Development of health care workers' mental health during the SARS-CoV-2 pandemic in Switzerland: two cross-sectional studies

BACKGROUND

Virus outbreaks such as the current SARS-CoV-2 pandemic are challenging for health care workers (HCWs), affecting their workload and their mental health. Since both, workload and HCW's well-being are related to the quality of care, continuous monitoring of working hours and indicators of mental health in HCWs is of relevance during the current pandemic. The existing investigations, however, have been limited to a single study period. We examined changes in working hours and mental health in Swiss HCWs at the height of the pandemic (T1) and again after its flattening (T2).

METHODS

We conducted two cross-sectional online studies among Swiss HCWs assessing working hours, depression, anxiety, and burnout. From each study, 812 demographics-matched participants were included into the analysis. Working hours and mental health were compared between the two samples.

RESULTS

Compared to prior to the pandemic, the share of participants working less hours was the same in both samples, whereas the share of those working more hours was lower in the T2 sample. The level of depression did not differ between the samples. In the T2 sample, participants reported more anxiety, however, this difference was below the minimal clinically important difference. Levels of burnout were slightly higher in the T2 sample.

CONCLUSIONS

Two weeks after the health care system started to transition back to normal operations, HCWs' working hours still differed from their regular hours in non-pandemic times. Overall anxiety and depression among HCWs did not change substantially over the course of the current SARS-CoV-2 pandemic.

Burnout, depression and anxiety among Swiss medical students - A network analysis

It is well established that burnout in medical students is associated with depression and anxiety at a syndromal level. Moreover, there is an ongoing debate about the extent to which burnout overlaps with depression and anxiety. The emerging network approach to psychopathology offers a new perspective on the interrelations between mental disorders focusing on symptom-level association. In this cross-sectional study, we exploratively investigated the associations among burnout, depression, and anxiety in 574 swiss medical students using a network analytic approach for the first time. Symptoms of depression and anxiety were assessed with the Patient Health Questionnaire and Generalized Anxiety Disorder respectively. Burnout was assessed with two single-item questions, one referring to emotional exhaustion and the other to depersonalization. We found a dense network in which at least one dimension of burnout was related to eleven of the sixteen included symptoms. This suggests that burnout is closely related to depression and anxiety but also has its own characteristics. Notably, suicidal ideation was not associated with either emotional exhaustion or depersonalization after adjusting for the influence of the remaining symptoms of anxiety and depression. Hence, the well-documented relationship between burnout and suicidal ideation in medical students may be entirely mediated by the experience of anxiety and depression. Hence, the well-documented relationship between burnout and suicidal ideation in medical students might be fully mediated by the experience of anxiety and depression. The collection of the sample after the first wave of infections during the SARS-CoV2 pandemic and the non-representativeness of the investigated sample limit the study's generalizability.

Health Care Workers' Mental Health During the First Weeks of the SARS-CoV-2 Pandemic in Switzerland-A Cross-Sectional Study

Objective: The current SARS-CoV-2 pandemic poses various challenges for health care workers (HCWs). This may affect their mental health, which is crucial to maintain high quality medical care during a pandemic. Existing evidence suggests that HCWs, especially women, nurses, frontline staff, and those exposed to COVID-19 patients, are at risk for anxiety and depression. However, a comprehensive overview of risk and protective factors considering their mutual influence is lacking. Therefore, this study aimed at exploring HCWs' mental health during the SARS-CoV-2 pandemic in Switzerland, investigating the independent effect of various demographic, work- and COVID-related factors on HCWs' mental health. Methods: In an exploratory, cross-sectional, nation-wide online survey, we assessed demographics, work characteristics, COVID-19 exposure, and anxiety, depression, and burnout in 1,406 HCWs during the beginning of the SARS-CoV-2 pandemic in Switzerland. Network analysis was used to investigate the associations among the included variables. Results: Women (compared to men), nurses (compared to physicians), frontline staff (compared to non-frontline workers), and HCWs exposed to COVID-19 patients (compared to non-exposed) reported more symptoms than their peers. However, these effects were all small. Perceived support by the employer independently predicted anxiety and burnout after adjustment for other risk factors. Conclusion: Our finding that some HCWs had elevated levels of anxiety, depression, and burnout underscores the importance to systematically monitor HCWs' mental health during this ongoing pandemic. Because perceived support and mental health impairments were negatively related, we encourage the implementation of supportive measures for HCWs' well-being during this crisis.

