Correction: Comparison of Four Active SARS-CoV-2 Surveillance Strategies in Representative Population Sample Points: Two-Factor Factorial Randomized Controlled Trial

[This corrects the article DOI: 10.2196/44204.].

Normative data for interpreting the SNOT-22

Objectives

The Sino-Nasal Outcome Test 22 (SNOT-22) is a validated patient-reported outcome instrument to evaluate the health-related quality of life (HRQoL) in patients with chronic rhinosinusitis (CRS). There are no published normative SNOT-22 scores, limiting its interpretation.

Methods

Symptom scores from 1,000 SNOT-22 questionnaires were analysed by principal component analysis (PCA) and exploratory factor analyses. Data were derived from a survey with 1,000 healthy Europeans (reference cohort) who were recruited using the Respondi panel for market and social science research. This subsample was quoted to the population distribution of the German Microcensus and selected from a non-probability panel.

Results

The overall normative SNOT-22 score can be detected to be 20.2 ± 19.44. Male (18.49 ± 19.15) and older (> 50 years old; 18.3 ± 17.49) participants had overall lower SNOT-22 mean results than females (21.8 ± 19.6) and younger (21.4 ± 20.55) participants, indicating higher levels of satisfaction. PCA proposed two SNOT-22 domains ("physiological well-being" and "psychological well-being"), which explained 65% of the variance.

Conclusions

These are the first published (German) normative scores for the SNOT-22 and provide a clinical reference point for the interpretation of data.

[Validity of the German Menière's Disease Patient-Oriented Symptom Severity Index]

BACKGROUND

The MD POSI is a disease-specific questionnaire to determine the health-related quality of life (HRQoL) of patients with Menière's disease (MD).

OBJECTIVES

Validity and reliability of the German translation of the MD POSI.

MATERIAL AND METHODS

Prospective data analysis of a patient group with vertigo (n = 162), which was treated in the otorhinolaryngology of a University Hospital from 2005-2019. A clinical selection was made according to the new Bárány classification in a "definite" and "probable" Menière's disease. HRQoL was assessed using the German translation of the MD POSI, the Vertigo Symptom Score (VSS) and the Short Form (SF-36). Reliability was measured by Cronbach's α and test-retesting after 12 months and again 2 weeks later. Content and agreement validity were examined.

RESULTS

Cronbach α values greater than 0.9 indicated good internal consistency. There was no statistically significant difference from baseline to 12 months, except for the subscore "during the attack". There were significant positive correlations between the VSS overall/VER/AA and the overall index of the MD POSI and negative significant correlations with the SF-36 domains physical functioning, physical role functioning, social functioning, emotional role functioning, mental well-being. There were low SRM (standardized response mean) values below 0.5.

CONCLUSIONS

The German translation of the MD POSI is a valid and reliable instrument to evaluate the impact of MD on patients' disease-specific quality of life.

Human papillomavirus prevalence and vaccine effectiveness in young women in Germany, 2017/2018: results from a nationwide study

Background

Infections with human papillomaviruses (HPV) are sexually transmitted and can cause cancer. In Germany, vaccination against HPV is recommended for girls and boys aged 9-17 years. We aimed to investigate HPV DNA prevalence, genotype distribution and vaccine effectiveness (VE) in women aged 20-25 years 10 years after the introduction of HPV vaccination in Germany (2018-2019), and compared these data to an equally designed study from 2010-2012.

Methods

Seventy six geographical clusters were randomly selected, followed by random selection of 61 women aged 20-25 years per cluster. Participants performed cervicovaginal self-sampling and answered questions on demographics, sexual behaviour and HPV vaccination. Samples were tested for 18 high risk and nine low risk HPV genotypes. We performed chi-square tests, Fisher's exact test, unpaired Student's t-test and proportion t-test, and calculated crude and adjusted prevalence ratios (PR) and 95% CIs.

Results

Of 7,858 contacted women a total of 1,226 agreed to participate. Of these, 94 women were positive for HPV types 16 and/or 18. HPV16 prevalence was 7.0% (95% CI 5.6-8.6) and HPV18 prevalence was 0.8% (95% CI 0.4-1.5). HPV6 and HPV11 were rare with only five (0.4%; 0.1-0.9) and one (0%; 95% CI 0.0-0.5) positive tests. Seven hundred fifty-seven women (62%) had received at least one HPV vaccine dose and 348 (28%) were vaccinated as currently recommended. Confounder-adjusted VE was 46.4% (95% CI 4.2-70.1) against HPV16/18 infection and 49.1% (95% CI 8.2-71.8) against infection with at least one HPV genotype covered by the quadrivalent HPV vaccine. Compared with the 2010-2012 study results, HPV16/18 prevalence dropped from 22.5% (95% CI 19.0-26.3) to 10.3% (95% CI 7.5-13.9; p < 0.0001) in unvaccinated participants.

Conclusion

Vaccine-covered HPV genotypes were rare among 20-25 years old women in Germany and decreased compared to the time point shortly after the start of the HPV vaccination program. HPV prevalence of almost all vaccine-covered genotypes was strongly reduced in vaccinated participants. A decrease of HPV16 and HPV18 was even observed in unvaccinated participants, compared to 2010-2012 data, suggesting indirect protection of unvaccinated women. Low VE against HPV16/18 and HPV6/11/16/18 in our study might be attributable to study design in combination with the endpoint selection of (mainly transient) HPV DNA positivity.

Comparison of Four Active SARS-CoV-2 Surveillance Strategies in Representative Population Sample Points: Two-Factor Factorial Randomized Controlled Trial

BACKGROUND

The COVID-19 pandemic is characterized by rapid increases in infection burden owing to the emergence of new variants with higher transmissibility and immune escape. To date, monitoring the COVID-19 pandemic has mainly relied on passive surveillance, yielding biased epidemiological measures owing to the disproportionate number of undetected asymptomatic cases. Active surveillance could provide accurate estimates of the true prevalence to forecast the evolution of the pandemic, enabling evidence-based decision-making.

