COVID-19 and chronic rhinosinusitis: management and comorbidity - what have we learned?

INTRODUCTION

Approximately 5%-12% of the population worldwide suffer from chronic rhinosinusitis (CRS). CRS is defined as a chronic respiratory disease and is considered to be a risk factor for COVID-19 patients.

AREAS COVERED

A non-systematic literature research was conducted on COVID-19 and treatment options for CRSwNP. The latest international publications in medical databases, international guidelines, and the internet were reviewed. Since there were no publications on all aspects of this topic during the pandemic, we included our own experience in this report. Based on the conducted literature research in addition to our previously reported experience, we discuss the treatment of CRSwNP during the COVID-19 pandemic and what can be taken for future pandemics.

EXPERT OPINION

Intranasal corticosteroids remain the standard treatment for CRS in patients with SARS-CoV-2 infection. Indications for surgical treatment of CRS should be critically evaluated and reserved for patients with complications and those with no other treatment options. For this purpose, COVID-19 status should be known if possible and, in case of unclear status (emergency), using appropriate personal protective equipment. Systemic corticosteroids should be avoided were possible. Biological treatment should be continued under careful monitoring in uninfected patients and should be temporarily interrupted during COVID-19 infection.

[Neuroimmunology of allergic rhinitis part 2 : Interactions of neurons and immune cells and neuroimmunological units]

Allergic rhinitis is an IgE-mediated, type‑2 inflammatory disease. neuropeptides are released by neurons and interact with immune cells. Via colocalization, neuroimmune cell units such as nerve-mast cell units, nerve-type 2 innate lymphoid cell (ILC2) units, nerve-eosinophil units, and nerve-basophil units are formed. Markedly elevated tryptase levels were found in nasal lavage fluid and were strongly associated with neuropeptide levels. A close anatomical connection allows bidirectional communication between immune and neuronal cells. Transient receptor potential vanilloid 1 (TRPV1) and transient receptor potential ankyrin repeat 1 (TRPA1) are critically involved in immunological reactions in the setting of allergic rhinitis. Neuroimmunological communication plays an important role in the inflammatory process, so that allergic rhinitis can no longer be considered a purely immunological disease, but rather a combined neuroimmunological disease.

[Neuroimmunology of allergic rhinitis : Part 1: Cellular and humoral basic principles]

Allergic rhinitis (AR) is a very common disease with a high prevalence worldwide. It is an IgE-mediated type 2 inflammatory disease following exposure to inhalant allergens. A multitude of different neuropeptides including substance P, vasoactive intestinal peptide (VIP), calcitonin gene-related peptide (CGRP), nerve growth factor (NGF), and neuromedin U (NMU) can be released via peripheral axon or central reflexes, interact with immune cells, and thus contribute to neurogenic inflammation which causes the nasal hyperreactivity (NHR) characteristic of AR. Independent production of neuroendocrine hormones and neuropeptides by immune cells has also been demonstrated. Neuro-immune cell units arise when immune and neuronal cells colocalize, for which typical anatomic regions are, e.g., the mast cell-nerve functional unit. The focus of this review is the elucidation of neuroimmune communication mechanisms in AR.

Positionspapier: ICD-Codierung der chronischen Rhinosinusitis mit Nasenpolypen (CRSwNP) im ICD-10-GM als Grundlage für eine Therapie mit Biologika – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA), der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) und des Deutschen CRS-Registers

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der Schleimhäute von Nase und Nasennebenhöhlen. In Deutschland sind 3 verschiedene monoklonale Antikörper für die Indikation „Zusatztherapie zu intranasalen Glukokortikosteroiden für die Behandlung Erwachsener mit schwerer chronischer Rhinosinusitis mit Nasenpolypen“ zugelassen. Um die Verordnung in der zugelassenen Indikation (In-Label) zu dokumentieren, ist neben einer Dokumentation zahlreicher medizinischer Parameter die korrekte Auswahl der ICD-10-GM-Codierung entscheidend. Hierfür existieren in Deutschland bislang keine konsentierten Empfehlungen.

Methoden Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium von AeDA, DGHNO-KHC und Deutschem CRS-Register Codierungsmöglichkeiten von CRS und CRSwNP analysiert und auf dieser Basis eine konsentierte Empfehlung für die ICD-10-GM-Codierung in Deutschland ausgesprochen.

