Assessment of minor health disorders with decision tree-based triage in community pharmacies.

BACKGROUND: Triaging in community pharmacies can lower the burden of minor health disorders on other primary health care settings. The netCare service, introduced in 2012 by the Swiss association of pharmacists, provides community pharmacists with 27 decision trees for the triage of minor health disorders. OBJECTIVES: (1) to describe the utilization and symptom resolving rate of decision trees in community pharmacies; (2) to identify the need for additional decision trees. METHODS: A descriptive, explorative analysis was conducted of netCare consultations between January 2019 and March 2020, as documented in phS-net, a service platform for public pharmacies. Client characteristics, weekdays, recommended course of action, availability of a general practitioner, and hypothetical course of action if netCare would not have been available were investigated. Follow-up information was assessed for resolution of symptoms and prevention of needing additional services. Data from consultations with empty assessment forms were used to identify minor health disorders in need of an additional decision tree. RESULTS: Information on 4256 performed netCare consultations were identified over a 14-month observation period, resulting in an average of 284 decision tree consultations per month in Switzerland. Customers were mainly female (n = 3253, 76.4%) with a mean age of 40.7 years (±18.5 years). Cystitis (39.5%), conjunctivitis (19.5%), and pharyngitis (10.9%) were the primary reasons for consultation. Minor health disorders were managed by pharmacists themselves (88.2%) and achieved a resolution rate of 84.7%. Eyelid inflammations were identified as in need for an additional decision tree. CONCLUSION: Pharmacist-led structured triaging services in Switzerland led to an 84.7% resolution rate of minor health disorders, thereby identifying the potential for pharmacists to minimize the demand on other primary health care providers.

Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis.

We aimed to assess the impact of timing of surgery in elderly patients with acute hip fracture on morbidity and mortality. We systematically searched MEDLINE, the Cochrane Library, Embase, PubMed, and trial registries from 01/1997 to 05/2017, as well as reference lists of relevant reviews, archives of orthopaedic conferences, and contacted experts. Eligible studies had to be randomised controlled trials (RCTs) or prospective cohort studies, including patients 60 years or older with acute hip fracture. Two authors independently assessed study eligibility, abstracted data, and critically appraised study quality. We conducted meta-analyses using the generic inverse variance model. We included 28 prospective observational studies reporting data of 31,242 patients. Patients operated on within 48 hours had a 20% lower risk of dying within 12 months (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.66-0.97). No statistical significant different mortality risk was observed when comparing patients operated on within or after 24 hours (RR 0.82, 95% CI 0.67-1.01). Adjusted data demonstrated fewer complications (8% vs. 17%) in patients who had early surgery, and increasing risk for pressure ulcers with increased time of delay in another study. Early hip surgery within 48 hours was associated with lower mortality risk and fewer perioperative complications.

Immediate versus delayed surgery for hip fractures in the elderly patients: a protocol for a systematic review and meta-analysis.

BACKGROUND: Hip fractures are a major public health problem in elderly populations and are accompanied by high-mortality rates. Whether timing of surgery has an impact on morbidity and mortality has been discussed controversially, numerous studies suggest that the delay of surgery can significantly increase the risk of morbidity and mortality; others report that achieving a stable medical condition is more important than early surgery. The goal of our systematic review is to assess the impact of timing of surgery on health outcomes in patients aged 60 years or older with acute hip fracture. In addition, we will investigate differences in beneficial or harmful effects of timing of surgery in subgroups of patients based on demographic characteristics, physical status, and the use of anticoagulant medications. METHODS: We will systematically search MEDLINE via Ovid, the Cochrane Library, Embase, PubMed, and clinical trial registries (from 1997 to 2017). In addition, we will search reference lists of pertinent reviews, archives of annual meetings of orthopaedic societies, and contact experts. We will include randomized controlled trials and non-randomized studies assessing the impact of timing of surgery after hip fracture in patients 60 years or older, published in English or German. Our outcomes of interest include health outcomes such as mortality, perioperative complications, functional capacity, and quality of life. We plan to perform meta-analyses if we have at least three sufficiently similar studies. If data are sufficient, we will conduct subgroup-analyses testing for differences between age groups, sex, patients' physical status as assessed with ASA (American Society of Anesthesiologists) scores, and the use of anticoagulation. DISCUSSION: Since this is the first systematic review on this topic since 2010, our findings will help to inform clinical practice guidelines concerning timing of surgery in hip fractures. Furthermore, our findings could contribute to define an optimal time period for surgery for different groups of patients with acute hip fracture. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2017 CRD42017058216.

