How to Respond to a Ransomware Attack? One Radiation Oncology Department's Response to a Cyber-Attack on Their Record and Verify System

The digitization of healthcare for patient safety and efficiency introduced third party networks into closed hospital systems increasing the probability of cyberattacks and their consequences(1). In April 2021, a major vendor of a Radiation Oncology (RO) record and verify system (RVS) suffered a ransomware attack, affecting our department and many others across the United States. This article summarizes our response to the ransomware event including workflows, team member roles, responsibilities, communications and departmental recovery. The RVS created or housed accurate patient dose records for 6 locations. The immediate response to the ransomware attack was to shut down the system including the ability to treat patients. With the utilization of the hospital EMR and pre-existing interfaces with RVS, the department was able to safely continue patient radiotherapy treatments innovatively utilizing a direct Digital Imaging and Communications in Medicine (DICOM) transfer of patient data to the linear accelerators and implementing paper charting. No patients were treated in the first 24 hours of the attack. Within 48 hours of the ransomware event, 50% of patients were treated, and within 1 week, 95% of all patients were treated using direct DICOM transfer and paper charts. The RVS was completely unavailable for 2.5 weeks and full functionality was not restored for 4.5 weeks. A phased approach was adopted for re-introduction of patient treatments back into the RVS. Human capital costs included communication, outreach, workflow creation, quality assurance and extended clinical hours. Key lessons learned were to have a back-up of essential information, employ 'dry run' emergency training, having consistent parameter requirements across different vendor hardware and software, and having a plan for the recovery effort of restoring normal operations once software is operational. The provided report presents valuable information for the development of cyber-attack preparedness for RO departments.

Graduated Compression Stockings in the Prevention of Postoperative Deep Vein Thrombosis: A Comparative Study of Pressure Profiles and Patient Compliance

Graded support stockings are widely used in the prophylaxis of postoperative deep vein thrombosis (DVT). For many years (following the results of early trials) one brand has dominated the market. We now describe an assessment of an alternative brand.

Fifty patients undergoing major abdominal surgery were provided with graduated support stockings postoperatively for the prophylaxis of DVT. Two different makes of stockings were used, one on each leg; the leg randomly determined by an odd or even year of birth. Data was collected from each patient in order to determine patient compliance. Patients experienced no significant difference in comfort between the two makes, although, on balance, product ‘A’ was found to be more comfortable. No pressure sores were caused by either stocking type and there was no clinical evidence of DVT in any of the 50 patients. However, there were two cases of pulmonary embolus.

Samples of both stockings were tested in a materials testing laboratory, to determine the pressure gradients which they could be expected to apply in normal use, and the results of these tests suggest that there are major differences in the performance of the products concerned.

Peritoneal T lymphocyte regulation by macrophages

The T cell composition of the peritoneal cavity (PerC) in naïve BALB/c, C57BL/6, DBA/2J, and B-1 B cell-defective BALB.xid mice was investigated. The BALB.xid PerC T cell pool had a high CD4:CD8 T cell ratio relative to the other strains whose ratios were similar to those found in their lymph node and spleen. All mice had significant representation of T cells with an activated (CD25(+), GITR(hi), CD44(hi), CD45RB(lo), CD62L(lo)) phenotype and low numbers of Foxp3(+) T(reg) cells in their PerC. Despite a phenotype indicative of activation, peritoneal T cell responses to CD3 ligation were very low for C57BL/6 and BALB.xid, but not BALB/c, mice. Enzyme inhibition and cytokine neutralization studies revealed active suppression of the T cell response mediated by the macrophages that represent a significant portion of PerC leucocytes. Driven by IFNγ to express iNOS, macrophages suppressed T cell activation in vitro by arginine catabolism. Although BALB/c T cells were also in a macrophage-dense environment their limited IFNγ production failed to trigger suppression. This difference between BALB/c and BALB.xid PerC T cells suggests a role for xid in shaping macrophage-mediated immune regulation.

Peritoneal macrophages suppress T-cell activation by amino acid catabolism

T-lymphocyte activation triggered by anti-CD3, endogenous or exogenous superantigen, and mitogens was suppressed in a cell-dose-dependent fashion by peritoneal cavity (PerC) leucocytes. Study of lymphocyte-deficient mice and the use of multiparameter fluorescence-activated cell sorter analyses revealed that macrophages were responsible for this form of immune regulation. Interferon-gamma was essential to trigger suppression, which, by enzyme inhibition studies, was shown to be the result of tryptophan and arginine catabolism. These results illustrate that macrophages, which are classically defined by their innate effector function as antigen-presenting cells, have the potential to temper adaptive immunity.

