Explosive COVID-19 outbreak in a German nursing home and the possible role of the air ventilation system.

BACKGROUND: Most COVID-19 outbreaks in nursing homes are explained by transmission of SARS-CoV-2 from nurses or visitors. METHODS AND RESULTS: We describe an outbreak with 64 of the 67 residents identified as COVID-19 cases within two weeks (34 in nursing block 1, 30 in nursing block 2), at least 32 of them had relevant symptoms of COVID-19. Thirteen of the residents' deaths were associated with COVID-19. In addition, 27 of approximately 60 staff members were identified as COVID-19 cases, 23 of them had relevant symptoms. In none of the samples from residents or staff was a mutation of SARS-CoV-2 detected. Quarantine of the residents was already in force at the beginning of the outbreak. A common source among the staff was considered to be unlikely because the two nursing home blocks had no staff rotation and the staff had to wear FFP2 masks during contact with residents. Three months after the outbreak the RNA of SARS-CoV-2 was detected on 14 of 39 sampled indoor surfaces of the air ventilation system with Ct values between 34.9 and 41.9, but only at the air supply in the corridor (11 of 24 samples) and the air overflow in the door between the corridor and the residents' rooms (three of 11 samples) but not at the air exhaust in the residents' bathrooms. CONCLUSIONS: The air ventilation system and an inversion weather situation three days before the first confirmed case may have enhanced viral spread inside the nursing home assuming that a common source with a high viral load had existed at the time of outbreak.

Detection of chronic lung allograft dysfunction using ventilation-weighted Fourier decomposition MRI.

Chronic lung allograft dysfunction (CLAD) remains the leading cause of morbidity and mortality after lung transplantation. Diagnosis requires spirometric change, which becomes increasingly difficult with advancing CLAD. Fourier decomposition magnetic resonance imaging (FD-MRI) permits acquisition of ventilated-weighted images during free-breathing. This study evaluates FD-MRI in detecting CLAD in selected patients after bilateral lung transplantation (DLTx). DLTx recipients demonstrating CLAD at various stages participated. Radiologists remained blinded to clinical status until completion of image analysis. Image acquisition used a 1.5-T MR scanner using a spoiled gradient echo sequence. After FD processing and regional fractional ventilation (RFV) quantification, the volume defect percentage at 2 thresholds (VDP1,2 ), median lung RFV and quartile coefficient of dispersion (QCD) were calculated. Sixty-two patients participated. CLAD was present in 29/62 (47%) patients, of whom 17/62 (27%) had forced expiratory volume in 1 second ≤65% at image acquisition. VDP1 was higher among these participants compared to other groups (P < .001). Increased VDP1 was associated with subsequent graft loss, with values >2% showing reduced survival, independent of degree of graft dysfunction (P = .005). VDP2 discriminated between presence or absence of CLAD (area under the curve = 0.71; P = .03). QCD increased significantly with advancing disease (P < .001). In conclusion, FD-MRI-derived parameters demonstrate potential in quantitative CLAD diagnosis and assessment after DLTx.

Novel Insights into the Pathogenesis of Osteoarthritis.

Osteoarthritis represents the most frequently diagnosed condition of the musculoskeletal system and accounts for a high amount of direct and indirect socioeconomic costs worldwide. While for rheumatoid arthritis much progress has been made in the past decades both in understanding its pathogenesis and in creating novel therapies, the pathophysiology of osteoarthritis still holds several secrets to be unraveled in the near future in order to also allow for the development of effective novel pharmacotherapeutical options. Though first categorized as a joint disorder being primarily non-inflammatory in nature for a long period of time with research focused on biomechanic aspects and imbalanced wear and tear, recent evidence including immunological processes helped to refine disease interpretation. Thus, showing true inflammatory characteristics that clinically emerge as synovitis, osteoarthritis is nowadays recognized to include signs of inflammation that at least histologically may sometimes be indistinguishable from rheumatoid synovial infiltration. Although this was known already more than 25 years ago, efforts made in solving pathophysiologic key issues did not succeed sufficiently. This review is thought to summarize elementary pathogenic aspects including genetic predisposition and epigenetic regulation and highlights important central innate but also putative adaptive immunological mechanisms today generally accepted to drive inflammation and tissue destruction in osteoarthritis.