Health Care Workers' Mental Health During the First Weeks of the SARS-CoV-2 Pandemic in Switzerland-A Cross-Sectional Study

Objective: The current SARS-CoV-2 pandemic poses various challenges for health care workers (HCWs). This may affect their mental health, which is crucial to maintain high quality medical care during a pandemic. Existing evidence suggests that HCWs, especially women, nurses, frontline staff, and those exposed to COVID-19 patients, are at risk for anxiety and depression. However, a comprehensive overview of risk and protective factors considering their mutual influence is lacking. Therefore, this study aimed at exploring HCWs' mental health during the SARS-CoV-2 pandemic in Switzerland, investigating the independent effect of various demographic, work- and COVID-related factors on HCWs' mental health. Methods: In an exploratory, cross-sectional, nation-wide online survey, we assessed demographics, work characteristics, COVID-19 exposure, and anxiety, depression, and burnout in 1,406 HCWs during the beginning of the SARS-CoV-2 pandemic in Switzerland. Network analysis was used to investigate the associations among the included variables. Results: Women (compared to men), nurses (compared to physicians), frontline staff (compared to non-frontline workers), and HCWs exposed to COVID-19 patients (compared to non-exposed) reported more symptoms than their peers. However, these effects were all small. Perceived support by the employer independently predicted anxiety and burnout after adjustment for other risk factors. Conclusion: Our finding that some HCWs had elevated levels of anxiety, depression, and burnout underscores the importance to systematically monitor HCWs' mental health during this ongoing pandemic. Because perceived support and mental health impairments were negatively related, we encourage the implementation of supportive measures for HCWs' well-being during this crisis.

The p38 Mitogen-Activated Protein Kinase Critically Regulates Human Keratinocyte Inflammasome Activation

Inflammasomes are key intracellular signaling platforms involved in innate immune responses to micro-organisms and danger signals. Extracellular signal-regulated kinase, Jun N-terminal kinase, and p38 mitogen-activated protein kinase family members are activated by numerous environmental stresses. Recently, it has been reported that Jun N-terminal kinase is involved in inflammasome activation in myeloid immune cells. To date, the role of mitogen-activated protein kinase in inflammasome activity in keratinocytes has not been investigated. Here, we show that, in primary human keratinocytes, p38 mitogen-activated protein kinase is required for inflammasome activation and IL-1β secretion. Using selective small molecule inhibitors, small interfering RNA gene silencing, and CRISPR/Cas9-based deletion, we demonstrate the above and identify p38α and p38δ as critical regulators of ASC oligomerization, inflammasome activation, and IL-1β secretion in keratinocytes. Furthermore, our data suggest that the nature of the mitogen-activated protein kinase regulating inflammasome activity exhibits a certain cell specificity, with p38 playing a predominant role in keratinocytes and Jun N-terminal kinase 1 in cells of myeloid origin.

Tumour hypoxia promotes melanoma growth and metastasis via High Mobility Group Box-1 and M2-like macrophages

Hypoxia is a hallmark of cancer that is strongly associated with invasion, metastasis, resistance to therapy and poor clinical outcome. Tumour hypoxia affects immune responses and promotes the accumulation of macrophages in the tumour microenvironment. However, the signals linking tumour hypoxia to tumour-associated macrophage recruitment and tumour promotion are incompletely understood. Here we show that the damage-associated molecular pattern High-Mobility Group Box 1 protein (HMGB1) is released by melanoma tumour cells as a consequence of hypoxia and promotes M2-like tumour-associated macrophage accumulation and an IL-10 rich milieu within the tumour. Furthermore, we demonstrate that HMGB1 drives IL-10 production in M2-like macrophages by selectively signalling through the Receptor for Advanced Glycation End products (RAGE). Finally, we show that HMGB1 has an important role in murine B16 melanoma growth and metastasis, whereas in humans its serum concentration is significantly increased in metastatic melanoma. Collectively, our findings identify a mechanism by which hypoxia affects tumour growth and metastasis in melanoma and depict HMGB1 as a potential therapeutic target.