OBJECTIVE

This study compared 4 different approaches of active SARS-CoV-2 surveillance focusing on feasibility and epidemiological outcomes.

METHODS

A 2-factor factorial randomized controlled trial was conducted in 2020 in a German district with 700,000 inhabitants. The epidemiological outcome comprised SARS-CoV-2 prevalence and its precision. The 4 study arms combined 2 factors: individuals versus households and direct testing versus testing conditioned on symptom prescreening. Individuals aged ≥7 years were eligible. Altogether, 27,908 addresses from 51 municipalities were randomly allocated to the arms and 15 consecutive recruitment weekdays. Data collection and logistics were highly digitized, and a website in 5 languages enabled low-barrier registration and tracking of results. Gargle sample collection kits were sent by post. Participants collected a gargle sample at home and mailed it to the laboratory. Samples were analyzed with reverse transcription loop-mediated isothermal amplification (RT-LAMP); positive and weak results were confirmed with real-time reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Recruitment was conducted between November 18 and December 11, 2020. The response rates in the 4 arms varied between 34.31% (2340/6821) and 41.17% (2043/4962). The prescreening classified 16.61% (1207/7266) of the patients as COVID-19 symptomatic. Altogether, 4232 persons without prescreening and 7623 participating in the prescreening provided 5351 gargle samples, of which 5319 (99.4%) could be analyzed. This yielded 17 confirmed SARS-CoV-2 infections and a combined prevalence of 0.36% (95% CI 0.14%-0.59%) in the arms without prescreening and 0.05% (95% CI 0.00%-0.108%) in the arms with prescreening (initial contacts only). Specifically, we found a prevalence of 0.31% (95% CI 0.06%-0.58%) for individuals and 0.35% (95% CI 0.09%-0.61%) for households, and lower estimates with prescreening (0.07%, 95% CI 0.0%-0.15% for individuals and 0.02%, 95% CI 0.0%-0.06% for households). Asymptomatic infections occurred in 27% (3/11) of the positive cases with symptom data. The 2 arms without prescreening performed the best regarding effectiveness and accuracy.

CONCLUSIONS

This study showed that postal mailing of gargle sample kits and returning home-based self-collected liquid gargle samples followed by high-sensitivity RT-LAMP analysis is a feasible way to conduct active SARS-CoV-2 population surveillance without burdening routine diagnostic testing. Efforts to improve participation rates and integration into the public health system may increase the potential to monitor the course of the pandemic.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien (DRKS) DRKS00023271; https://tinyurl.com/3xenz68a.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-021-05619-5.

Does a tonsillectomy indicated according to the German S2k guideline affect short-term quality of life in adults?

BACKGROUND

Tonsillectomy (TE) for recurrent tonsillitis (RT) is one of the most common surgical interventions. Since 2015, the indication criteria for TE have become much stricter (German S2k guideline). Patient-reported outcome measures (PROMs) of short-term quality of life (QoL) after TE have not yet been investigated.

PURPOSE

To clarify if stringent indication for TE will better identify patients worthy of surgery and patients' QoL.

METHODS

We prospectively studied the Tonsillectomy Outcome Inventory 14 (TOI-14) responses of 38 RT-patients recruited according to the S2k guideline in 2020 and compared their TOI-14 scores with those of a historical RT cohort from 2006 to 2008 and with a healthy middle-European cohort. New RT patients were assessed before, 2, 4, and 14 days and 6 months after TE. TOI-14 was measured as total and as disease-specific score.

RESULTS

From pre- to 6-month postoperative, patients' QoL was significantly different, measured by TOI-14 (49.92 vs. 6.35; p < 0.001) and disease-specific score (60.35 vs. 9.9; p < 0.001). Preoperative disease-specific score was not different from that of the 2nd and 4th postoperative days but from the 14th postoperative day (60.35 vs. 29.26; p < 0.001). The historical cohort had significantly less RT complaints than the new cohort beforehand, but more dissatisfaction in QoL after TE. New TE patients had worse QoL pre- (49.92 vs. 11.78; p < 0.001) but more QoL postoperatively (6.34 vs. 11.78; p = 0.004) than healthy individuals.

CONCLUSIONS

Our results show that the tightening of the indication criteria for TE was justified and that TE patients significantly benefit from this surgery from day 14.

Can Patient-Reported Outcomes and Inflammatory Markers define Endotype 2 in Chronic Rhinosinusitis without Nasal Polyps?

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease at the clinical phenotype level (without nasal polyp [CRSsNP] vs with nasal polyp [CRSwNP]) and at the underlying inflammatory endotype level (type 2 vs non-type 2). Whether the endotype is associated with clinical presentation in patients with CRSsNP has yet to be explored in detail.

OBJECTIVE

To identify associations between endotypes and their clinical significance in patients with CRSsNP based on tissue interleukin-5 levels.

METHODS

A total of 104 patients with CRSsNP who underwent functional endoscopic sinus surgery between 2013 and 2017 were endotyped. We collected immunologic and clinical parameters and evaluated whether there were associations between the endotype and clinical features using Visual Analog Scale (VAS), Sino-Nasal Outcome Test-22 (SNOT-22), Sniffin' Sticks test, Lund-Mackay CT score, and nasal endoscopy.

RESULTS

Mean tissue interleukin-5 levels were used to identify type 2 inflammation (non-type 2: 3.37 vs type 2: 191.98 pg/g tissue; P < .001). There were no significant clinical differences measured by patient-reported outcome measures between patients with type 2 CRSsNP and those with non-type 2 CRSsNP preoperatively. Type 2 and non-type 2 CRSsNP did not differentiate in CT score, Sniffin' Sticks test, and nasal endoscopy. Postoperative SNOT-22 and VAS scores correlated well with each other (r = 0.75; P < .01). Postoperative VAS scores were in both groups significantly lower than before the operation (type 2: 5.07 vs 2.99; P < .01; non-type 2: 5.74 vs 3.22; P < .01), but not associated to the inflammatory subtype.