Ergebnis Die Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme ICD-10-GM (International Classification of Diseases, 10. Revision, German Modification) ist die amtliche Klassifikation zur Verschlüsselung von Diagnosen in der ambulanten und stationären Versorgung in Deutschland. Der ICD-10-GM unterscheidet nicht adäquat zwischen heute anerkannten klinischen und immunologischen Differenzierungen der CRSsNP und der CRSwNP. Dennoch wird insbesondere bei indiziertem Einsatz von Biologika in der Therapie der schweren CRSwNP eine möglichst exakte Verschlüsselung mit den Codes J33.8 (im Einzelfall J33.1 oder J33.9) empfohlen.

Schlussfolgerungen Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue Behandlungsansätze mit monoklonalen Antikörpern für Patienten mit schwerer, unkontrollierter Erkrankung. Hier geben wir Empfehlungen für eine adäquate ICD-10-GM-Codierung in Deutschland.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

Protein quality as a complementary functional unit in life cycle assessment (LCA)

GOAL AND THEORETICAL COMMENTARY

A number of recent life cycle assessment (LCA) studies have concluded that animal-sourced foods should be restricted-or even avoided-within the human diet due to their relatively high environmental impacts (particularly those from ruminants) compared with other protein-rich foods (mainly protein-rich plant foods). From a nutritional point of view, however, issues such as broad nutrient bioavailability, amino acid balances, digestibility and even non-protein nutrient density (e.g., micronutrients) need to be accounted for before making such recommendations to the global population. This is especially important given the contribution of animal sourced foods to nutrient adequacy in the global South and vulnerable populations of high-income countries (e.g., children, women of reproductive age and elderly). Often, however, LCAs simplify this reality by using 'protein' as a functional unit in their models and basing their analyses on generic nutritional requirements. Even if a 'nutritional functional unit' (nFU) is utilised, it is unlikely to consider the complexities of amino acid composition and subsequent protein accretion. The discussion herein focuses on nutritional LCA (nLCA), particularly on the usefulness of nFUs such as 'protein,' and whether protein quality should be considered when adopting the nutrient as an (n)FU. Further, a novel and informative case study is provided to demonstrate the strengths and weaknesses of protein-quality adjustment.

CASE STUDY METHODS

To complement current discussions, we present an exploratory virtual experiment to determine how Digestible Indispensable Amino Acid Scores (DIAAS) might play a role in nLCA development by correcting for amino acid quality and digestibility. DIAAS is a scoring mechanism which considers the limiting indispensable amino acids (IAAs) within an IAA balance of a given food (or meal) and provides a percentage contribution relative to recommended daily intakes for IAA and subsequent protein anabolism; for clarity, we focus only on single food items (4 × animal-based products and 4 × plant-based products) in the current case exemplar. Further, we take beef as a sensitivity analysis example (which we particularly recommend when considering IAA complementarity at the meal-level) to elucidate how various cuts of the same intermediary product could affect the interpretation of nLCA results of the end-product(s).

RECOMMENDATIONS

First, we provide a list of suggestions which are intended to (a) assist with deciding whether protein-quality correction is necessary for a specific research question and (b) acknowledge additional uncertainties by providing mitigating opportunities to avoid misinterpretation (or worse, dis-interpretation) of protein-focused nLCA studies. We conclude that as relevant (primary) data availability from supply chain 'gatekeepers' (e.g., international agri-food distributors and processors) becomes more prevalent, detailed consideration of IAA provision of contrasting protein sources needs to be acknowledged-ideally quantitatively with DIAAS being one example-in nLCA studies utilising protein as a nFU. We also contend that future nLCA studies should discuss the complementarity of amino acid balances at the meal-level, as a minimum, rather than the product level when assessing protein metabolic responses of consumers. Additionally, a broader set of nutrients should ideally be included when evaluating "protein-rich foods" which provide nutrients that extend beyond amino acids, which is of particular importance when exploring dietary-level nLCA.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Dupilumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the nasal and paranasal mucosa. A Type-2 inflammation is described as the most common endotype. Since October 2019 the anti-IL-4/-IL-13 antibody dupilumab has been approved in Germany as an add-on therapy to intranasal corticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps, when systemic corticosteroids alone or surgery do not provide adequate disease control. While recommendations for the use of dupilumab in CRSwNP exist at both national and international levels, until now it has not been adequately established, how therapy should be monitored and when it should be discontinued in the German Health Care System.

