Are intravitreal injections essential during the COVID-19 pandemic? Global preferred practice patterns and practical recommendations

Tertiary outpatient ophthalmology clinics are high-risk environments for COVID-19 transmission, especially retina clinics, where regular follow-up is needed for elderly patients with multiple comorbidities. Intravitreal injection therapy (IVT) for chronic macular diseases, is one of the most common procedures performed, associated with a significant burden of care because of the vigorous treatment regimen associated with multiple investigations. While minimizing the risk of COVID-19 infection transmission is a priority, this must be balanced against the continued provision of sight-saving ophthalmic care to patients at risk of permanent vision loss. This review aims to give evidence-based guidelines on managing IVT during the COVID-19 pandemic in common macular diseases such as age-related macular degeneration, diabetic macula edema and retinal vascular disease and to report on how the COVID-19 pandemic has affected IVT practices worldwide.

To illustrate some real-world examples, 18 participants in the International Retina Collaborative, from 15 countries and across four continents, were surveyed regarding pre- and during- COVID-19 pandemic IVT practices in tertiary ophthalmic centers. The majority of centers reported a reduction in the number of appointments to reduce the risk of the spread of COVID-19 with varying changes to their IVT regimen to treat various macula diseases. Due to the constantly evolving nature of the COVID-19 pandemic, and the uncertainty about the normal resumption of health services, we suggest that new solutions for eye healthcare provision, like telemedicine, may be adopted in the future when we consider new long-term adaptations required to cope with the COVID-19 pandemic.

Structure of the human inner kinetochore CCAN complex and its significance for human centromere organization

Centromeres are specialized chromosome loci that seed the kinetochore, a large protein complex that effects chromosome segregation. A 16-subunit complex, the constitutive centromere associated network (CCAN), connects between the specialized centromeric chromatin, marked by the histone H3 variant CENP-A, and the spindle-binding moiety of the kinetochore. Here, we report a cryo-electron microscopy structure of human CCAN. We highlight unique features such as the pseudo GTPase CENP-M and report how a crucial CENP-C motif binds the CENP-LN complex. The CCAN structure has implications for the mechanism of specific recognition of the CENP-A nucleosome. A model consistent with our structure depicts the CENP-C-bound nucleosome as connected to the CCAN through extended, flexible regions of CENP-C. An alternative model identifies both CENP-C and CENP-N as specificity determinants but requires CENP-N to bind CENP-A in a mode distinct from the classical nucleosome octamer.

[Real-life results of anti-VEGF treatment in fellow eyes with nAMD]

PURPOSE

Neovascular age-related macular degeneration (nAMD) often affects both eyes. This study compared real-life outcomes of the first affected eye (1st eye) and the last affected eye (2nd eye) after anti-vascular endothelial growth factor (anti-VEGF) treatment.

MATERIAL AND METHODS

For this retrospective monocenter study 3217 eyes from 2793 patients with nAMD were identified, who received at least 3 anti-VEGF injections between 2006 and 2014 at the University Eye Hospital of Munich. Included in the study were patients with bilateral nAMD when the 1st and 2nd eyes were not previously treated and there was a strict adherence with continuous follow-up for at least 5 years. Corrected visual acuity, number of intravitreal injections and visits as well as central macular thickness were compared.

RESULTS

A total of 72 eyes of 36 patients were included in this analysis. Before anti-VEGF therapy, the group of 2nd eyes showed significantly better mean visual acuity than the 1st eyes (p < 0.001). This difference in visual acuity between 1st and 2nd eyes was noted at all time points throughout the follow-up period (p < 0.05). The mean number of cumulative injections was higher in the group of 2nd eyes (p = 0.04) with a comparable number of visits between both groups. In more than half of all patients the 2nd eye became affected by nAMD within 12 months following treatment initiation of the 1st eye and the majority (83%) followed within 3 years.

CONCLUSION

In unilateral nAMD, regular monitoring of the fellow eye is essential to avoid severe bilateral vision loss. Early diagnosis with rapid initiation of treatment can preserve visual acuity and quality of life.