Correlation between humoral and cellular immune responses and the expression of the hepatitis A receptor HAVcr-1 on T cells after hepatitis A re-vaccination in high and low-responder vaccinees.

INTRODUCTION: We recently published a study on the persistence of seroprotection 10 years after primary hepatitis A vaccination in an unselected study population of 1014 vaccinees. The majority of these vaccinees still exhibited sufficient protective antibody levels, while 2% displayed antibody concentrations below detection level. In order to investigate whether the low antibody levels were due to decline after primary vaccination or due to an intrinsic inability to sufficiently respond to hepatitis A antigen, we sought to recruit these low/no responder vaccinees to characterize their immune responses in more detail after booster vaccination in comparison to high responder vaccinees. MATERIALS AND METHODS: Prior to and one week after booster vaccination with a hepatitis A vaccine, antibody levels, cytokine levels (IL-2, IFN-gamma and IL-10) and CD surface marker expression on peripheral blood mononuclear cells were determined in a study population comprised of 52 individuals. Additionally, the hepatitis A HAV cellular receptor 1 (HAVcr-1) TIM-1, being also expressed on CD4+ T cells and associated with immunomodulatory properties, was measured by RT-PCR before and after hepatitis A booster. RESULTS: Our data indicate that there is indeed a small group of hepatitis A vaccinees that can be classified as low/no responders as their antibody levels remain below the seroprotection level of 20mIU/ml after booster vaccination. We further describe a good correlation between antibody concentrations and cellular responses, showing that low antibody production is associated with low antigen specific cytokine levels (IL-2, IFN-gamma, IL-10) and vice versa. While there was no significant difference in the expression of the most common surface markers on T and B cells before and after booster vaccination in low and high responder vaccinees, the expression of HAVcr-1 on CD4 T cells correlated significantly with the antibody responses and cytokine levels, suggesting this receptor as cellular prediction marker of immune responsiveness to hepatitis A. CONCLUSION: Whether hepatitis A low/non-responders deserve particular attention as a risk group or might display certain resistance to hepatitis A infection due to a lack of the hepatitis A receptor needs further investigations. At this stage we suggest that persons at high exposure risk should be carefully observed.

Persistence of seroprotection 10 years after primary hepatitis A vaccination in an unselected study population.

Hepatitis A vaccines have been demonstrated to be highly immunogenic. Mathematical models have predicted antibodies to persist for at least 20-25 years. Most of these studies have been conducted in young and healthy study populations. We aimed to evaluate long-term immunity 10 years following complete primary immunization according to a 3-dose schedule (Havrix 720 El.U at months 0, 1, 6-12) in an adult and unselected study population. In total, 999 (98.3%) of 1016 vaccinees (mean age 54.7+/-S.D. 13.0), tested 10 years after primary vaccination, still had protective antibody levels (> or = 10 mIU/ml) as measured by ELISA. An anti-HAV titer cut off level of 11,400 mIU/ml was calculated to differentiate between vaccine-induced and infection-induced titer levels. The vaccine-induced geometric mean titer (GMT) was 406.1 mIU/ml (95% CI: 369.2-446.7 mIU/ml), showing an age-related trend, the 10-years seroprotection rate (SPR) was 97.9%. Females exhibited significantly higher GMTs than male vaccinees (p<0.001). The only parameter predicting a titer below 10 mIU/ml 10 years after vaccination was the body mass index (p=0.001). This study confirms that protection following primary hepatitis A vaccination persists for more than 10 years.

Intranasal tolerance induction with polypeptides derived from 3 noncross-reactive major aeroallergens prevents allergic polysensitization in mice.