[Fibroblasts as pathogenic cells in rheumatic inflammation]. / Fibroblasten als pathogene Zellen in der rheumatischen Entzündung.

Rheumatoid arthritis (RA) is an autoimmune disease characterized by synovitis, synovial hyperplasia and progressive degeneration of affected joints. These processes are mediated by cells of the immune system as well as by synovial fibroblasts (RASF) originating from the lining layer of the synovium. In this scenario RASFs display an activated phenotype: they show an altered expression of adhesion molecules which allows attachment to articular cartilage and by synthesis of proteases they mediate progressive cartilage and bone destruction. Furthermore, they produce various cytokines and chemokines, which are essential for promoting the inflammatory response. In recent years it has become evident that RASFs not only passively respond to the proinflammatory milieu in the joints of RA patients but also actively contribute by the overproduction of several cytokines and chemokines. These proinflammatory cytokines trigger the transformation of RASFs into an aggressive and invasive phenotype. Additionally, the primarily altered genuine RASFs are actively involved in the recruitment and activation of immune cells. Taken together, they are key players in the development of the well-known chronic, destructive inflammatory response in joints affected by RA.

Bovine Tuberculosis and Brucellosis in Cattle and African Buffalo in the Limpopo National Park, Mozambique.

Bovine tuberculosis (BTB) and brucellosis are prevalent in buffaloes of the Kruger National Park (KNP, South Africa). Both diseases were considered to have no or a very low prevalence in wildlife and livestock in and around the Limpopo National Park (LNP, Mozambique). The same applies for tuberculosis in Gonarezhou National Park (GNP, Zimbabwe), but just recently, BTB was detected in buffaloes in the GNP and fears arose that the disease might also spread to the LNP as a result of the partial removal of the fences between the three parks to form the Great Limpopo Transfrontier Park. To assess the status of both diseases in and around LNP, 62 buffaloes were tested for bovine tuberculosis (BTB) and bovine brucellosis. The percentage of positive BTB reactors in buffalo was 8.06% using BovidTB Stat-Pak® and 0% with BOVIGAM® IFN-γ test and IDEXX ELISA. The brucellosis seroprevalence in buffalo was found to be 17.72% and 27.42% using Rose Bengal Test (RBT) and ELISA, respectively. In addition, 2445 cattle in and around the LNP were examined for BTB using the single intradermal cervical comparative tuberculin test (SICCT), and an apparent prevalence of 0.98% was found with no significant difference inside (0.5%) and outside (1.3%) the park. This is the first published report on the presence of positive reactors to BTB and bovine brucellosis in buffalo and cattle in and outside the LNP. Monitoring the wildlife-livestock-human interface of zoonotic high-impact diseases such as BTB and brucellosis is of outmost importance for the successful implementation and management of any transfrontier park that aims to improve the livelihoods of the local communities.

23- vs 20-gauge pars plana vitrectomy in combination with bimanual microincisional cataract surgery (b-MICS) for the treatment of macular hole and cataract as a one-step procedure.

BACKGROUND/AIMS: 23-gauge pars plana vitrectomy (ppv) is a new method for vitreo-retinal surgery. It may reduce operation time, the risk of complications, and patient discomfort, especially in combination with simultaneous bimanual microincisional cataract surgery (b-MICS). METHODS: Seventy-five consecutive patients who underwent combined cataract surgery and ppv at our center between 1 January 2008 and 31 December 2010 were included. The first 36 patients were treated with 20-gauge ppv, the following 39 patients with 23-gauge ppv. Study end points 8 weeks after surgery were duration of the procedure, improvement of visual acuity, and occurrence of complications. RESULTS: Duration of surgery was reduced in 23- vs 20-gauge ppv (54.0 ± 11.6 vs 61.0 ± 19.0 min, P=0.08). Visual acuity improved significantly in both the groups (20-gauge: logMAR 0.750 ± 0.304 before and 0.369 ± 0.273 after surgery; 23-gauge: logMAR 0.663 ± 0.340 before and 0.339 ± 0.273 after surgery). There were no appreciable group differences in baseline or post-treatment visual acuity. CONCLUSIONS: 23-gauge ppv in combination with b-MICS is a suitable, safe, and effective method for the treatment of combined cataract and vitreo-retinal diseases. The procedure is somewhat shorter and patient discomfort during and after surgery is improved. In terms of efficacy and safety, 23-gauge ppv is equivalent with conventional 20-gauge ppv.