CONCLUSION

The type of inflammation does not affect the symptoms, the computed tomography scan, or the postoperative results in CRSsNP in contrast to former findings in CRSwNP.

TRIAL REGISTRATION

Belgian registration number (B.U.N.) No. B6702020000097.

Long-term outcomes and quality of life following parotidectomy for benign disease

Objective

Parotidectomy worsens quality of life (QoL) in the short-term, but the long-term impact is unknown. In this study, we analysed the long-term effects of parotidectomy on QoL.

Methods

In this prospective long-term follow-up study, participants were divided into three groups: short-term (ST) follow-up of six weeks, long-term (LT) follow-up of 13 years and short- and long-term (SLT) follow-up. QoL was assessed using the Parotidectomy Outcome Inventory (POI-8). Parotidectomies were classified based on whether the great auricular nerve (GAN) had been preserved or sacrificed.

Results

In total, 164 observations were analysed, 74 in the LT group, 57 in the ST group and 33 in the SLT group. Hypoaesthesia was a major problem and facial palsy was a minor problem. Pain (p < 0.01) and hypoaesthesia (p < 0.001) were significantly lower after 13 years compared with after six weeks, and QoL was higher after 13 years compared with after six weeks (p = 0.04). The disease-specific impairment rate decreased from 70% at short-term follow-up to 30% at long-term follow-up. Removal of the GAN was associated with hypoaesthesia in the ST group (p = 0.028).

Conclusions

Hypoaesthesia has a long-term impact on the QoL, and this should be emphasised during preoperative discussions.

Effectiveness and cost-effectiveness of four different strategies for SARS-CoV-2 surveillance in the general population (CoV-Surv Study): study protocol for a two-factorial randomized controlled multi-arm trial with cluster sampling

BACKGROUND

To achieve higher effectiveness in population-based SARS-CoV-2 surveillance and to reliably predict the course of an outbreak, screening, and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic.

METHODS

This trial implements a two-factorial, randomized, controlled, multi-arm, prospective, interventional, single-blinded design with cluster sampling and four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy based on individuals' self-collection of saliva samples which are then sent to and analyzed by a laboratory. The targeted sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (2500 participants per arm). Strategies differ with respect to tested population groups (individuals vs. all household members) and testing approach (without vs. with pre-screening survey). The trial is complemented by an economic evaluation and qualitative assessment of user experiences. Primary outcomes include costs per completely screened person, costs per positive case, positive detection rate, and precision of positive detection rate.

DISCUSSION

Systems for active surveillance of the general population will gain more importance in the context of pandemics and related disease prevention efforts. The pandemic parameters derived from such active surveillance with routine population monitoring therefore not only enable a prospective assessment of the short-term course of a pandemic, but also a more targeted and thus more effective use of local and short-term countermeasures.

TRIAL REGISTRATION

ClinicalTrials.gov DRKS00023271 . Registered November 30, 2020, with the German Clinical Trials Register (Deutsches Register Klinischer Studien).

How to predict the outcome of septorhinoplasty? A normative study of ROE and FROI-17 scores

Objective

Normative values of patient-reported outcome instruments are needed to identify good candidates for rhinoplasty. Rhinoplasty Outcome Evaluation (ROE) and Functional Rhinoplasty Outcome Inventory-17 (FROI-17) are disease-specific questionnaires that evaluate quality of life in patients undergoing rhinoplasty.

Methods

The reference cohort contained 1,000 participants, selected from a non-probability panel. Normative ROE and FROI-17 scores from this reference cohort were compared with ROE and FROI-17 scores from a patient cohort before (n = 104) and 6 (n = 55) and 12 months (n = 32) after septorhinoplasty.

Results

Mean FROI-17 scores (± SD) were: overall score, 20.8 ± 17; nasal symptoms, 16.8 ± 7; general symptoms, 24.8 ± 22; and self-confidence, 16.4 ± 21. The ROE total score was 73.1 ± 16. Normative values differed significantly from the preoperative ROE and FROI-17 scores of septorhinoplasty patients (p < 0.01). Except for the FROI-17 general score at 12 months postoperatively (p = 0.004), there were no significant differences between normative ROE/FROI-17 and septorhinoplasty scores postoperatively, indicating that they returned to normalcy.

Conclusions

Normative scores for ROE and FROI-17 provide a reference point from which to identify patients who are most likely to benefit from rhinoplasty.

Monitoring the health and healthcare provision for refugees in collective accommodation centres: Results of the population-based survey RESPOND

To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee health status and healthcare provision. The core elements of the survey consisted of a population-based sampling procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of primary care services, frequent ambulatory care sensitive hospitalisations, i.e. hospitalisations that could potentially have been avoided through primary care (25.3%), as well as subjective deficits in the quality of care, suggest barriers to accessing healthcare services. Almost half of all refugees (45.3%) live in accommodation facilities of poor structural quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling, multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could complement established procedures for conducting health surveys and be extended to other federal states.

Effectiveness and cost-effectiveness of four different strategies for SARS-CoV-2 surveillance in the general population (CoV-Surv Study): a structured summary of a study protocol for a cluster-randomised, two-factorial controlled trial

Objectives

In this cluster-randomised controlled study (CoV-Surv Study), four different “active” SARS-CoV-2 testing strategies for general population surveillance are evaluated for their effectiveness in determining and predicting the prevalence of SARS-CoV-2 infections in a given population. In addition, the costs and cost-effectiveness of the four surveillance strategies will be assessed. Further, this trial is supplemented by a qualitative component to determine the acceptability of each strategy. Findings will inform the choice of the most effective, acceptable and affordable strategy for SARS-CoV-2 surveillance, with the most effective and cost-effective strategy becoming part of the local public health department’s current routine health surveillance activities. Investigating its everyday performance will allow us to examine the strategy’s applicability to real time prevalence prediction and the usefulness of the resulting information for local policy makers to implement countermeasures that effectively prevent future nationwide lockdowns.