RADIOMETRIC NORMALIZATION OF LARGE AIRBORNE IMAGE DATA SETS ACQUIRED BY DIFFERENT SENSOR TYPES

Generating seamless mosaics of aerial images is a particularly challenging task when the mosaic comprises a large number of im-ages, collected over longer periods of time and with different sensors under varying imaging conditions. Such large mosaics typically consist of very heterogeneous image data, both spatially (different terrain types and atmosphere) and temporally (unstable atmo-spheric properties and even changes in land coverage). <br><br> We present a new radiometric normalization or, respectively, radiometric aerial triangulation approach that takes advantage of our knowledge about each sensor’s properties. The current implementation supports medium and large format airborne imaging sensors of the Leica Geosystems family, namely the ADS line-scanner as well as DMC and RCD frame sensors. A hierarchical modelling – with parameters for the overall mosaic, the sensor type, different flight sessions, strips and individual images – allows for adaptation to each sensor’s geometric and radiometric properties. Additional parameters at different hierarchy levels can compensate radiome-tric differences of various origins to compensate for shortcomings of the preceding radiometric sensor calibration as well as BRDF and atmospheric corrections. The final, relative normalization is based on radiometric tie points in overlapping images, absolute radiometric control points and image statistics. It is computed in a global least squares adjustment for the entire mosaic by altering each image’s histogram using a location-dependent mathematical model. This model involves contrast and brightness corrections at radiometric fix points with bilinear interpolation for corrections in-between. The distribution of the radiometry fixes is adaptive to each image and generally increases with image size, hence enabling optimal local adaptation even for very long image strips as typi-cally captured by a line-scanner sensor. <br><br> The normalization approach is implemented in HxMap software. It has been successfully applied to large sets of heterogeneous imagery, including the adjustment of original sensor images prior to quality control and further processing as well as radiometric adjustment for ortho-image mosaic generation.

IL-1β drives inflammatory responses to propionibacterium acnes in vitro and in vivo

Acne vulgaris is potentially a severe skin disease associated with colonization of the pilo-sebaceous unit by the commensal bacterium Propionibacterium acnes and inflammation. P. acnes is considered to contribute to inflammation in acne, but the pathways involved are unclear. Here we reveal a mechanism that regulates inflammatory responses to P. acnes. We show that IL-1β mRNA and the active processed form of IL-1β are abundant in inflammatory acne lesions. Moreover, we identify P. acnes as a trigger of monocyte-macrophage NLRP3-inflammasome activation, IL-1β processing and secretion that is dependent on phagocytosis, lysosomal destabilization, reactive oxygen species, and cellular K+ efflux. In mice, inflammation induced by P. acnes is critically dependent on IL-1β and the NLRP3 inflammasome of myeloid cells. These findings show that the commensal P. acnes-by activating the inflammasome-can trigger an innate immune response in the skin, thus establishing the NLRP3-inflammasome and IL-1β as possible therapeutic targets in acne.

Epidermal IL-15Rα acts as an endogenous antagonist of psoriasiform inflammation in mouse and man

Stromal cells at epithelial surfaces contribute to innate immunity by sensing environmental danger signals and producing proinflammatory cytokines. However, the role of stromal cells in controlling local inflammation is unknown. We show that endogenous soluble IL-15 receptor α (IL-15Rα) derived from epidermal stroma, notably keratinocytes, protects against dendritic cell/IL-15-mediated, T cell-driven skin inflammation in vivo, and is relevant to human psoriasis. Selective lack of IL-15Rα on stromal epidermal cells exacerbated psoriasiform inflammation in animals. Epidermal IL-15Rα was shed by keratinocytes via proteolytic cleavage by matrix metalloproteinases upon stimulation with proinflammatory cytokines to counteract IL-15-induced proliferation of IL-17(+) αβ and γδ T cells and production of TNF, IL-23, IL-17, and IL-22 during skin inflammation. Notably, administration of soluble IL-15Rα was able to repress secretion of IL-1β, IL-6, and TNF by keratinocytes, dampen expansion of IL-17(+) αβ and γδ T cells in vivo, and prevent psoriasis in two mouse models, including human xenograft AGR mice. Serum levels of soluble IL-15Rα negatively correlated with disease severity, and levels rose upon successful treatment of psoriasis in patients. Thus, stressed epidermal stromal cells use soluble IL-15Rα to dampen chronic inflammatory skin disease.