[Methods of anesthesia in eye surgery]. / Anästhesieverfahren in der Augenheilkunde.

There are several methods for local and general anesthesia in ophthalmological surgery that attempt to provide a stress and pain-free operating environment for both patient and surgeon. The decision-making depends on medical as well as on ophthalmological criteria and jointly falls to ophthalmologists and anesthesiologists. Topical and injective anesthesia (with or without conscious sedation) are generally methods of choice but general anesthesia can be preferable or mandatory in patients with particular internal diseases, children, emergencies and for extended surgical procedures. Pre-emptive analgesia before the operation is a meaningful complement in ophthalmological anesthesia.

Bilateral Exudative Retinal Detachment in HELLP Syndrome.

The HELLP syndrome is a pregnancy complication, life-threatening for mother and child, characterized by hypertension, elevated liver enzymes and low platelets. Blurred vision is the most common visual complaint. A rare case of bilateral exudative retinal detachment associated with the HELLP syndrome is described in a 30-year-old Caucasian woman at 33 weeks' gestation. The retinal detachment did reattach with good improvement in vision under steroid therapy. The case highlights the importance of early involvement of the ophthalmologist when pregnant women complain about visual disorders.

[Different pathoanatomic circumstances in bony lumbar foraminal stenosis have no influence on surgical outcome]. / Unterschiedliche Pathologien bei einer knöchernen lumbalen Foramenstenose beeinflussen das Operationsergebnis nicht.

OBJECTIVES: The purpose of this prospective observational study was to evaluate the clinical efficacy of nerve decompression in bony foraminal stenosis in different pathoanatomical circumstances. MATERIAL AND METHODS: Thirty-three consecutive patients (mean age: 63 years) were evaluated. All had leg-dominant monoradicular pain and were treated via a midline approach (lateral foraminotomy, with caudal resection of the pedicle in selected cases). Thirteen patients (39 %) had undergone prior lumbar surgery. The patients were divided into four pathoanatomic groups: (A) facet joint hypertrophy, n = 16; (B) dorsolateral spondylosis, n = 7; (C) height reduction of intervertebral disc, n = 3; (D) mixed group, n = 7. The clinical outcome was graded using a modified Prolo scale (pain and medication) and a visual analogue scale (VAS) after 2 and 12 months. RESULTS: Based on the Prolo scale score, an excellent (n = 18) or good (n = 12) outcome was achieved in 91 % of the patients. There were no outcome differences among the four pathoanatomic groups. However, the groups B, C and D are small. Three patients in group B required revision surgery because of osteophytes in the transition area of the intra- and extraforaminal regions. All but one (97 %) of the patients experienced significant leg pain reduction following surgery as assessed by VAS (including the three revisions). No statistically significant associations were found between back pain, symptom duration, previous surgery, segment level, or pediculotomy and the outcome. There were no surgery-related complications. CONCLUSIONS: Foraminal decompression alone for leg-dominant symptoms is a clinically effective procedure in the majority of patients without differences in the four pathoanatomic groups.

[An in-vivo evaluation of Brilliant Blue G in macular surgery]. / Anfärbung der inneren Grenzmembran der Netzhaut mit Brilliant Blau.