The authors would like to emphasize the importance and relevance of this study and its expected findings in the context of population-based disease surveillance, especially in respect to the current SARS-CoV-2 pandemic. In Germany, but also in many other countries, COVID-19 surveillance has so far largely relied on passive surveillance strategies that identify individuals with clinical symptoms, monitor those cases who then tested positive for the virus, followed by tracing of individuals in close contact to those positive cases.

To achieve higher effectiveness in population surveillance and to reliably predict the course of an outbreak, screening and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic.

To better control and manage the SARS-CoV-2 pandemic, current strategies therefore need to be complemented by an active surveillance of the wider population, i.e. routinely conducted testing and monitoring activities to identify and isolate infected individuals regardless of their clinical symptoms. Such active surveillance strategies will enable more effective prevention of the spread of the virus as they can generate more precise population-based parameters during a pandemic. This essential information will be required in order to determine the best strategic and targeted short-term countermeasures to limit infection spread locally.

Trial design

This trial implements a cluster-randomised, two-factorial controlled, prospective, interventional, single-blinded design with four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy.

Participants

Eligible are individuals age 7 years or older living in Germany’s Rhein-Neckar Region who consent to provide a saliva sample (all four arms) after completion of a brief questionnaire (two arms only). For the qualitative component, different samples of study participants and non-participants (i.e. eligible for study, but refuse to participate) will be identified for additional interviews. For these interviews, only individuals age 18 years or older are eligible.

Intervention and comparator

Of the four surveillance strategies to be assessed and compared, Strategy A1 is considered the gold standard for prevalence estimation and used to determine bias in other arms. To determine the cost-effectiveness, each strategy is compared to status quo, defined as the currently practiced passive surveillance approach.

Strategy A1: Individuals (one per household) receive information and study material by mail with instructions on how to produce a saliva sample and how to return the sample by mail. Once received by the laboratory, the sample is tested for SARS-CoV-2 using Reverse Transcription Loop-mediated Isothermal Amplification (RT-LAMP).

Strategy A2: Individuals (one per household) receive information and study material by mail with instructions on how to produce their own as well as saliva samples from each household member and how to return these samples by mail. Once received by the laboratory, the samples are tested for SARS-CoV-2 using RT-LAMP.

Strategy B1: Individuals (one per household) receive information by mail on how to complete a brief pre-screening questionnaire which asks about COVID-19 related clinical symptoms and risk exposures. Only individuals whose pre-screening score crosses a defined threshold, will then receive additional study material by mail with instructions on how to produce a saliva sample and how to return the sample by mail. Once received by the laboratory, the saliva sample is tested for SARS-CoV-2 using RT-LAMP.

Strategy B2: Individuals (one per household) receive information by mail on how to complete a brief pre-screening questionnaire which asks about COVID-19 related clinical symptoms. Only individuals whose pre-screening score crosses a defined threshold, will then receive additional study material by mail with instructions how to produce their own as well as saliva samples from each household member and how to return these samples by mail. Once received by the laboratory, the samples are tested for SARS-CoV-2 using RT-LAMP.

In each strategy, RT-LAMP positive samples are additionally analyzed with qPCR in order to minimize the number of false positives.

Main outcomes

The identification of the one best strategy will be determined by a set of parameters. Primary outcomes include costs per correctly screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Secondary outcomes include participation rate, costs per asymptomatic case, prevalence estimates, number of asymptomatic cases per study arm, ratio of symptomatic to asymptomatic cases per study arm, participant satisfaction.

Additional study components (not part of the trial) include cost effectiveness of each of the four surveillance strategies compared to passive monitoring (i.e. status quo), development of a prognostic model to predict hospital utilization caused by SARS-CoV-2, time from test shipment to test application and time from test shipment to test result, and perception and preferences of the persons to be tested with regard to test strategies.

Randomisation

Samples are drawn in three batches of three continuous weeks. Randomisation follows a two-stage process. First, a total of 220 sampling points have been allocated to the three different batches. To obtain an integer solution, the Cox-algorithm for controlled rounding has been used. Afterwards, sample points have been drawn separately per batch, following a probability proportional to size (PPS) random sample. Second, for each cluster the same number of residential addresses is randomly sampled from the municipal registries (self-weighted sample of individuals). The 28,125 addresses drawn per municipality are then randomly allocated to the four study arms A1, A2, B1, and B2 in the ratio 5 to 2.5 to 14 to 7 based on the expected response rates in each arm and the sensitivity and specificity of the pre-screening tool as applied in strategy B1 and B2. Based on the assumptions, this allocation should yield 2500 saliva samples in each strategy. Although a municipality can be sampled by multiple batches and the overall number of addresses per municipality might vary, the number of addresses contacted in each arm is kept constant.

Blinding (masking)

The design is single-blinded, meaning the staff conducting the SARS-CoV-2 tests are unaware of the study arm assignment of each single participant and test sample.

Sample sizes

Total sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (i.e. 2,500 participants per arm).

For the qualitative component, up to 60 in-depth interviews will be conducted with about 30 study participants (up to 15 in each arm A and B) and 30 participation refusers (up to 15 in each arm A and B) purposefully selected from the quantitative study sample to represent a variety of gender and ages to explore experiences with admission or rejection of study participation. Up to 25 asymptomatic SARS-CoV-2 positive study participants will be purposefully selected to explore the way in which asymptomatic men and women diagnosed with SARS-CoV-2 give meaning to their diagnosis and to the dialectic between feeling concurrently healthy and yet also being at risk for transmitting COVID-19. In addition, 100 randomly selected study participants will be included to explore participants’ perspective on testing processes and implementation.

Trial Status

Final protocol version is “Surveillance_Studienprotokoll_03Nov2020_v1_2” from November 3, 2020. Recruitment started November 18, 2020 and is expected to end by or before December 31, 2020.

