having realistic goals. In this review, the authors sought to provide a guide to important evidence about communication for patients with advanced cancer regarding communication at diagnosis, discussing prognosis, decision making about palliative anticancer therapy and phase 1 trials, advance care planning, transitions in focus from anticancer to palliative care, and preparing patients and families for dying and death.

Spirituality is a major domain of palliative medicine training. No data exist on how it is taught, nor is there a consensus about the content or methods of such education. We surveyed palliative medicine fellowship directors in the United States to learn how they teach spirituality, who does the teaching, and what they teach.A PubMed (www.pubmed.gov) search using the terms "spirituality" and "medical education" was completed. Thirty-two articles outlined spirituality education content and methods in medical schools and residency programs. From these articles, a survey on spirituality education in palliative medicine fellowship training was prepared, pilot-tested, revised, and then distributed by e-mail in June 2004 to the 48 U.S. palliative medicine fellowship directors listed on the American Board of Hospice and Palliative Medicine (AAHPM) website, but excluding the three fellowship programs represented by the authors. Follow-up requests were sent by email twice during the 6-week collection period. The Institutional Review Board at the Medical College of Wisconsin approved the study.Fourteen fellowship directors completed the survey (29% of all programs; 42% of those currently teaching fellows as indicated on the AAHPM website). All programs indicated they taught "spirituality"; 12 of 14 had separate programs for teaching spirituality and 2 of 14 reported they taught spirituality to their fellows but not as a distinct, separate program. All respondents taught the definitions of spirituality and religion, common spiritual issues faced by patients at end of life (which was not defined further), and the role of chaplains and clergy. Chaplains provided spirituality education in all of the responding programs, but other team members were frequently involved. The most common formats for education in the domains of knowledge and attitudes were small group discussion, lecture, and self-study. Small group discussion, supervision, and shadowing a chaplain or other professional were the most common methods used for skills. Faculty written or oral evaluations of fellows were the most common forms of evaluation, with little evidence of more robust assessment methods, such as structured role-play (none of the programs surveyed).Palliative medicine fellowship programs generally agree on the content of training on spirituality, but have not incorporated robust educational and evaluation methods to ensure that fellows have obtained the desired attitudes, knowledge, and skills to meet the Initial Voluntary Program Standards for Residency Education in Palliative Medicine of the American Board of Hospice and Palliative Medicine. Based on the survey data and results from the literature review, broad recommendations are made to enhance spirituality education.

Palliative medicine was recognized as a unique medical specialty in 2006. Since that time, the number of hospital-based palliative care services has increased dramatically. It is unclear how palliative care consultation services (PCCS) are utilized by surgical services. The purpose of this study was to examine utilization of PCCS by surgical services compared to medical services at the University of New Mexico.A database of palliative care consultations performed at University of New Mexico Hospital between 2009 and 2013 was queried to identify consultations requested by surgical vs. medical services. Demographic, clinical, and outcome variables were compared.A total of 521 consultations were analyzed: 441 (85%) consultations from medical and 80 (15%) consultations from surgical services. Surgical patients were older than medical patients and more likely to be in an intensive care unit (ICU) at the time of consultation. There was no difference between referring services in indication for palliative care consultation or time from hospital admission to consultation. Surgical patients were more likely to die in the hospital compared to medical patients. Among patients discharged from the hospital alive, there was no difference between the groups in discharge disposition. More patients in both groups had a change from full code to do-not-resuscitate (DNR) status following palliative care consultation.Referrals for palliative care consultations are much less common from surgical than medical services. Characteristics of surgical patients suggest that palliative care consultations are reserved for older patients, critically ill patients, and those more likely to be at end-of-life. Our findings suggest the possible need for increased palliative care consultations among less critically ill patients and/or those with an improved prospect of recovery.

Objectives:1. Explore the history and meaning of each participant’s own professional identity2. Reflect on how professional identity affects the ability to be present with the patient3. Create a space to playfully explore benefits and burdens of the professional persona for caregivers and patients4. Consider possible new ways of being present as professional caregivers which may be safe, authentic, and often joyful.Background: Health care is highly professionalised. Health professionals are perceived as powerful and prestigious, with great responsibility for patients’ well-being. Social expectations of health professionals are extremely pervasive. Professionalisation involves learning and negotiating one’s role, and becoming comfortable in the professional persona. To offer whole person care requires the professional caregiver to be simply and authentically present with the patient. Yet the professional persona can be a barrier to presence, often using behaviours that are distancing, disease-focused, and impersonal. Over time, working as a professional can deeply affect our experience of ourselves.Workshop process: This workshop offers an opportunity to explore the effects of professional identities on us as caregivers and as persons.Some topics that will be considered: How do we experience our professional identities? Benefits and burdens of the roles we have adopted? Do they sustain us or not? How do they help, and hinder, our ability to be present for patients? How do we want to proceed in future? Through interactive, creative exercises in a supportive environment, participants will investigate the professional identities they have crafted over time. Using meditation and writing exercises, participants will reflect on the self that offers whole person care to patients, and what is needed for this self to flourish. Participants will share insights and challenges to being present, as a professional, with patients.