OBJECTIVE: The aim of this study was to evaluate the functional outcome of Brilliant Blue G (BBG) and the staining properties in macular surgery. METHODS: BBG was applied during vitrectomy for macular holes (n = 21) or epiretinal membranes (n = 18) in a prospective, non-comparative consecutive series of patients (Brilliant Peel®; Fluoron® GmbH, Neu-Ulm, Germany). Before and after surgery all patients underwent a complete clinical examination including measurement of best corrected visual acuity and intraocular pressure, perimetry, fundus photography and optical coherence tomography. RESULTS: Vitrectomy was performed in combination with a cataract operation in 14 patients. All macular holes were closed successfully. Visual acuity was in average 0.16 preoperatively in macular hole cases and increased up to 0.4 after 6 months. Visual acuity of patients with epiretinal membranes changed on average from 0.3 to 0.45 after 6 months. The retina thickness in patients with epiretinal membranes was initially 402.6 µm according to the OCT and 304.7 µm after 6 months postoperatively. No toxic effects attributable to the dye were noted during patient follow-up, especially all perimetry tests were normal. CONCLUSIONS: Brilliant blue provides a sufficient and selective staining of the ILM. No retinal toxicity or adverse effects related to the dye were observed in this study. The long-term safety of this dye will have to be evaluated in larger patient series and a longer follow-up.

[Sports after surgical treatment of a herniated lumbar disc: a prospective observational study]. / Sport nach lumbaler Bandscheibenoperation: Eine prospektive Beobachtungsstudie.

AIM: Lumbar discectomy is the most frequent spinal surgical procedure in Germany. Surgeons vary widely in their preferences with regard to patients' return to sports after spinal surgery. The self-reported sporting activity before and after microdiscectomy was evaluated in a prospective observational study with 5 year follow-up. METHOD: One hundred and five patients (mean age 45.4 years) with self-reported sporting activity before lumbar single-level discectomy were re-evaluated after 5 years. The clinical outcome was graded using a modified Prolo scale (pain and medication). RESULTS: Based on the Prolo scale, an excellent (n = 80) or good (n = 17) outcome was achieved in 92.4% of patients. Altogether, 91.4% of patients (n = 96) resumed sporting activities: 87 patients returned to their previous sport. Only 8.6% of the patients (n = 9) were unable to return to sports, for various reasons (e.g., poor general health, lumbar pain, or lack of time). The mean time until return to sports after operation was 5.8 months (range 6 weeks to 24 months).The recurrence rate was 5.7% (n = 6), with 3 of the herniations occurring before the return to sporting activities (after 1, 2 and 7 months). CONCLUSIONS: The success rate of single-level microdiscectomy in athletes was frequently good or excellent, with over 90% of patients able to return to sports. The reherniation rate after postoperative athletic activity was comparable with results reported in the literature.

[Training program for vitreoretinal surgery in Nairobi, Kenya from 2000 - 2006]. / Trainingsprogramm zur vitreoretinalen Chirurgie in Nairobi, Kenia, in den Jahren 2000 - 2006.

BACKGROUND: After the U. S. Embassy bombing in 1998 in Nairobi, Kenya, a relief operation was immediately initiated by the Department of Ophthalmology of the Ludwig Maximilians University (LMU) Munich, Germany. Surgical devices and material (such as a vitrectomy unit, silicon oil, perfluorodecalin, intraocular lenses, sutures) were supplied to operate on 42 ocular-injured victims of this bombing attack. Apart from these specific operations in Kenya, there is a big need for vitreoretinal surgery in East Africa, as in all other developing countries. Therefore, a vitreoretinal training program was started in 2000 in Nairobi, Kenya. We report about the first 7 years of collaboration between the Ludwig Maximilians University of Munich, Germany and the University of Nairobi in cooperation with the Kenyatta National Hospital, Kenya. MATERIAL AND METHODS: The training program was based on an annual project week in which the author (CLS) carried out vitreoretinal surgery himself and assisted and supervised surgery done by the local Kenyan colleagues at the Kenyatta National Hospital. Within the observation period of the present work (2000 - 2006) the following data were collected: number and kind of surgery, indications, surgeons, grading of eye pathology and the surgical procedure, time to prepare for surgery and duration of surgery. RESULTS: In total, 293 vitreoretinal surgeries were performed during the observation period. Surgeries carried out by the local Kenyan colleagues independently, without intervention of the author, increased from 29.4 % (2000) to 78.6 % (2006). Due to a constant development in the learning process during the project week more severe cases were treated and preparation time for surgery from the nursing side has shortened. CONCLUSIONS: By initiating a project week with high frequency surgery, supported by a highly experienced visiting surgeon, vitreoretinal surgery can be successfully set up in an ophthalmic clinic of a developing country. This approach has some advantages when compared to long-period projects, especially for the purposes of sustainability. However, to be successful it requires systematic planning which is described in this article.