Carcinogen treatment in mouse selectively expressing activated N-Ras Q61K in melanocytes recapitulates metastatic cutaneous melanoma development

The incidence of melanoma has significantly increased, and a better understanding of its pathogenesis and development of new therapeutic strategies are urgently needed. Here, we describe a murine model of metastatic cutaneous melanoma using C57BL/6 mice expressing a mutated human N-Ras gene under the control of a tyrosinase promoter (TyrRas). These mice were topically exposed to 7,12- dimethylbenzanthracene (DMBA) for brief exposure periods. Cutaneous melanoma developed at the site of exposure on average by 19 weeks of age and in 80% of mice. Importantly, as in humans, melanoma development was associated with subsequent metastasis to tumor-draining lymph nodes. Critically, such metastatic behavior is transplantable, as intradermal inoculation of melanoma cells from TyrRas-DMBA mice into non-transgenic mice led to the growth of melanoma and, again, metastasis to skin-draining lymph nodes. This metastatic melanoma model closely mimics human pathology and should be a useful tool for studying melanoma pathogenesis and developing new therapies.

Dermoscopy of Pitted Keratolysis

Irritated hyperhidrotic soles with multiple small pits are pathognomonic for pitted keratolysis (PK). Here we show the dermatoscopic view of typical pits that can ensure the diagnosis. PK is a plantar infection caused by Gram-positive bacteria, particularly Corynebacterium. Increases in skin surface pH, hyperhidrosis, and prolonged occlusion allow these bacteria to proliferate. The diagnosis is fundamentally clinical and treatment generally consists of a combination of hygienic measures, correcting plantar hyperhidrosis and topical antimicrobials.

Development of a heterologous, multigenotype vaccine against hepatitis C virus infection

BACKGROUND

Unquestionably viral diversity and genetic heterogeneity in hepatitis C virus (HCV) infection and other viral diseases play an essential role in viral immune escape and the development of chronicity. Despite this knowledge most vaccine approaches against HCV have excluded this important issue. Moreover the feasibility of developing an effective HCV vaccine has been questioned, mainly because prophylactic immunity against HCV cannot be achieved in chimpanzees by either vaccination or previous HCV infection, and reinfection in men has been reported, most likely due to genetic shift and immune escape. To analyse and characterize a new technique of a 'multigenotype'- and/or 'library'-vaccine, we established an envelope 1 (E1) plasmid vaccine against HCV and characterized humoral and cellular immune responses after vaccination in a mouse model.

MATERIAL AND METHODS

Normally genetic information of one or two target proteins is cloned into a DNA-vaccine. In our approach we cloned a defined number of different genotypes and subtypes (defined vaccine, DV) or the genetic information from 20 patients (undefined) into a plasmid (library vaccine, LV).

RESULTS

As expected, immunized animals showed both stronger humoral (ELISA) and cellular (T-cell proliferation, ELISPOT) immune responses against genotype 1, since the stimulating antigen was genotype 1 derived. However, not all genotype 1 immunized animals recognized this viral antigen leading to the assumption that some epitopes lost their immunogenicity through a change in the amino acid sequence. Interestingly, some of the genotype 4 and 5 immunized mice sera were able to react against E1 protein.

CONCLUSION

Most of the assays showed immune reactivity against the DV or LV vaccine demonstrating the cross-reactive potential of such a vaccination approach. This cloning and immunization strategy based on the viral heterogeneity of the virus has in our view major implications for HCV, a virus with a broad viral genetic diversity, and may become in the future in the context of DNA- or viral-based vaccination strategies a possibility to overcome viral immune escape both in the prophylactic or therapeutic setting.

Gender-specific expression of liver organic anion transporters in rat

BACKGROUND

Sex differences in drug pharmacokinetics have been well recognized and gender has been considered a risk factor for adverse events to medications. The aim of this study was to investigate the effect of gender on the expression of hepatocellular transport proteins involved in uptake and secretion of organic anions in rat.