X-chromosome-linked immune-deficient mice have B-1b cells

The B lymphocyte subsets of X-chromosome-linked immune-deficient (XID) mice were examined by flow cytometric analyses of spleen and peritoneal cells. As shown in prior studies, young adult XID mice had reduced representation of the CD5+ (B-1a) subset in their peritoneal cavity. However, the CD11b+ (B-1b) B-cell subset was present and exhibited the IgM(hi) CD45(lo) CD23- phenotype characteristic of most B-1 cells. Although present at a lower frequency than that found in their normal counterparts, B-1b cells were evident in CBA/N and (XD2J)F1 male mice. With increasing age, B-1b cell number increased and in the oldest XID mice were present as B-cell chronic lymphocytic leukaemia. These results show that XID mice do have B-1 cells, particularly the B-1b subset.

Superantigen disruption of CD8+ T and B lymphocyte homeostasis

Superantigens (SAgs) activate TH cells and induce their differentiation into cytokine-producing effector cells. Supranormal cytokine production is characteristic of SAg-induced polyclonal TH activation. Study of this interaction has focused upon TH cell function to the relative exclusion of other lymphocyte populations. SAgs also impact cells dependent upon TH cells for their differentiation and disrupt the normal homeostasis of the immune system. In this report, several changes in lymphocyte biology that result from SAg activation of TH cells are described. SCID mice, reconstituted with the SAg-expressing cells of DBA/2J mice, were employed as secondary recipients of SAg-reactive TH cells. Significant increases in serum IgM and IgG2a production were noted after the transfer of SAg-reactive It cells. Both B and CD8 T lymphocyte numbers increased with those of CD8 T cells surpassing levels found in normal mice. These results illustrate the ability of the TH-SAg interaction to disrupt B and CD8+ T lymphocyte homeostasis.

Chlorhexidine lavage in the treatment of experimental intra-abdominal infection

HYPOTHESIS

Closed postoperative peritoneal lavage (CPPL) with chlorhexidine gluconate reduces the number of intraperitoneal bacteria and improves the outcome of intra-abdominal infection.

DESIGN

Laboratory animal trial.

INTERVENTIONS

Intra-abdominal infection was produced in mice by the cecal ligation and puncture technique. After 16 to 18 hours, the animals underwent relaparotomy and placement of an intra-abdominal catheter for CPPL. In the first experiment animals were randomly divided into 4 groups: no lavage (served as a control), CPPL with chlorhexidine. CPPL with cefoxitin, and CPPL with lactated Ringer solution (LR). Lavage was continued intermittently every 8 hours for 24 hours. All animals received systemic cefoxitin every 8 hours for 7 days. Mortality was recorded every 8 hours for 10 days. In the second experiment, animals were divided into 3 groups: no lavage (served as a control), CPPL with chlorhexidine, and CPPL with LR. Lavage was continued intermittently every 8 hours for 24 hours. The animals were killed 48 hours after reoperation. Bacterial counts from peritoneal fluid and biopsy specimens, as well as peritoneal white blood cell counts, were measured before and after lavage.

RESULTS

Closed postoperative peritoncal lavage with chlorhexidine reduced mortality from 71% in a control group to 37% (P = .003). There was no survival benefit in either the CPPL with cefoxitin (91% mortality) (P = .14) or CPPL with LR groups (90% mortality) (P = .17). The statistically significant findings of analysis of variance evaluation demonstrated a decrease in bacterial counts after cecal excision in all 3 groups. There was a greater reduction in bacterial counts in the chlorhexidine group compared with the control group (P<.05). Bacterial counts decreased in peritoneal fluid, as well as in tissue biopsy specimens, after cecal excision. White blood cell counts significantly decreased after cecal excision in all 3 groups. There was no difference in white blood cell counts between the groups. Correlation analyses demonstrated weak interaction between bacterial and white blood cell counts before or after treatment in all the groups. Pearson r ranged from -0.37 to +0.35, none of which were statistically significant.

CONCLUSIONS

In our experiments chlorhexidine lavage resulted in a 50% reduction in mortality and a significant reduction in bacterial counts compared with the control group. There was no survival benefit from lavage with either cefoxitin or LR. There was no reduction in bacterial counts in the LR group relative to the control group. Thus, the survival benefit and the reduction in bacterial numbers are attributed to the antibacterial properties of chlorhexidine rather than to the mechanical washing of the abdominal cavity. Closed postoperative peritoneal lavage with 0.05% chlorhexidine gluconate might be useful in the multimodal treatment of intra-abdominal infection.