Trial registration

The trial is currently being registered with the German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00023271 (https://www.drks.de/drks_web/navigate.do?navigationId=trial. HTML&TRIAL_ID=DRKS00023271). Retrospectively registered 30 November 2020.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Normative tonsillectomy outcome inventory 14 values as a decision-making tool for tonsillectomy

Purpose

The study aimed to determine normative values for the Tonsillectomy Outcome Inventory 14 (TOI-14) in a healthy middle-European cohort. We also compared these generated values with TOI-14 scores from a patient population with recurrent tonsillitis (RT) and explored the factorial structure of the TOI-14.

Methods

We systematically studied the responses of healthy individuals (reference cohort) and patients with RT (clinical cohort) to the TOI-14 survey. The reference cohort contained 1000 participants, who were recruited using the Respondi panel for market and social science research. This subsample was quoted to the population distribution of the German Microcensus and selected from a non-probability panel. Tonsillitis patients were assessed before and 6 and 12 months after tonsillectomy.

Data were analysed using principal component and exploratory factor analyses.

Results

The PCA revealed three TOI-14 domains (physiological, psychological and socio-economic), which explained 73% of the total variance. The reference cohort perceived a good quality of life (QOL) with a TOI-14 total score of 11.8 (physiological: 8.0, psychological: 5.8, and socio-economic subscale score: 13.9). TOI-14 scores were higher in the patient cohort, indicating that the TOI-14 discriminates between patients with RT and healthy individuals with no RT. Age and female gender significantly influenced the total TOI-14 score, especially in the psychological (age) and socio-economic (gender) subscales.

Conclusion

We have developed a set of normative values that, together with the TOI-14, can determine the disease burden indicating tonsillectomy.

Climate Impacts From a Removal of Anthropogenic Aerosol Emissions

Limiting global warming to 1.5 or 2.0°C requires strong mitigation of anthropogenic greenhouse gas (GHG) emissions. Concurrently, emissions of anthropogenic aerosols will decline, due to coemission with GHG, and measures to improve air quality. However, the combined climate effect of GHG and aerosol emissions over the industrial era is poorly constrained. Here we show the climate impacts from removing present-day anthropogenic aerosol emissions and compare them to the impacts from moderate GHG-dominated global warming. Removing aerosols induces a global mean surface heating of 0.5-1.1°C, and precipitation increase of 2.0-4.6%. Extreme weather indices also increase. We find a higher sensitivity of extreme events to aerosol reductions, per degree of surface warming, in particular over the major aerosol emission regions. Under near-term warming, we find that regional climate change will depend strongly on the balance between aerosol and GHG forcing.

BH3-only protein Bim predicts advanced stage of cutaneous melanoma

BACKGROUND

Bim having strong pro-apoptotic effects belongs to the BH3-only proteins of the Bcl-2 protein family and contributes to survival pathways in cancer cells.

OBJECTIVES

We aimed to investigate Bim protein expression in cutaneous melanoma (CM).

METHODS

Bim protein expression was assessed by immunohistochemistry in primary and metastatic melanomas and correlated with clinical and histopathological features.

RESULTS

The Bim immunoreactivity score of the primary melanomas investigated (4.6 ± 1.5) was significantly (P < 0.0001) higher than that observed in metastases (2.8 ± 1.1). Low Bim expression was significantly associated with primary nodular melanoma type (P = 0.005). Moreover, Bim expression was significantly inversely correlated with tumour thickness (r = -0.36; P = 0.0035), advanced stage of disease (stage III and IV; r = -0.60; P < 0.0001), disease relapse (r = -0.18; P = 0.034) and disease-related death (r = -0.19; P = 0.026). Advanced stage of disease was independently predicted by low Bim expression (P = 0.0010, odds ratio: 0.22, 95% CI: 0.10-0.56) on multivariate analysis; however, Bim was not shown to be an independent predictor for disease relapse (P = 0.40) and disease-related death (P = 0.77).

CONCLUSIONS

Our data demonstrate that Bim protein expression is significantly inversely correlated with melanoma features that are associated with worse prognosis. We have shown that Bim protein expression in CM is an independent predictor for advanced disease confirming that this pro-apoptotic BH3-only protein might be a potent biomarker and promising therapeutic target.

Histopathological correlates of basal cell carcinoma in the slice and en face imaging modes of high-definition optical coherence tomography

BACKGROUND

High-definition optical coherence tomography (HD-OCT) scanners have recently been developed, providing significantly higher resolution than conventional OCT.

OBJECTIVES

To assess the relationship between recently defined histopathological HD-OCT correlates of basal cell carcinomas (BCC) and possible predictors for the most common tumour subtypes.

METHODS

For HD-OCT imaging, we used the Skintell(®) device. Twenty-five BCCs were histopathologically confirmed (including both vertical and horizontal haematoxylin and eosin and Alcian blue sectioning) and correlated with HD-OCT images.

RESULTS

In the en face mode, lobulated nodules were seen in 21/25 BCCs (84%), peripheral rimming in 18/25 (72%), epidermal disarray in 18/25 (72%) and variably refractile stroma in 22/25 (88%). In the slice imaging mode, we observed destruction of layering in 19/25 (76%) BCCs. In both the slice and en face modes a significant correlation was observed between peritumoral rimming and grey/dark oval structures and lobulated nodules. Alcian blue stains showed peritumoral mucin deposits correlating with peripheral rimming around the tumour nodules. In a logistic regression model, we did not observe significant independent micromorphological HD-OCT predictors for either the solid or superficial BCC subtypes.

CONCLUSIONS

In agreement with recent studies we have demonstrated that HD-OCT using the slice and en face imaging modes can visualize histopathological correlates of BCC, and potentially aid noninvasive diagnostics. However, using HD-OCT correlation it was not possible to predict the superficial or solid BCC subtypes. For the first time we have shown that peripheral rimming in HD-OCT correlates with peritumoral mucin deposition.