METHODS

 A literature search was performed analyzing previous data on the treatment of CRSwNP with dupilumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to 05/2022 were included.

RESULTS

 Based on international literature and previous experience, recommendations are given by an expert panel for follow-up and possible therapy breaks, therapy intervals or termination of therapy when using dupilumab for the indication CRSwNP in the German health care system based on a documentation form.

CONCLUSIONS

 Understanding the immunological basis of CRSwNP opens new non-surgical therapy approaches with biologics for patients with severe courses. The authors give recommendations for follow-up, possible therapy breaks, therapy intervals and a termination for dupilumab treatment as add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP that cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Mepolizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the paranasal sinus mucosa with eosinophilic inflammation as the most common endotype. The anti-IL5 antibody mepolizumab was approved for the treatment of severe CRSwNP in the EU in November 2021.

METHODS

 A literature search was performed to analyze the immunology of CRSwNP and determine the available evidence by searching Medline, Pubmed, and the German national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 12/2021 that investigated the effect of mepolizumab in CRSwNP were considered.

RESULTS

 Based on the international literature and previous experience, recommendations for the use of mepolizumab in CRSwNP in the German health care system are given by an expert panel on the basis of a documentation form.

CONCLUSIONS

 Understanding about the immunological basis of CRSwNP opens new non-surgical therapeutic approaches with biologics for patients with severe courses. Mepolizumab is approved since November 2021 for add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP who cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Omalizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine TH2-Inflammation zugrunde liegt. IgE-Antikörper spielen dabei eine wichtige Rolle. Der anti-IgE-Antikörper Omalizumab wurde im August 2020 für die Therapie der schweren CRSwNP zugelassen.

Methoden In einer Literatursuche wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Omalizumab bei dieser Erkrankung ermittelt durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinien-Registern und der Cochrane Library.

Ergebnisse Basierend auf diesen Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Omalizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung Omalizumab ist zugelassen für Patienten ab 18 Jahren mit schwerer chronischer Rhinosinusitis mit Nasenpolypen als Zusatztherapie zu intranasalen Kortikosteroiden (INCS), wenn durch eine Therapie mit INCS keine ausreichende Krankheitskontrolle erzielt werden kann.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.

The toll of noninfected CRS patients to the COVID-19 pandemic

Social distancing with the aim of avoiding infections and pre-serve critical care capacities during the COVID-19 pandemic has been implemented in Germany according to World Health Organization (WHO) recommendations from early March onwards. Limitations of physical contacts to reduce exposure to SARS-CoV-2 infected individuals were handled strictly, particularly in medical centers dealing with airway diseases, like rhinology and pneumology clinics. Such measures and reluctance to visit out- and inpatient services resulted in a 82% decrease in consultations to the 12 German oto-rhino-laryngological (ORL) centres forming our database during the 50 days following March 09 in 2020 if compared to the same period in 2019. Our data on CRS care underline reports on undertreatment of non-COVID-19 individuals with several different diseases during the current pandemic. We should try to reduce the toll these patients have to pay as much as possible. We established telemedicine, e-Health and artificial intelligence-supported triage for selecting the right patients for onsite-consultations and to advise patients in several demands.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) – Teil 1: Dupilumab

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhaut, der oftmals eine Typ-2-Inflammation zugrunde liegt. Durch die Entwicklung von Biologika, die in diese Entzündungsmechanismen eingreifen können, steht eine neuartige Therapiemöglichkeit zur Verfügung.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und der Wirkung von Biologika sowie deren mögliche unerwünschte Wirkungen werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Biologika bei CRSwNP entwickelt und auf dieser Grundlage einen Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten ist vor der Verordnung bzw. Verabreichung von Biologika erforderlich. Das vorliegende Positionspapier enthält wichtige Informationen hierzu und einen Vorschlag für eine Patienteninformation.