ContextIn the last 3 decades, herpes simplex virus type 2 (HSV-2) infection seroprevalence and neonatal herpes have increased substantially. An effective vaccine for the prevention of genital herpes could help control this epidemic.ObjectiveTo evaluate the efficacy of a vaccine for prevention of HSV-2 infection.DesignTwo randomized, double-blind, placebo-controlled multicenter trials of a recombinant subunit vaccine containing 30 µg each of 2 major HSV-2 surface glycoproteins (gB2 and gD2) against which neutralizing antibodies are directed, administered at months 0, 1, and 6. Control subjects were given a citrate buffer vehicle. Participants were followed up for 1 year after the third immunization.Setting and ParticipantsWe enrolled 2393 persons from December 10, 1993, to April 4, 1995, who were HSV-2 and human immunodeficiency virus seronegative. One trial with 18 centers enrolled 531 HSV-2–seronegative partners of HSV-2–infected persons; the other, with 22 centers, enrolled 1862 persons attending sexually transmitted disease clinics. A total of 2268 (94.8%) met inclusion criteria and were included in the analysis with 1135 randomized to placebo and 2012 to vaccine.Main Outcome MeasureTime to acquisition of HSV-2 infection, defined by seroconversion or isolation of HSV-2 in culture during the study period by randomization group.ResultsTime-to-event curves indicated a 50% lower acquisition rate among vaccine vs placebo recipients during the initial 5 months of the trial; however, overall vaccine efficacy was 9% (95% confidence interval,−29% to 36%). Acquisition rates of HSV-2 were 4.6 and 4.2 per 100 patient-years in the placebo and vaccine recipients, respectively (P=.58). Follow-up of vaccine recipients acquiring HSV-2 infection showed vaccination had no significant influence on duration of clinical first genital HSV-2 episodes (vaccine, median of 7.1 days; placebo, 6.5 days; P>.10) or subsequent frequency of reactivation (median monthly recurrence rate with vaccine, 0.2; with placebo, 0.3; P>.10). The vaccine induced high levels of HSV-2–specific neutralizing antibodies in vaccinated persons who did and did not develop genital herpes.ConclusionsEfficient and sustained protection from sexual acquisition of HSV-2 infection will require more than high titers of specific neutralizing antibodies. Protection against sexually transmitted viruses involving exposure over a prolonged period will require a higher degree of vaccine efficacy than that achieved in this study.

6529 Background: Racial/ethnic minorities and patients who turn to religion to cope receive more aggressive EOL care. Beliefs underlying these associations are unknown. Methods: Coping with Cancer is an ongoing, multi-site, NCI-funded study examining factors influencing racial/ethnic EoL disparities. From 11/2010-10/2012, 133 advanced cancer patients underwent baseline interviews, including 7 items assessing religious beliefs about EoL care (RBEC). Univariate analyses assessed racial/ethnic differences in RBEC and EoL treatment preferences. Multivariable analyses (MVA) modeled mean RBEC score as a function of race/ethnicity, controlling for confounders, and assessed the relationship of race/ethnicity and RBEC to treatment preferences. Results: Religious beliefs about EoL care are common and more often held by racial/ethnic minorities (Table); racial/ethnic differences persisted in MVA (p

The 402AX murine teratocarcinoma is a spontaneous testicular tumor of 129 (H-2b) origin which does not express MHC encoded antigens. Rejection of this tumor is immunologically mediated and the tumor cells are induced in vivo to synthesize H-2b antigens when passaged in genetically resistant host mice. The present studies demonstrate that serum from tumor primed genetically resistant host mice can induce tumor cell MHC antigen expression in vitro as measured by indirect immunofluorescence using monoclonal antibodies. The inducing factor is specific for 402AX tumor cells and is not interferon as shown by the lack of response of the 402AX tumor to gamma interferon, and the absence of significant interferon activity in inducer serum. These studies demonstrate another factor independent of interferon that can induce MHC class I antigen expression on tumor cells.

Background End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal disease patients are referred to hospice. Furthermore, conversations between dialysis team members and patients about end-of-life planning are uncommon. Lack of provider training about how to communicate prognostic data may contribute to the limited number of end-of-life care discussions that take place with this chronically ill population. In this study, we will test the Shared Decision-Making Renal Supportive Care communication intervention to systematically elicit patient and caretaker preferences for end-of-life care so that care concordant with patients’ goals can be provided. Methods/design This multi-center study will deploy an intervention to improve end-of-life communication for hemodialysis patients who are at high risk of death in the ensuing six months. The intervention will be carried out as a prospective cohort with a retrospective cohort serving as the comparison group. Patients will be recruited from 16 dialysis units associated with two large academic centers in Springfield, Massachusetts and Albuquerque, New Mexico. Critical input from patient advisory boards, a stakeholder panel, and initial qualitative analysis of patient and caretaker experiences with advance care planning have informed the communication intervention. Rigorous communication training for hemodialysis social workers and providers will ensure that standardized study procedures are performed at each dialysis unit. Nephrologists and social workers will communicate prognosis and provide advance care planning in face-to-face encounters with patients and families using a social work-centered algorithm. Study outcomes including frequency and timing of hospice referrals, patient and caretaker satisfaction, quality of end-of-life discussions, and quality of death will be assessed over an 18 month period. Discussion The Shared Decision-Making Renal Supportive Care Communication intervention intends to improve discussions about prognosis and end-of-life care with end-stage renal disease patients. We anticipate that the intervention will help guide hemodialysis staff and providers to effectively participate in advance care planning for patients and caretakers to establish preferences and goals at the end of life. Trial registration NCT02405312