Next-generation sequencing of the basal cell carcinoma miRNome and a description of novel microRNA candidates under neoadjuvant vismodegib therapy: an integrative molecular and surgical case study

BACKGROUND

MicroRNAs (miRNAs) have been identified as key players in posttranscriptional gene regulation and have a significant impact on basal cell carcinoma (BCC) development. The Sonic hedgehog pathway inhibitor vismodegib has been approved for oral therapy of metastatic or advanced BCC. Here, a high-throughput miRNA sequencing analysis was carried out to identify differentially expressed miRNAs and possible novel miRNA candidates in vismodegib-treated BCC tissue. Additionally, we described our surgical experience with neoadjuvant oral vismodegib therapy.

PATIENTS AND METHODS

A punch biopsy (4 mm) from a patient with an extensive cranial BCC under oral vismodegib therapy and a corresponding nonlesional epithelial skin biopsy were harvested. Total RNA was isolated, after which a sequencing cDNA library was prepared, and cluster generation was carried out, which was followed by an ultra-high-throughput miRNA sequencing analysis to indicate the read number of miRNA expression based on miRBase 21. In addition to the identification of differentially expressed miRNAs from RNA sequencing data, additional novel miRNA candidates were determined with a tool for identifying new miRNA sequences (miRDeep2).

RESULTS

We identified 33 up-regulated miRNAs (fold change ≥2) and 39 potentially new miRNA candidates (miRDeep scores 0-43.6). A manual sequence analysis of the miRNA candidates on the genomic locus of chromosome 1 with provisional IDs of chr1_1913 and chr1_421 was further carried out and rated as promising (chr1_1913) and borderline (chr1_421). Histopathology revealed skip lesions in clinically healthy appearing skin at the tumor margins, which were the cause of seven re-excisions by micrographic controlled surgery to achieve tumor-free margins.

CONCLUSION

miRNA sequencing revealed novel miRNA candidates that need to be further confirmed in functional Dicer knockout studies. Clinically, on the basis of our surgical experience described here, neoadjuvant vismodegib therapy in BCC appears to impede histopathologic evaluations with effects on surgical therapy. Thus, larger studies are necessary, but are not preferable at this time if other options are available.

Comparison of lipidocolloid and chlorhexidine-impregnated tulle gras dressings following microscopically controlled surgery

OBJECTIVE

Modified microscopically controlled surgery (MCS) is a staged and margin-controlled excision; after MCS, the selection of an appropriate initial wound dressing plays an important role in wound healing. A wide range of dressings is available for temporary wound coverage; however, data comparing different types of wound dressings after MCS are lacking. The aim of this study was to compare two commonly used and commercially available types of wound dressings.

METHOD

We assessed pain levels, wound adherence, bleeding upon dressing removal and signs of infection, with chlorhexidine-impregnated tulle gras and a lipidocolloid dressing used for primary wound dressing following MCS.

RESULTS

A total of 42 patients were included. Adherence of the dressing to the wound (p<0.001) and bleeding after removal (p=0.001) were significantly higher in the chlorhexidine-impregnated tulle gras dressing group. Pain during removal of wound dressing had a higher visual analogue scale score (1.9 ± 2.2) in the chlorhexidine-impregnated tulle gras dressing group compared to 0.7 ± 1.0 in the lipidocolloid dressing group (p=0.022).

CONCLUSION

The results indicate that the lipidocolloid dressing, when compared with the chlorhexidine-impregnated tulle gras dressing, offers a significant benefit during removal in terms of less pain, less wound adherence and less wound bleeding.

DECLARATION OF INTEREST

The authors have no conflict of interest to declare.

New aeromagnetic and gravity compilations from Norway and adjacent areas: methods and applications

The Geological Survey of Norway (NGU) has produced new aeromagnetic and gravity maps from Norway and adjacent areas, compiled from ground, airborne and satellite data. Petrophysical measurements on core samples, hand specimens and onin situbedrock exposures are essential for the interpretation of these maps. Onshore, the most prominent gravity and magnetic anomalies are attributed to lower crustal rocks that have been brought closer to the surface. The asymmetry of the gravity anomalies along the Lapland Granulite Belt and Kongsberg–Bamble Complex, combined with the steep gradient, points to the overthrusted high-density granulites as being the main source of the observed anomalies. The Kongsberg–Bamble anomaly can be traced southwards through the Kattegat to southern Sweden. This concept of gravity field modelling can also be applied to the Mid-Norwegian continental shelf and could partially explain the observed high-density rocks occurring below the Møre and Vøring basins and in the Lofoten area. Extrapolations of Late-Caledonian detachment structures occurring on the mainland can be traced on aeromagnetic and gravimetric images towards the NW across the continental margin. Subcropping Late Palaeozoic to Cenozoic sedimentary units along the mid-Norwegian coast produce a conspicuous magnetic anomaly pattern. The asymmetry of the low-amplitude anomalies, with a steep gradient and a negative anomaly to the east and a gentler gradient to the west, relates the anomalies to gently westward dipping strata. Recent aeromagnetic surveys in the Barents Sea have revealed negative magnetic anomalies associated with shallow salt diapirs. Buried Quaternary channels partly filled with gravel and boulders of crystalline rocks generate magnetic anomalies in the North Sea. The new maps also show that the opening of the Norwegian–Greenland Sea occurred along stable continental margins without offsets across minor fracture zones, or involving jumps in the spreading axis. A triple junction formed at 48 Ma between the Lofoten and Norway Basins.

Flibanserin: A Potential Treatment for Hypoactive Sexual Desire Disorder in Premenopausal Women

Hypoactive Sexual Desire Disorder (HSDD) is defined as a persistent or recurrent deficiency of sexual fantasies and desire for sexual activity, which causes marked personal distress or interpersonal difficulty, and is not better accounted for by another psychiatric disorder or the direct physiological effects of a substance (e.g., a medication) or medical condition. HSDD is believed to be the most common form of Female Sexual Dysfunction and is associated with emotional distress and relationship problems. No pharmacologic therapy is approved for the treatment of HSDD in premenopausal or naturally postmenopausal women. Flibanserin is a 5-HT1A agonist/5-HT2A antagonist that is under investigation as a treatment for HSDD in women. The aim of this article is to present an overview of the pharmacology, clinical efficacy and safety of flibanserin. Flibanserin is an investigational drug that is not licensed for any indication in any country.