Positionspapier: Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis (CRS) betrifft weltweit ca. 5–12 % der Allgemeinbevölkerung und wird traditionell eingeteilt in einen Phänotyp ohne (CRSsNP) und einen mit Ausbildung von Nasenpolypen (CRSwNP). Wurden Nasenpolypen bis vor kurzem eher als mechanisches Hindernis mit der Notwendigkeit einer operativen Beseitigung betrachtet, wird die CRSwNP heute als eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhäute angesehen, der als Endotyp häufig eine T2-Inflammation zugrunde liegt. Biologika, die mit diesen Entzündungsmechanismen interferieren, stellen interessante neue Therapiemöglichkeiten dar.

Methoden Das aktuelle Wissen zur Immunologie der CRSwNP und Wirkung von Biologika wurde mittels einer Literaturanalyse durch Recherchen in Medline, PubMed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library zusammengestellt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium Empfehlungen für die Anwendung von Biologika bei CRSwNP im deutschen Gesundheitssystem auf der Grundlage eines Dokumentationsbogens gegeben.

Schlussfolgerung Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue nichtoperative Therapieansätze mit Biologika für Patienten mit schweren Verlaufsformen.

Positionspapier: Empfehlungen zur Behandlung der chronischen Rhinosinusitis während der COVID-19-Pandemie im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNO-KHC) – Diese Empfehlungen basieren auf dem EAACI Positionspapier „Treatment of chronic RhinoSinusitis with nasal polyps (CRSwNP) in the COVID-19 pandemics – An EAACI Position Paper”, Allergy, 2020 und wurden auf die Situation im deutschen Gesundheitswesen angepasst

Hintergrund  Von der chronischen Rhinosinusitis (CRS) sind weltweit etwa 5–12 % der Allgemeinbevölkerung betroffen. Die CRS gilt als chronische Atemwegserkrankung, die nach den Empfehlungen der WHO ein Risikofaktor für COVID-19-Patienten sein kann. Die entzündlichen Veränderungen der Nasenschleimhäute bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) sind in den meisten Fällen vom Entzündungsendotyp 2 (T2).

Methoden  Der aktuelle Wissensstand sowohl zu COVID-19 als auch zu den Behandlungsmöglichkeiten von CRSwNP wurde durch eine Literaturrecherche in Medline, Pubmed, internationalen Leitlinien, der Cochrane Library und im Internet analysiert.

Ergebnisse  Auf Grundlage der internationalen Literatur, der aktuellen Empfehlungen der WHO und anderer internationaler Organisationen sowie der bisherigen Erfahrungen gab ein Expertengremium von EAACI und ARIA Empfehlungen für die Behandlung von CRSwNP während der COVID-19-Pandemien.

Schlussfolgerung  Intranasale Kortikosteroide stellen die Standardbehandlung für CRS bei Patienten mit einer SARS-CoV-2-Infektion dar. Chirurgische Behandlungen sollten auf ein Minimum reduziert werden und nur bei Patienten mit lokalen Komplikationen und solchen, für die keine anderen Behandlungsmöglichkeiten bestehen, durchgeführt werden. Systemische Kortikosteroide sollten bei COVID-19-Patienten vermieden werden. Die Behandlung mit Biologika kann bei nicht infizierten Patienten unter sorgfältiger Überwachung fortgesetzt werden und sollte während einer SARS-CoV-2-Infektion vorübergehend unterbrochen werden.

Genome-wide association study for αS1- and αS2-casein phosphorylation in Dutch Holstein Friesian