Assembly principles and stoichiometry of a complete human kinetochore module

Centromeres are epigenetically determined chromosomal loci that seed kinetochore assembly to promote chromosome segregation during cell division. CENP-A, a centromere-specific histone H3 variant, establishes the foundations for centromere epigenetic memory and kinetochore assembly. It recruits the constitutive centromere-associated network (CCAN), which in turn assembles the microtubule-binding interface. How the specific organization of centromeric chromatin relates to kinetochore assembly and to centromere identity through cell division remains conjectural. Here, we break new ground by reconstituting a functional full-length version of CENP-C, the largest human CCAN subunit and a blueprint of kinetochore assembly. We show that full-length CENP-C, a dimer, binds stably to two nucleosomes and permits further assembly of all other kinetochore subunits in vitro with relative ratios closely matching those of endogenous human kinetochores. Our results imply that human kinetochores emerge from clustering multiple copies of a fundamental module and may have important implications for transgenerational inheritance of centromeric chromatin.

Comprehensive health literacy in general populations – An international comparison

Background

The HLS-EU study in 2011 demonstrated for 8 EU Member States that there exists limited comprehensive health literacy for considerable proportions of the general population, that there is a social gradient for health literacy and that limited health literacy has problematic consequences for healthy lifestyles, self-reported health and utilization of professional health services. It was also shown that distributions and associations of health literacy differ considerable between countries. WHO-Europe started the Acton Network on Measuring Population and Organizational Health Literacy (M-POHL) to measure health literacy regularly with the Health Literacy Survey 2019 (HLS19).

Methods

Based on the design and instrument of the HLS-EU study (to allow comparisons for countries participating in both surveys) a core questionnaire was developed for measuring comprehensive health literacy and its relevant correlates. Optional packages were created to measure, among others, digital health literacy and its most relevant correlates. Data were collected from probability samples of at least 1.000 respondents per country for the general population 18+ by personal interviews, telephone interviews or internet surveys in at least 15 member states of the WHO-Europe region.

Results

Distributions for indices, scales and levels of comprehensive health literacy will be presented as well as correlations and regressions for associations of health literacy with social determinants and with consequences for selected life style indicators, indicators for self-reported health and use of professional health care services.

Conclusions

Preliminary results show that the general trends of the HLS-EU study concerning health literacy hold true for HLS19 and that there are considerable differences between participating countries. Health literacy is relevant for health policy in all countries, but to understand the differences between countries a more detailed analysis is necessary.

[Lamellar macular holes with hyporeflective epiretinal proliferation : OCT diagnostics and clinical course]

BACKGROUND

High-resolution spectral domain optical coherence tomography (SD-OCT) is the standard examination for assessment of lamellar macular holes (LMH). According to the current SD-OCT classification of LMHs, they are characterized by (1) an irregular foveal contour, (2) a defect in the inner fovea, and (3) a separation of inner retinal layers from outer retinal layers of the fovea leading to an intraretinal splitting with loss of retinal tissue.

OBJECTIVE

The article aims to give an overview on the current knowledge of retinal imaging in LMH diagnostics and clinical course of disease.

MATERIALS AND METHODS

This review is based on current literature and analyses of data from different case series from the Department of Ophthalmology, Ludwig-Maximilian University Munich, Germany.

RESULTS

In eyes with LMH, a homogenous atypical, hyporeflective epiretinal tissue has been described in addition to conventional tractional epiretinal membranes (ERM). By SD-OCT, this named lamellar hole-associated epiretinal proliferation (LHEP) does not show common signs of traction and is characterized as a thick homogenous layer of moderately reflective material. LHEP has been demonstrated to be related to the occurrence of photoreceptor layer defects, enlargement of LMH diameter and poor visual acuity.

CONCLUSION

The correlation of SD-OCT and en-face OCT can help to identify LMH subgroups and morphology progression early on. FAF enables detection of structural changes at a subclinical stage without visual deterioration. With regard to a high variability of intraretinal changes in LMHs and epimacular fibro-cellular proliferation, the current classification of LMH should be discussed and re-evaluated.