HIV-associated facial lipoatrophy--review of current therapy options

Highly active antiretroviral therapy (HAART) has dramatically improved the life expectancy for HIV-infected patients. Long-term complications of both HIV-infection and antiretroviral agents are therefore of increasing concern. Facial lipoatrophy (FLA) is a stigmatizing complication associated with sever social impact and a reduced quality of life for the patient. - We aimed to review the treatment options of HIV-associated FLA. The current treatments available for treating FLA are limited and can be classified in three main categories: I. Medial therapy, II. Injectables with different duration of effect, and III. Surgical treatment options. Medical therapy can provide a small benefit but improvement is, at best, slow and partial. Injectables can yield marked results but are costly, time consuming and may be associated with complications such as granuloma formation. Surgical options such as augmentation with specially designed silicone implants may be of benefit for severe cases of FLA, however, they are associated with higher surgical complications and do not account for the dynamic process of FLA. - To summarize, until today no ideal strategies for treatment of HIV-associated FLA are available, and new therapies are strongly required. heart disease.

Laser Doppler scanning study of axillary skin before and after liposuction curettage in patients with focal hyperhidrosis

BACKGROUND

Minimally invasive surgeries are frequently used in patients suffering from focal axillary hyperhidrosis (FAH). Sweat glands are removed surgically and the axillary skin is thinned out, with skin necrosis being a possible complication due to reduced microcirculation. Although of considerable interest, studies evaluating pre- and postoperative skin perfusion are unavailable.

OBJECTIVE

To evaluate the blood flow of axillary skin in patients with severe focal axillary hyperhidrosis before and after liposuction curettage (LC).

MATERIAL AND METHODS

The blood flow in the axillary skin of 11 patients was measured by laser Doppler perfusion imaging before surgery and on days 1, 7 and 28 after LC with a rasping cannula. Skin perfusion was measured in arbitrary units (AU) with measuring points in the axillary center (AC), the operated skin 2 cm from the center (2C) and the surrounding healthy skin (HS).

RESULTS

No significant differences of preoperative skin perfusion were found (AC: 0.39 +/- 0.08 AU/2C: 0.38 +/- 0.07 AU/HS: 0.39 +/- 0.07 AU; p > 0.05). On the first and seventh postoperative days, AC (0.2 +/- 0.04 AU/0.27 +/- 0.81 AU) and 2C (0.2 +/- 0.03 AU/0.28 +/- 0.06 AU) area were significantly less perfused, whereas the HS showed higher perfusion values (0.59 +/- 0.1 AU/0.53 +/- 0.09 AU). Twenty-eight days after LC the 2C (0.36 +/- 0.07 AU) and HS (0.4 +/- 0.06 AU) skin revealed no significant differences compared to preoperative skin perfusion (p > 0.05). The AC perfusion was still slightly reduced (0.37 +/- 0.09 AU) without significant difference compared to preoperative findings.

CONCLUSION

LC reduces the axillary skin blood flow with the axillary center being the least perfused area. However, in our collective, no correlation to possible side effects was observed.

Factors influencing lymph node harvest in colorectal surgery

BACKGROUND AND AIMS

Lymphadenectomy in colorectal cancer is a critical component concerning prognosis and survival of patients. Several variables influence the number of harvested lymph nodes (LN). However, results of studies are contradictory, and influencing factors remain to be identified. The aim of the present study was to identify factors that have a significant influence on the number of assessed LN in oncologic colorectal cancer resection.

MATERIALS AND METHODS

Three hundred and forty-one patients (190 men and 151 women), who underwent a colorectal cancer resection in a curative intention in the years 2000-2005, were analysed retrospectively. All specimens were histologically examined by two pathologists.

RESULTS

In a median, 15.1 LN per operation were resected. Early tumour stage (p<0.01), length of resected bowel segment (p<0.05) and right-sided location (p<0.001) had a significant influence on the number of resected LN. Age, gender, surgeon volume, differentiation of the tumour, LN metastases, lymphatic invasion and depth of tumour invasion had no significant association with harvested LN number. Furthermore, the presence or absence of the vermiform appendix and the length of the resected ileum segment in right-sided resections did not significantly affect the assessed LN.

CONCLUSION

The question arises whether for colorectal cancers of all locations the same amount of resected and analysed LNs should be lasting to fulfill oncologic criteria, as the number of harvested LNs depends on several parameters.

Repeat liposuction-curettage treatment of axillary hyperhidrosis is safe and effective

BACKGROUND

Liposuction-curettage (LC) is an effective surgical therapy option for axillary hyperhidrosis, with less scarring compared with radical excision of axillary skin. Although this method has proven to be effective, the treatment of nonresponders to minimally invasive surgery has not been previously defined. Whether these patients benefit from a second surgical procedure has not been evaluated so far.

OBJECTIVES

To investigate efficacy and side-effects of a second LC with an aggressive rasping cannula in patients with insufficient prior surgery.

METHODS

Nineteen nonresponders to prior LC (13 female and six male) underwent a second LC with a rasping cannula. Gravimetry was performed before and 8 months after surgery. Side-effects, patient satisfaction, the surgeons' intraoperative evaluation and the Vancouver Scar Scale (VSS) before and after surgery were documented.

RESULTS

Sweat rates showed a reduction of 69% in 17 (89%) patients. Two patients (11%) did not respond to surgery. Eighty-four per cent of all patients were completely satisfied or satisfied with postoperative results. No severe side-effects were observed. The surgeon reported slightly increased difficulties during dissection of dermis from subcutaneous fat in three patients. Assessment of scars showed an excellent aesthetic outcome (mean VSS 0.79 before vs. 1.1 after surgery).

CONCLUSIONS

LC using an aggressive cannula is an effective therapy option for patients with insufficient response to prior LC surgery, with a low risk of side-effects.