Phosphorylation of caseins (CN) is a crucial post-translational modification that allows caseins to form colloid particles known as casein micelles. Both α_S1- and α_S2-CN show varying degrees of phosphorylation (isoforms) in cow milk and were suggested to be more relevant for stabilizing internal micellar structure than β- and κ-CN. However, little is known about the genetic background of individual α_S2-CN phosphorylation isoforms and the phosphorylation degrees of α_S1- and α_S2-CN (α_S1-CN PD and α_S2-CN PD), defined as the proportion of isoforms with higher degrees of phosphorylation in total α_S1- and α_S2-CN, respectively. We aimed to identify genomic regions associated with these traits using 50K single nucleotide polymorphisms for 1,857 Dutch Holstein Friesian cows. A total of 10 quantitative trait loci (QTL) regions were identified for all studied traits on 10 Bos taurus autosomes (BTA1, 2, 6, 9, 11, 14, 15, 18, 24, and 28). Regions associated with multiple traits were found on BTA1, 6, 11, and 14. We showed 2 QTL regions on BTA1, one affecting α_S2-CN production and the other harboring the SLC37A1 gene, which encodes a phosphorus antiporter and affects α_S1- and α_S2-CN PD. The QTL on BTA6 harbors the casein gene cluster and affects individual α_S2-CN phosphorylation isoforms. The QTL on BTA11 harbors the PAEP gene that encodes for β-lactoglobulin and affects relative concentrations of α_S2-CN-10P and α_S2-CN-11P as well as α_S1-CN PD and α_S2-CN PD. The QTL on BTA14 harbors the DGAT1 gene and affects relative concentrations of α_S2-CN-10P and α_S2-CN-11P as well as α_S1-CN PD and α_S2-CN PD. Our results suggest that effects of identified genomic regions on phosphorylation of α_S1- and α_S2-CN are related to changes in milk synthesis and phosphorus secretion in milk. The actual roles of SLC37A1, PAEP, and DGAT1 in α_S1- and α_S2-CN phosphorylation in Dutch Holstein Friesian require further investigation.

Influence of partially demineralized milk proteins on rheological properties and microstructure of acid gels

Innovative clean label processes employed in the manufacture of acid gels are targeted to modify the structure of proteins that contribute to rheological properties. In the present study, CO₂-treated milk protein concentrate powder with 80% protein in dry matter (TMPC80) was mixed with nonfat dry milk (NDM) in different ratios for the manufacture of acid gels. Dispersions of NDM and TMPC80 that provided 100, 90, 70, and 40% of protein from NDM were reconstituted to 4.0% (wt/wt) protein and 12.0% (wt/wt) total solids. Dispersions were adjusted to pH 6.5, followed by heat treatment at 90°C for 10 min. Glucono-δ-lactone was added and samples were incubated at 30°C, reaching pH 4.5 ± 0.05 after 4 h of incubation. Glucono-δ-lactone levels were adjusted to compensate for the lower buffering capacity of samples with higher proportions of TMPC80, which is attributable to the depletion of buffering minerals from both the serum and micellar phase during preparation of TMPC80. Sodium dodecyl sulfate-PAGE analysis indicated a higher amount of caseins in the supernatant of unheated suspensions with increasing proportions of CO₂-treated TMPC80, attributable to the partial disruption of casein micelles in TMPC80. Heat treatment reduced the level of whey proteins in the supernatant due to the heat-induced association of whey proteins with casein micelles, the extent of which was larger in samples containing more micellar casein (i.e., samples with a lower proportion of TMPC80). Particle size analysis showed only small differences between nonheated and heated dispersions. Gelation pH increased from ˜5.1 to ˜5.3, and the storage modulus of the gels at pH 4.5 increased from ˜300 to ˜420 Pa when the proportion of protein contributed by TMPC80 increased from 0 to 60%. Water-holding capacity also increased and gel porosity decreased with increasing proportion of protein contributed by TMPC80. The observed gel properties were in line with microstructural observations by confocal microscopy, wherein sample gels containing increasing levels of TMPC80 exhibited smaller, well-connected aggregates with uniform, homogeneous pore sizes. We concluded that TMPC80 can be used to partially replace NDM as a protein source to improve rheological and water-holding properties in acid gels. The resultant gels also exhibited decreased buffering, which can improve the productive capacity of yogurt manufacturing plants. Overall, the process can be leveraged to reduce the amount of hydrocolloids added to improve yogurt consistency and water-holding capacity, thus providing a path to meet consumer expectations of clean label products.

Genetic parameters for αS1-casein and αS2-casein phosphorylation isoforms in Dutch Holstein Friesian