MATERIALS AND METHODS

Expression of the rat liver organic anion transporting polypeptides (Oatps) and multidrug resistance proteins (Mrps) was analysed by reverse transcription polymerase chain reaction (RT-PCR), immunoblot analysis and immunofluorescence microscopy in male and female rats. Regulation of these transport proteins in response to the steroid dehydroepiandrosterone (DHEA) was investigated.

RESULTS

In untreated rats, protein expression significantly differed between genders being higher (Mrp2, Mrp3), comparable [Oatp1a1 (Oatp1); Oatp1b2 (Oatp4)] or lower [Oatp1a4 (Oatp2)] in female than in male rat. DHEA treatment over 3 days (100 mg d(-1)) led to a further increase in Mrp3 expression only in female rats. Mrp2 expression was not influenced by DHEA treatment. Oatp1a1 and Oatp1b2 were significantly down-regulated after DHEA treatment in both male and female rats. In contrast, Oatp1a4 was down-regulated in male rats only.

CONCLUSIONS

In rat, liver transport proteins of the Oatp and Mrp family are expressed and regulated in a gender-specific manner according to sexual differences in the hepatic metabolism of steroids and drugs. These findings may partly explain the well-known sex differences in hepatic handling of organic anions.

[A young diabetic with small-nodule liver cirrhosis, high transferrin saturation and negative HFE test]

HISTORY

A 28 year young female presented to our hospital for further evaluation with recently diagnosed diabetes mellitus, hyperpigmentation of the skin, hepato- and splenomegaly, thrombocytopenia and an elevated transferrin saturation (96 %), but a negative test for HFE gene mutations such as C282Y and H63D.

FINDINGS

Using the mini-laparascopic technique we diagnosed a smallnodular liver cirrhosis with an iron overload.

DIAGNOSIS AND TREATMENT

This is the clinical presentation of one subtype of the so called Non-HFE-hemochromatosis, the juvenile hemochromatosis (HFE2). Other causes of primary and secondary iron overload have been ruled out. Different from the HFE-positive hemochromatosis (HFE 1) in which the gene defect is located on chromosome 6, the defect in HFE 2 is located on chromosome 1. The underlying genetic defect has been localized within recently identified HJV gene. Phlebotomy is the treatment of choice, to be performed until the ferritin level is lower than 50 microg/l.

CONCLUSIONS

If liver cirrhosis is present in hemochromatosis, the overall risk of developing heptatocellular carcinoma is 20 times higher than in the normal population. Therefore it is suggested to perform an ultrasound examination of the liver and an AFP-test every 6 months, whereas an MRI-scan should be performed once a year, as a basis for further treatment options.

Identification of two new HLA alleles: B*3546* and B*5611*. How reliable are the published HLA-B intron 2 sequences?

Polymerase chain reaction-sequence-specific primer (PCR-SSP) typing for human leukocyte antigen (HLA)-B in a male 25-year-old Caucasian individual of Iranian origin and in a 42-year-old German Caucasian bone marrow donor revealed reaction patterns that did not agree with any known HLA specificity, thus suggesting in both cases the existence of a novel allele. Sequence-based typing (SBT) after allelic separation revealed the sequences of the new alleles HLA-B*5611 and B*3546. The sequence patterns of both new alleles might have been generated as the results of double crossing over, possibly over several generations. During the analysis of the HLA-B*3546 intron 2 sequence for possible crossing over points, a base insert, an additional G after position 700, was found. This insert was analyzed using SBT and PCR-SSP and was found to be present not only in all samples carrying B*35, but also in all HLA-B specificities tested. It appears that all known HLA-B alleles may contain a G insert at position 700 of intron 2, and that the published intron 2 sequence alignments of the HLA-B locus may contain errors at this position.