[Prevalence of psychiatric disorders, psychopathology, and the need for treatment in female and male prisoners]. / Prävalenz psychischer Störungen, Psychopathologie und Behandlungsbedarf bei weiblichen und männlichen Gefangenen.

BACKGROUND: While the international literature documents a high prevalence of psychiatric disorders in prisoners, German studies in this field are rare. The base of knowledge is even worse with regard to female prisoners. The purpose of this study was to investigate DSM-IV axis I and II psychiatric disorders and current psychopathology and to estimate treatment needs in prisoners. SAMPLE AND METHODS: On the 1st of May 2002, all female prisoners in Brackwede I Prison in Bielefeld, Germany, were included; and a sample of incarcerated men was matched according to age, nationality, and length of stay. Sixty-three women and 76 men participated. Criminal history and current living conditions were investigated using a questionnaire and prison documents. Psychopathology and psychiatric disorders were investigated using structured clinical interviews. RESULTS: In 88.2% of the sample, at least one current axis I (83.5%) and/or axis II personality disorder (53.2%) was found. Comorbidity rates were high, with 3.5+/-2.7 diagnoses per case. Mean SCL scores revealed a substantial psychopathologic burden. In female prisoners, opiate-related and polysubstance use disorders and affective and post-traumatic stress disorders were more frequent than in the male subsample, which in turn showed higher rates of alcohol-related disorders. Specific treatment needs were indicated in 83.4% of the sample. CONCLUSION: These results indicate that the proportion of mentally ill persons in prisons is substantially higher than in specialized hospitals for mentally ill criminals. More treatment options are urgently needed than has been realized up to now.

[Relationship between lens power in refraction]. / Linsenbrechkraft bei unterschiedlicher Refraktion.

BACKGROUND: To achieve emmetropia, several components such as the cornea and lens power, and axial length have to be coordinated. Until now, not much is known about the influence of these factors on each other. METHODS: A total of 66 healthy subjects were enrolled in this study. Ocular dimensions including anterior chamber depth, lens thickness, vitreous chamber depth, and axial length were measured by A-scan ultrasonography. Corneal radius and corneal refractive power were determined by ophthalmometry. The equivalent lens power was calculated by a method based on the Gullstrand schematic eye. RESULTS: As expected, a good correlation was found to exist between refraction and axial length. Lens power was independent of refraction, but in emmetropic eyes a good correlation between lens power and axial length could be found. Higher axial length was related to lower values of lens power and vice versa. CONCLUSION: In emmetropic eyes, deviation of axial length seems to be compensated by lens power and if this mechanism does not function, ametropia results.

Vitreoretinal surgery: pre-emptive analgesia.

AIM: Vitrectomies are performed either under general anesthesia (GA), local anesthesia (LA), or a combination of both. Postoperative pain is expected to be less in patients with LA because of prolonged action of the local anaesthetic. Pre-emptive analgesia is based on the idea that analgesia initiated before a nociceptive event will be more effective than analgesia commenced afterwards. The authors compared postoperative analgesia in patients with GA combined with preoperative or postoperative LA. METHODS: 90 patients scheduled for vitrectomy without buckling were enrolled in the study. 60 patients underwent GA, 30 without LA, 15 with preoperative LA, and 15 with postoperative LA. 30 patients received LA alone. Subjective postoperative pain was determined using the visual analogue scale. RESULTS: Postoperative pain was less under LA alone compared to GA alone (p < 0.0001). Additional preoperative application of LA resulted in less pain than additional postoperative application (p <0.05). Additional postoperative peribulbar aneasthesia did not differ from GA alone. CONCLUSION: The authors conclude that LA alone or preoperatively in addition to GA provides the best comfort for the patient in vitreoretinal surgery.