DBA/2J (Mls-1a) B-cell differentiation in BALB.xid recipients

Studies of superantigens (SAg) have focused primarily on their impact on CD4+ T cells, largely bypassing the impact of the sequelae of this interaction upon the antigen-presenting cell (APC). Sequelae of SAg-induced CD4+ T-cell activation include the 'bathing' of the SAg-presenting cell with cytokines that promote the differentiation of the APC. In this report, the SAg-induced differentiation of Mls+ DBA/2J B cells was studied in vivo by their transplantation into B-cell-defective BALB.xid recipients. Rapid, high-level serum immunoglobulin M (IgM) production was noted shortly after transfer, disappearing by 3 weeks. Donor B cells, as evidenced after their chemical and genetic impairment and by the use of an IgM allotype-disparate donor-recipient combination, contributed to this transient IgM production. These results clarify a discrepancy in the literature regarding donor B-cell contribution to IgM production and illustrate a model system to utilize SAg to study B-lymphocyte diversity.

Increased serum IgG1 levels and reduced numbers of B-1 B cells in DBA/2J mice

B-cell heterogeneity studies have historically focused upon BALB/c mice and their derivatives. In contrast, the B cells of DBA/2J mice, a prototype strain for the study of the endogenous minor lymphocyte stimulatory (Mls) viral superantigen Mls-1a, have not been extensively investigated. DBA/2J B cells, by functioning as Mls-1a antigen-presenting cells, influence their own differentiation and diversity by inducing the proliferation and differentiation of specific CD4 T-cell subsets. In this report, the B cells of DBA/2J and BALB/c mice were compared for their ability to restore B-cell function in severe combined immunodeficient (SCID) recipients. Although spleen and bone marrow cells from these strains exhibited similar restoration of serum IgM production, the transfer of DBA/2J B cells into SCID mice led to greater IgG1 production. The peritoneal cells of DBA/2J mice consisted of a lower percentage of B-1 B cells and were less capable of restoring B-cell function after transfer into SCID recipients. These differences are discussed with respect to the possible role of viral superantigens in influencing B-lymphocyte diversity.

Declines in patient volume: an obstetrics and gynecology teaching program's response

Historically, University teaching hospitals have been the primary providers of health care to the indigent population. With the advent of managed health-care plans, the university hospitals have seen a rapid decline in their obstetrical patient populations. This decrease is reflected in the numbers of deliveries and gynecological surgeries. From 1990 to 1995, these changes resulted in a significant decline in deliveries at our hospital, the Lyndon B. Johnson General Hospital. To reverse this ominous trend, we instituted a variety of changes resulting in a more patient-centered system and found an improvement in the numbers of obstetrical patients. In the following report, we describe these changes and the subsequent outcome.

Recipient age determines the success of intraperitoneal transplantation of peritoneal cavity B cells

In vivo studies of lymphocyte biology have used intravenous (i.v.) injection as the primary mode of cell transfer, a protocol consistent with the anatomic distribution of most lymphocytes. However, for study of peritoneal cavity B cells, i.v. injection does not correlate with anatomical localization. This report describes the restoration of B-cell function in B lymphocyte-defective X-chromosome-linked immune-defective (XID) mice after intraperitoneal transfer of immunoglobulin heavy chain (Igh)-disparate peritoneal cavity (PerC) cells. In contrast to i.v. transfer, intraperitoneal (i.p.) transfer restored B-cell function in young, but not adult (> 8 weeks), XID mice. When host and donor Igh allotype matched, PerC B-cell engraftment was noted in older recipients; this reconstitution however, was also age-dependent. Migration from the peritoneum to systemic circulation was necessary for serum IgM production as shown by the presence of donor antibody-secreting cells in the host spleen. Host lymphocytes also influenced the success of i.p. transplantation as severe combined immune-deficient mice, regardless of age, exhibited donor serum IgM production. Recipient age, Igh allotype, and immune-deficiency were found to have an impact on the ability of i.p.-transferred PerC B cells to restore B-cell function in XID mice.

Ability of spleen, peritoneal cavity, and lymph node B cells to reconstitute serum immunoglobulin in SCID mice

The impact of intrinsic B lymphocyte heterogeneity and of microenvironmental influences on serum immunoglobulin production by B cells was examined by intravenous (i.v.) and intraperitoneal (i.p.) transfer of BALB/c and BALB.xid (X-chromosome-linked immunedefective; XID) lymph node (LN), splenic (SP) and peritoneal cavity (PerC) cells into severe-combined immune-defective (SCID) mice. The results indicate that each B-cell source restores all immunoglobulin classes within 5 weeks of transfer, the rates for each isotype, however, differ between the B-cell sources. Serum IgM levels were restored most rapidly by PerC cell transfer, followed by SP and LN cell transfer. In addition, normal immunoglobulin levels were reached in the absence of complete lymphoid reconstitution. Serum immunoglobulin phenotypes characteristic of the donor strain, e.g. reduced IgM and IgG3 production by XID B cells, were maintained after transfer into the SCID recipient. Microenvironmental influences were indicated by reduced immunoglobulin production after i.p. transfer and after i.v. transfer into irradiated SCID recipients. The data show that both B-cell type and microenvironment play significant roles in generating the heterogeneous pool of B cells required for humoral immunity.