The multinational Men's Attitudes to Life Events and Sexuality study: the influence of diabetes on self-reported erectile function, attitudes and treatment-seeking patterns in men with erectile dysfunction

AIMS

To identify the prevalence of erectile dysfunction (ED) in men with diabetes, and to compare the perceptions of ED and the treatment-seeking behaviour of these men with men with ED without diabetes.

METHODS

Phase I of this multinational study involved 27,839 men who were questioned about a number of men's health issues including ED, diabetes and cardiovascular conditions (i.e. hypertension, high cholesterol and angina). Epidemiological associations between these conditions were explored. Phase II involved 2912 men with self-reported ED, aged 20-75 years. Participants completed questionnaires concerning their ED, efforts to seek treatment for their ED, and potential influences that might affect treatment-seeking behaviour. Comparison of these responses was made between men with ED and diabetes and men with ED without diabetes.

RESULTS

There was a clear association between self-reported ED and diabetes, hypertension, angina and high cholesterol. Men with diabetes were more likely to consider their ED to be severe and permanent and to speak to a physician or a nurse about their ED, compared with men without diabetes. Sildenafil use was similar in both groups, but men with diabetes were more likely to have discontinued use, mainly because of the lack of treatment efficacy.

CONCLUSION

Men with diabetes were more likely to consider their ED to be severe and permanent, compared with men without diabetes. Furthermore, men with diabetes were more likely to discontinue sildenafil therapy, primarily because of poor efficacy. These findings suggest a need for alternative treatments for ED, especially in men with diabetes.

Validation of optical coherence tomographyin vivousing cryostat histology

We aimed to validate for the first time optical coherence tomography (OCT) measurements of epidermal thickness (ET) using cryopreparation for histology. OCT assessments of ET were performed on healthy skin using the algorithms as follows: first, peak-to-valley analysis of the A-scan (ET-OCT-V), second, line-traced image analysis of the B-scan (ET-OCT-IA). Histology was performed using cryostat sections which were also evaluated using the image analysis (ET-Histo). We selected 114 samples, including B-scans and corresponding histology, for method comparison between ET-OCT-IA and ET-Histo. Forty-two A-scans were available for method comparison between ET-OCT-V and ET-Histo. Bland and Altman plots revealed a marked bias with wide 95% limits of agreement for ET-OCT-V versus ET-Histo. Comparison of ET-OCT-IA versus ET-Histo revealed only a slight bias and narrow 95% limits of agreement. A-scan analysis for ET determination is linked to significant limitations and lacks agreement with histology. By contrast, we observed satisfactory agreement between ET-OCT-IA and ET-Histo indicating that both methods can be utilized interchangeably. OCT using the line-traced image analysis of the B-scan appears to be a valid and relatively practicable method for the determination of ET in vivo. Furthermore, the comparisons with the in vivo OCT profiles demonstrate that cryostat sectioning provides a better preservation of relative and absolute dimensions of skin layers than paraffin embedding.

Epidermal thickness assessed by optical coherence tomography and routine histology: preliminary results of method comparison

BACKGROUND

Optical coherence tomography (OCT) is a promising non-invasive imaging technique for studying the epidermis and upper dermis in vivo. As proposed previously by Welzel et al. (J Am Acad Dermatol 1997; 37: 958-963), distance measurements between the entrance peak and the second peak of the A-scan seem to correspond to epidermal thickness (ET). However, there is a lack of systematic studies comparing OCT with histology.

METHODS

Sixteen healthy subjects were included in this pilot study. OCT assessments were conducted on the upper back. To determine ET by OCT, the distance between the entrance peak and the second peak of the A-scan was calculated (ET-OCT). After OCT measurement a 4 mm punch biopsy was taken on each subject from the same site previously assessed. The maximum thickness of the epidermis (ET-Histo) was determined microscopically using routine histological slices (formalin-paraffin technique, haematoxylin-eosin staining). Correlation and agreement between the two methods were assessed by means of the Pearson correlation procedure and Bland-Altman plots, respectively.

RESULTS

ET-Histo was 79.4 +/- 21.9 microm, including a stratum corneum thickness of 20 +/- 12.1 microm. OCT measurements resulted in an ET of 106 +/- 15.4 microm. No correlation between ET-Histo and ET-OCT was observed (r = 0.29, P = 0.27). There was a considerable lack of agreement between histology and OCT measurements as expressed in a high bias of 26.63 microm [95% confidence interval (CI) 14.49-38.77]. Furthermore, the lower 95% limits of agreement were -18.03 microm (95% CI -37.11 to 1.05) and the upper 95% limits of agreement were 71.28 microm (95% CI 52.2-90.36) indicating that ET-OCT may be 71.28 microm above or 18.03 microm below ET-Histo.

CONCLUSIONS

Our preliminary data suggest that the above-described OCT algorithm is probably not a valid measure for the evaluation of ET. The second peak of the A-scan seems not to correspond to the dermo-epidermal junction zone, but rather to fibrous structures in the upper dermis. Nevertheless, further systematic comparison studies between OCT and histology are warranted, using different OCT algorithms for ET determination and cryopreparation, which has a higher reliability than the formalin-paraffin technique.

Bilateral cheek-to-nose advancement flap: an alternative to the paramedian forehead flap for reconstruction of the nose

Skin cancer on the nose is commonly treated with surgical excision resulting in defects that require closure. The surgeon is faced with many reconstructive options. The paramedian forehead flap is one commonly used technique. In this study we describe the bilateral cheek-to-nose advancement flap as an alternative to the paramedian forehead flap in patients with strong nasolabial folds and prominent cheek tissue laxity, who require closure of MOHS surgery defects on the nasal dorsum and sidewall. Twelve patients were treated with the latter flap and evaluated after 2 weeks and 6 months. The patients' subjective and the surgeons' objective evaluation after 6 months were either completely satisfied or satisfied. The bilateral cheek-to-nose advancement flap is a reliable tool in the interventional portfolio of the reconstructive surgeon.