BACKGROUND: Specific immunotherapy is less effective in patients with multiple allergic sensitizations compared with monosensitized patients. OBJECTIVE: We therefore established a mouse model of polysensitization to the major birch and timothy grass pollen allergens to test whether allergic polysensitization can be prevented by multiple allergen application via the mucosal route. METHODS: Female BALB/c mice were immunized intraperitoneally with recombinant (r) Bet v 1, rPhl p 1, and rPhl p 5. For intranasal tolerance induction, a mixture of the complete allergens was compared with allergen-derived immunodominant peptides applied either as a mixture or as a synthetic hybrid peptide composed of the T-cell epitopes of the 3 allergens. RESULTS: Intranasal application of the mixture of the complete allergen molecules did not prevent polysensitization to the same allergens. In contrast, pretreatment with a mixture of the immunodominant peptides or the hybrid peptide led to significantly reduced allergen-specific IgE responses in sera, IL-4 production in vitro, and suppressed airway inflammation. TGF-beta mRNA levels did not change, and IL-10 production was significantly suppressed after the pretreatment. The fact that the reduction of IL-10 was not abrogated after IL-10 receptor neutralization and that tolerance was not transferable with splenocytes indicates that the suppression of T(H)2 responses in polysensitized mice might not be mediated by immunosuppressive cytokines. CONCLUSION: Our study demonstrates that it is possible to suppress allergic immune responses simultaneously to several clinical important allergens. Thus, mucosal coapplication of selected peptides/hybrid peptides could be the basis of a mucosal polyvalent vaccine to prevent multiple sensitivities in atopic patients.

Allergen-specific immunosuppression by mucosal treatment with recombinant Ves v 5, a major allergen of Vespula vulgaris venom, in a murine model of wasp venom allergy.

Up to 5% of the population suffer from systemic, 19% from local allergic hypersensitivity reactions to stinging insects. Even though specific immunotherapy is very effective in treating allergy to insect venom, new concepts of treatment strategies with only the disease eliciting allergen in recombinant form, along with antigen application via a less invasive route might be suggested for enhanced treatment efficacy and compliance. In the present study we aimed (i) to establish a mouse model of wasp venom allergy, mimicking the natural mode of sensitization, and (ii) to develop a prophylactic treatment strategy based on mucosal tolerance induction, using one major wasp venom allergen in recombinant form, i.e. recombinant (r)Ves v 5. Immunization with wasp venom--with or without the use of the adjuvant aluminium hydroxide--led to comparable T helper 2-like immune responses in vivo and in vitro. Intranasal administration of rVes v 5 prior to sensitization with wasp venom resulted in a significant reduction of wasp venom-specific antibody levels (immunoglobulin E (IgE)/IgG2a), type I hypersensitivity reactions in vivo and cytokine production in vitro. Pretreatment with the whole venom was less effective and caused toxic side reactions in higher concentrations, suggesting a favourable use of the recombinant venom allergen for mucosal application. Increased mRNA levels of transforming growth factor-beta and interleukin-10, along with adoptive cell transfer experiments indicated that the immunosuppression after intranasal rVes v 5-application has been mediated by regulatory mechanisms. This is further supported by the fact that the immunosuppression to rVes v 5 was associated with a bystander suppression to the unrelated aero-allergen Bet v 1. In conclusion, we demonstrated that the intranasal application of recombinant Ves v 5 prevented subsequent allergic sensitization to all components of the whole wasp venom. As allergy to insect venom develops in dependence of the frequency of insect stings, a prophylactic treatment based on mucosal tolerance induction with recombinant allergens might be of interest for people at high risk to frequent exposure to the stinging insects.

Identification of in vivo expressed vaccine candidate antigens from Staphylococcus aureus.

For the design of potent subunit vaccines, it is of paramount importance to identify all antigens immunologically recognized by a patient population infected with a pathogen. We have developed a rapid and efficient procedure to identify such commonly recognized antigens, and here we provide a comprehensive in vivo antigenic profile of Staphylococcus aureus, an important human pathogen. S. aureus peptides were displayed on the surface of Escherichia coli via fusion to one of two outer membrane proteins (LamB and FhuA) and probed with sera selected for high Ab titer and opsonic activity. A total of 60 antigenic proteins were identified, most of which are located or predicted to be located on the surface of the bacterium or secreted. The identification of these antigens and their reactivity with individual sera from patients and healthy individuals greatly facilitate the selection of promising vaccine candidates for further evaluation. This approach, which makes use of whole genome sequence information, has the potential to greatly accelerate and facilitate the formulation of novel vaccines and is applicable to any pathogen that induces Abs in humans and/or experimental animals.