Effect of alpha-lipoic acid on the progression of endothelial cell damage and albuminuria in patients with diabetes mellitus: an exploratory study

Oxidative stress plays a central role in the pathogenesis and progression of late microangiopathic complications (diabetic nephropathy) in diabetes mellitus. Previous studies suggested that treatment of diabetic patients with the antioxidant alpha-lipoic acid reduce oxidative stress and urinary albumin excretion. In this prospective, open and non-randomized study, the effect of alpha-lipoic acid on the progression of endothelial cell damage and the course of diabetic nephropathy, as assessed by measurement of plasma thrombomodulin and urinary albumin concentration (UAC), was evaluated in 84 patients with diabetes mellitus over 18 months. Forty-nine patients (34 with Type 1 diabetes, 15 with Type 2 diabetes) had no antioxidant treatment and served as a control group. Thirty-five patients (20 with Type 1 diabetes, 15 with Type 2 diabetes) were treated with 600 mg alpha-lipoic acid per day. Only patients with an urinary albumin concentration <200 mg/l were included into the study. After 18 months of follow up, the plasma thrombomodulin level increased from 35.9+/-9.5 to 39.7+/-9.9 ng/ml (P<0.05) in the control group. In the alpha-lipoic acid treated group the plasma thrombomodulin level decreased from 37.5+/-16.2 to 30.9+/-14.5 ng/ml (P<0.01). The UAC increased in patients without alpha-lipoic acid treatment from 21.2+/-29.5 to 36.9+/-60.6 ng/l (P<0.05), but was unchanged with alpha-lipoic acid. It is postulated that the significant decrease in plasma thrombomodulin and failure of UAC to increase observed in the alpha-lipoic acid treated group is due to antioxidative effects of alpha-lipoic acid, and if so that oxidative stress plays a central role in the pathogenesis of diabetic nephropathy. Furthermore, progression of the disease might be inhibited by antioxidant drugs. A placebo-controlled study is needed.

Hepatic iron overload in aceruloplasminaemia

We report the case of a 52 year old male with diabetes mellitus and long standing evidence of hepatic iron excess. Initially considered to have haemochromatosis, this patient was reevaluated when hepatic iron stores were found to be unaffected by a prolonged course of weekly phlebotomy. The development of neurological disease prompted diagnostic consideration of aceruloplasminaemia, which we confirmed by demonstration of a novel frameshift mutation in the ceruloplasmin gene. Our inability to resolve the patient's iron overload by regular phlebotomy is consistent with recent animal studies indicating an essential role for ceruloplasmin in cellular iron efflux. Evaluation of this case underscores the clinical relevance of aceruloplasminaemia in the differential diagnosis of hepatic iron overload and provides insight into the pathogenetic mechanisms of hepatocellular iron storage and efflux.

[Flu-like infection and liver disease after a stay in the tropics]

HISTORY AND ADMISSION FINDINGS

A 38-year-old patient, an experienced traveller to the tropics, fell ill with a flu-like infection, a fever of up to 38.6 degrees C and nausea on returning from an 8-week trip to southern Africa (Namibia, Zambia and Zimbabwe). Physical examination was unremarkable, except for slight physical debility. His father had died of liver cirrhosis of unknown aetiology, aged 68 years.

INVESTIGATIONS

Laboratory tests revealed eosinophilia (12% on a count of 7,800 WBC/microliter, increased transaminase activities [SGPT 142 U/l, SGOT 50 U/l, gamma GT 32 U/l], slightly increased serum ferritin [1057 ng/dl], but normal serum iron and transferrin levels). Untreated stool contained Schistosoma mansoni eggs. Tests for a haemochromatosis gene and its type showed a homozygotic C282Y variant. Liver biopsy demonstrated chronic portal hepatitis with parenchymal transformation and marked haemosiderin deposits in liver epithelium.

DIAGNOSIS, TREATMENT AND COURSE

The schistosomiasis was treated with praziquantel, 40 mg/kg by mouth on one day, divided in three doses, without complication. The haemochromatosis was treated symptomatically, at first by weekly bloodletting 500 ml while monitoring serum ferritin concentration. Life-long bloodletting at longish intervals is anticipated.

CONCLUSIONS

The incidence of some infectious diseases has greatly risen as a result of an increase in tourism to distant lands. In particular, the diagnosis of frequent parasitic diseases should become part of the expertise in internal medicine. The combination of several diseases should be considered in the differential diagnosis.