How to determine whether conceptual endophenotypes can improve clinical outcomes in patients suffering from major depression: An exploratory approach

Depression is a complex mental health disorder, resulting in a high degree of disability. Since symptom constellation, course, and outcome are heterogeneous in these patients, current research initiatives are striving to establish stratified diagnostic and treatment approaches. In the past two decades, Dirk Hellhammer and his team introduced Neuropattern, a new diagnostic concept, which is based on conceptual endophenotypes of the stress response network. We explore how to use this concept in clinical practice in order to ultimately determine whether it brings any value over standard care. In view of the novelty of the concept and the difficulties dealing with such a concept at a practical level, it was necessary to initiate an exploratory study to determine key factors for planning future clinical trials. We report results and knowledge gained from an exploratory single-site study investigating the use and potential benefits of Neuropattern in standard care. Inpatients (ICD-10 diagnosis F32, F33; Nö=ö178) were allocated to either treatment as usual (standard group, SG) or a novel Neuropattern oriented exploratory treatment (intervention group, IG). Symptom severity was assessed with psychometric tests at admission to hospital, during the first six weeks, and upon discharge from the hospital. In addition, direct and indirect costs were assessed for the 3-month-intervals prior to and after the hospital stay. Compared to the SG, depression scores of patients in the IG showed a faster decline once psychotherapeutic and pharmacological treatment were based on an individualized explanatory model. The patients in the IG with an F33 diagnosis showed a more pronounced reduction of depression severity during the stay in the hospital and a stronger and quicker reduction of general symptom severity. Comparing the average depression scores at the start of the study and after six weeks, symptom severity was reduced in all Neuropattern groups. Some limitations of the study have to be mentioned: The study was not blinded, was single-site, included highly depressed inpatients only, and was conducted for no longer than 8 months. The results highlight some important issues regarding taking the Neuropattern approach to the bedside and researching its efficacy and effectiveness to support personalized treatments in clinical care.

Value of antigranulocyte scintigraphy with Tc-99m-sulesomab in diagnosing combat-related infections of the musculoskeletal system

AIM

Combat-related extremity injuries are regularly associated with long-term complications such as chronic infection, especially osteomyelitis. Clinical examination and laboratory parameters do not usually allow reliable diagnosis. In contrast, imaging techniques enable constructive assertions to be made about the location and extent of an infection of the peripheral musculoskeletal system. The aim of this study was therefore to determine the diagnostic reliability of three-phase bone scanning and antigranulocyte scintigraphy using Tc-99m-sulesomab (Leukoscan) in the diagnostic clarification of infections associated with combat-related extremity injuries.

METHODS

Twenty-seven male patients (mean age 33.9 years) with suspected combat-associated infections of the extremities were included in this retrospective analysis. All patients underwent three-phase bone scanning using Tc-99m-HDP followed by antigranulocyte scintigraphy with Tc-99m-sulesomab. In 26 of the 27 patients, a CT scan of affected limb was obtained, where the secondary fusion with single photon emission CT data set was possible. The diagnostic reliability of imaging techniques was validated against microbiological samples obtained during surgery and used as gold standard.

RESULTS

Three-phase bone scanning yielded a positive result in all patients, with 18 scans classified as true positive (TP) and nine scans as false positive (FP). This produced a sensitivity of 100%, a specificity of 0% and a positive predictive value (PPV) of 67%. Antigranulocyte scintigraphy recognised 13 patients as TP, 1 patient as FP, 8 patients as true negative (TN) and 5 patients as false negative (FN), which gave a sensitivity of 72%, a specificity of 88%, a PPV of 93%, a negative predictive value (NPV) of 62% and an accuracy of 78%. CT recognised in 7 cases a TP result, in 3 cases an FP, in 5 cases a TN and in 11 cases an FN result. This produced a sensitivity of 39%, a specificity of 63%, a PPV of 70%, an NPV of 31% and an accuracy of 46%.