Rapid restoration of B-cell function in XID mice by intravenous transfer of peritoneal cavity B cells

The primary method employed to correct immune deficiency is bone marrow transfer. Depending upon the exact nature of the immune deficiency, however, alternative cell sources may be used to provide a more rapid reconstitution of immune function. In this report, peritoneal cavity (PerC) B cells are shown to be effective in the rapid emendation of the B-cell defect exhibited by XID mice. Restoration of normal numbers of splenic IgM antibody-secreting cells (ASC) and serum IgM levels were observed 4 and 7 days, respectively, after the i.v. transfer of 3 x 10(6) PerC. This regimen also restored responsiveness to thymus-independent type 2 (TI-2) antigens in XID recipients. Transfer of 30 x 10(6) spleen (SP) cells restored these functions in XID recipients but at a considerably slower rate. The data indicate that introducing a small number of PerC B cells into systemic circulation results in the rapid restoration of serum IgM levels in unirradiated XID mice.

Age and gender differences in beliefs about personal power and injustice

College students and community-dwelling older adults were compared on Injustice and Personal Power scales and measures of religiosity. "Personal Power" scores varied significantly as a function of age and gender. These differences were attributable to a significantly lower belief in "Personal Power" for the group of older women. As predicted, "Injustice" scores were significantly higher for women than for men, reflecting a greater belief that conditions can be unjust. No significant difference between older and younger adults on "Injustice" scores was obtained. Significant positive correlations between measures of religiosity and "Injustice" scores were obtained, while religiosity was not significantly correlated with "Personal Power." This pattern of results suggests that there is value in utilizing separate measures of "Injustice" and "Personal Power" scores. Suggestions are made for examining further the complex relationship among demographic variables, belief in a just world, and measures of religiosity.

Sexual practices and risk of infection by the human immunodeficiency virus. The San Francisco Men's Health Study

The San Francisco Men's Health Study is a prospective study of the epidemiology and natural history of the acquired immunodeficiency syndrome in a cohort of 1034 single men, 25 to 54 years of age, recruited by multistage probability sampling. At entry, June 1984 through January 1985, the seropositivity rate for human immunodeficiency virus (HIV) infection among homosexual/bisexual study participants was 48.5%. No heterosexual participants were HIV seropositive. Among homosexual/bisexual men reporting no male sexual partners in the two years before entry into the study, seropositivity was 17.6%. For those reporting more than 50 partners, seropositivity was 70.8%. Only receptive anal/genital contact had a significantly elevated risk of HIV infection. Douching was the only ancillary sexual practice that contributed significantly to risk of infection.

Fibronectin production by human mammary cells

Human mammary cells were examined for the presence of the high-molecular-weight surface glycoprotein fibronectin. Early passage mammary epithelial cell and fibroblast cultures from both carcinomas and normal tissues were tested for the presence of cell-associated fibronectin by immunofluorescence microscopy and for the synthesis and secretion of fibronectin by specific immunoprecipitation of metabolically labeled protein. In vivo frozen sections of primary carcinomas and normal tissues were tested for the localization of fibronectin by immunofluorescence microscopy. In contrast to the extensive fibrillar networks of fibronectin found in the fibroblast cultures, the epithelial cell cultures from both tissue sources displayed a pattern of cell-associated fibronectin characterized by powdery, punctate staining. However, the cultured epithelial cells, as well as the fibroblasts, secreted large quantities of fibronectin into the medium. Putative myoepithelial cells also displayed extensive fibrillar networks of fibronectin. The difference in cell-associated fibronectin distribution between the epithelial cells and the fibroblasts and putative myoepithelial cells provided a simple means of quantitating stromal and myoepithelial cell contamination of the mammary epithelial cells in culture. In vivo, normal tissues showed fibronectin primarily localized in the basement membrane surrounding the epithelial cells and in the stroma. Most primary carcinomas displayed powdery, punctate staining on the epithelial cells in addition to the fibronectin present in the surrounding stroma.

Studies on morphological transformation of BALB/3T3-derived clones by murine leukemia virus

We have described a cell line, UC1-B, derived spontaneously from BALB/3T3 mouse embryo cells, which, unlike the standard BALB/3T3, are morphologically transformed and produce bizarre viral forms in response to murine leukemia virus. Although UC1-B and BALB/3T3 are morphologically similar, and both form contact-inhibited monolayers at confluence, the UC1-B cells are partially transformed because: they grow to a slightly higher saturation density than 3T3 cells, they grow in medium lacking serum growth factors, and they produce tumors in mice. Another clone, 12A-3, derived from BALB/3T3, also transforms and produces bizarre viral forms after infection with murine leukemia virus. Unlike UC1-B cells, the 12A3-8 cells are identical in growth properties to BALB/3T3; therefore, a partially altered morphology is not required for the induction of transformation by murine leukemia virus.