CONCLUSIONS

Three-phase bone scanning did not deliver any diagnostic benefit, since no result was able to differentiate unequivocally between infection-related and reactive changes. Antigranulocyte scintigraphy using Tc-99m-sulesomab represented a highly suitable technique for diagnostically clarifying combat-related infections of the extremities. It is superior to CT in sensitivity, specificity, PPV, NPV and accuracy.

Colloidal polymer particles as catalyst carriers and phase transfer agents in multiphasic hydroformylation reactions

HYPOTHESIS

Colloidal particles have been used to covalently bind ligands for the heterogenization of homogeneous catalysts. The replacement of the covalent bonds by electrostatic interactions between particles and the catalyst could preserve the selectivity of a truly homogeneous catalytic process.

EXPERIMENTS

Functionalized polymer particles with trimethylammonium moieties, dispersed in water, with a hydrophobic core and a hydrophilic shell have been synthesized by emulsion polymerization and have been thoroughly characterized. The ability of the particles with different monomer compositions to act as catalyst carriers has been studied. Finally, the colloidal dispersions have been applied as phase transfer agents in the multiphasic rhodium-catalyzed hydroformylation of 1-octene.

FINDINGS

The hydrodynamic radius of the particles has been shown to be around 100 nm, and a core-shell structure could be observed by atomic force microscopy. The polymer particles were proven to act as carriers for the water-soluble hydroformylation catalyst, due to electrostatic interaction between the functionalized particles bearing ammonium groups and the sulfonated ligands of the catalyst. The particles were stable under the hydroformylation conditions and the aqueous catalyst phase could be recycled three times.

[Acute therapeutic measures for limb salvage Part 1 : Haemorrhage control, emergency revascularization, compartment syndrome]

The primary care of Gustilo-Anderson type IIIC extremity injuries with relevant vessel lacerations is decisive for the success of a limb salvage procedure. This article shall present substantial emergency procedures for the salvage of the nutritive perfusion of a mangled extremity, based on the current literature. After provisory control of a peripheral haemorrhage (e. g. by manual pressure or tourniquet), an immediate decision must be made about the kind of emergency revascularization to be implemented as the limb salvage procedure. Here, the temporary intravascular shunt will be the fastest technique that can ensure a sufficient tissue perfusion in the case of vessel lacerations. Regarding the treatment of a fracture versus perfusion recovery, a shortening of ischemia time should have priority over fracture stabilization.If an acute compartment syndrome is suspected, a documented monitoring has to be performed in the limb salvage situation for 24 hours with clinical controls every 4 hours. Disproportional pain that does not respond to analgesics, and passive muscle stretching pain can be seen as cardinal symptoms. The positive predictive value of clinical findings is <15 %. During the observation period with an impending but not manifest compartment syndrome, an elevation of the extremity above heart level or its cooling are contraindicated. An intracompartmental pressure measurement is the most important instrument-based supplemental diagnostic method. The open fasciotomy of the affected compartments is the only causal therapy and should be performed as fast as possible. A decision against fasciotomy in cases of non-explicit clinical signs should not be made without a documented intracompartmental pressure measurement.

[Acute therapeutic measures for limb salvage Part 2 : Debridement, lavage techniques and anti-infectious strategies]

The quality of the primary care of Gustilo-Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60 %. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36-48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3-9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain "decontamination" and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.

[Health literacy among less well-educated young people: Influencing factors and consequences]

OBJECTIVES

Health literacy is known to influence health. Findings on the unequal distribution of health literacy among less well-educated young people are presented. The influence of socio-demographic factors and the consequences of a low level of health literacy with regard to health-related behaviour are discussed.

MATERIALS AND METHODS

Data from a survey on the health literacy of young people with a lower level of education, older people and migrants (n = 1,000) were used. Health literacy was measured using the instruments of the European Health Literacy Survey (HLS-EU-Q47).

RESULTS

The results demonstrate a lower level of health literacy among young people with less education and especially among young migrants. Explanations for a lower level of health literacy among young people with less well-educated young people were parents' educational background and parents' wealth. Migration-related factors had no influence on young people. Further correlations between health literacy and health behaviour were explored.

CONCLUSION

It is concluded that health literacy is linked to health behaviour and that unequal distributions of health literacy among young people may increase health inequalities.

[Differences in Health Literacy of Adolescents with Lower Educational Attainment, Older People and Migrants]

Not everyone seems to have adequate health literacy to take care of their own health. Especially older people, people with migration background, and adolescents with lower educational attainment face challenges when dealing with the healthcare system. Our cross-sectional study focuses on these vulnerable groups. We found that vulnerable populations showed high prevalence of limited health literacy, and there were considerable differences between these groups. Older people were more likely to have limited health literacy compared to younger people. Older people with migration background had the lowest health literacy.

A study on the selective hydrogenation of nitroaromatics to N-arylhydroxylamines using a supported Pt nanoparticle catalyst

Selective hydrogenation of nitroarenes to N-arylhydroxylamines at high rates over supported Pt-NPs.

Ion-Molekül-Reaktionen und Ladungsaustausch bei Stößen von O– auf O2 / Ion-Molecule Reactions and Charge Transfer in Collisions of O– on O2

Investigations of the cross section for the reaction O- + O2 → O2 - + O have been made for laboratory kinetic energies 0-100 eV. The reaction shows a sharp maximum in the cross section at low energies (5 eV lab.). By the use of the primary ion 18O- it can be shown that above 20 eV (lab.) there is only charge exchange whereas in the lower energy region ion-molecule-reactions as well as charge exchange occure. The reaction O- + O2 → O+ + … has also been observed above 27 eV (lab.).

[Hyperbaric oxygen therapy for necrotizing soft tissue infections: contra]

INTRODUCTION

Hyperbaric oxygen therapy (HBOT) is discussed as an adjuvant option to treat necrotizing soft tissue infections (NSTI). While the Federal Joint Committee decided in 2007 not to support HBOT for the indication necrotizing fasciitis and Fournier's gangrene, it was decided to accept HBOT for treatment of clostridial myonecrosis for the German health insurance. Thus, in Germany necrotizing fasciitis (NF) is not a confirmed indication for HBOT. Against this background the cons of the clinical benefits of HBOT should be formulated.

METHODS

A literature search (MEDLINE/EMBASE/COCHRANE/manual search) using the keywords "necrotizing fasciitis", "Fournier's gangrene", "necrotizing cellulitis", "necrotizing soft tissue infections" as well as "hyperbaric medicine", "hyperbaric therapy" and "hyperbaric treatment" was carried out. An analysis of the spatial distribution of German hyperbaric oxygen chambers enabling intensive care (HOC-IC) was made.

RESULTS

A total of 250 articles with n=2,556 NSTI patients (n=993 treated by HBOT) was found and 50% of the articles were case reports or series. There were only ten retrospective studies comparing the effects of HBOT with non-HBO treatment and none of them verified the benefit of HBOT in NF patients. In Germany only nine hyperbaric oxygen chambers (HOC-IC) enable intensive care. Currently, patient data are not included in scientific studies or multicenter studies, while studies assessing the benefit with higher evidence levels have been required for more than 15 years.

CONCLUSIONS

The previously published human clinical studies do not confirm any therapeutic benefit of HBOT in NF patients. Any time delay in the start of surgical therapy by HBOT would not be acceptable. In Germany a comprehensive clinical care with HOC is not possible. On average the additional costs of HBO treatment for NF patients is approximately 8,000-25,000 <euro>/patient which is not generally reimbursed by health insurance companies. Initializing a register study to assess the benefit of HBOT in NF patients appears feasible and is urgently needed.

Asymmetric Nickel-Catalyzed Hydrocyanation of Vinylarenes by Applying Homochiral Xantphos Ligands

New homochiral xantphos-type diphosphonite ligands with binaphthoxy substituents have been prepared and characterized by NMR spectroscopy. These ligands have been applied in the nickel-catalyzed hydrocyanation of styrene and other vinylarenes. Enantioselectivities up to 63% ee have been obtained by using 4-isobutylstyrene as a substrate. Addition of an excess of ligand strongly inhibits the hydrocyanation reaction since the bis-chelate nickel complexes formed are highly stable and catalytically inactive.