Relative concentrations of α_S1-casein and α_S2-casein (α_S1-CN and α_S2-CN) phosphorylation isoforms vary considerably among milk of individual cows. We estimated heritabilities for α_S2-CN phosphorylation isoforms, determined by capillary zone electrophoresis from 1,857 morning milk samples, and genetic correlations among α_S2-CN phosphorylation isoforms in Dutch Holstein Friesian. To investigate if phosphorylation of α_S1-CN and α_S2-CN are due to the same genetic mechanism, we also estimated genetic correlations between α_S1-CN and α_S2-CN phosphorylation isoforms as well as the genetic correlations between the phosphorylation degrees (PD) of α_S1-CN and α_S2-CN defined as the proportion of isoforms with higher degrees of phosphorylation in total α_S1-CN and α_S2-CN, respectively. The intra-herd heritabilities for the relative concentrations of α_S2-CN phosphorylation isoforms were high and ranged from 0.54 for α_S2-CN-10P to 0.89 for α_S2-CN-12P. Furthermore, the high intra-herd heritabilities of α_S1-CN PD and α_S2-CN PD imply a strong genetic control of the phosphorylation process, which is independent of casein production. The genetic correlations between α_S2-CN phosphorylation isoforms are positive and moderate to high (0.33-0.90). Furthermore, the strong positive genetic correlation (0.94) between α_S1-CN PD and α_S2-CN PD suggests that the phosphorylation processes of α_S1-CN and α_S2-CN are related. This study shows the possibility of breeding for specific α_S1-CN and α_S2-CN phosphorylation isoforms, and relations between the phosphorylation degrees of α_S1-CN and α_S2-CN and technological properties of milk need to be further investigated to identify potential benefits for the dairy industry.

Phosphorylation of αS1-casein is regulated by different genes

Casein phosphorylation is a posttranslational modification catalyzed by kinase enzymes that attach phosphate groups to specific AA in the protein sequence. This modification is one of the key factors responsible for the stabilization of calcium phosphate nanoclusters in casein micelles and for the internal structure of the casein micelles. α(S1)-Casein (α(s1)-CN) is of special interest because it constitutes up to 40% of the total casein fraction in milk, and it has 2 common phosphorylation states, with 8 (α(S1)-CN-8P) and 9 (α(S1)-CN-9P) phosphorylated serine residues. Factors affecting this variation in the degree of phosphorylation are not currently known. The objective of this research was to determine the genetic background of α(S1)-CN-8P and α(S1)-CN-9P. The genetic and phenotypic correlation between α(S1)-CN-8P and α(S1)-CN-9P was low (0.18 and 0.19, respectively). This low genetic correlation suggests a different genetic background. These differences were further investigated by means of a genome-wide association study, which showed that both α(S1)-CN-8P and α(S1)-CN-9P were affected by a region on Bos taurus autosome (BTA) 6, but only α(S1)-CN-8P was affected by a region on BTA11 that contains the gene that encodes for β-lactoglobulin (β-LG), and only α(S1)-CN-9P was affected by a region on BTA14 that contains the diacylglycerol acyltransferase 1 (DGAT1) gene. Estimated effects of β-LG protein genotypes showed that only α(S1)-CN-8P was associated with the β-LG A/B polymorphism (g.1772G>A and g.3054C>T); the AA genotype of β-LG was associated with a lower concentration of α(S1)-CN-8P (-0.32% wt/wt) than the BB genotype (+0.41% wt/wt). Estimated effects of DGAT1 K232A genotypes showed that only α(S1)-CN-9P was associated with the DGAT1 gene polymorphism; DGAT1 AA genotype was associated with a higher α(S1)-CN-9P concentration (+0.53% wt/wt) than the DGAT1 KK genotype (-0.44% wt/wt). The results give insight in phosphorylation of α(S1)-CN-8P and α(S1)-CN-9P, which seem to be regulated by a different set of genes.

[Validation of the prehospital mSTaRT triage algorithm. A pilot study for the development of a multicenter evaluation]

INTRODUCTION

Successful management of a mass casualty incident requires integrated operating procedures. A common division of victims into descriptive needs-based groups and the corresponding decision processes is the key to ensuring a successful operational response. The mSTaRT ("modified simple triage and rapid treatment") algorithm should enable emergency medical technicians to conduct triage, perform appropriate medical interventions, and coordinate transportation to adequate care facilities. The aim of this study was to design a concept to validate the mSTaRT algorithm.

METHODS

Standardized evaluation sheets were distributed to emergency medical services (EMS) staff to prospectively classify trauma patients according to the mSTaRT algorithm: red (immediate: critically injured patients who can be helped by immediate transport), yellow (urgent: severely injured patients whose transport can be delayed), or green (delayed: patients with minor injuries who need help less urgently). The patients were then reevaluated in the emergency department, and the results were compared. The main points of the comparison were consistency of triage category and rates of overtriage and undertriage.

RESULTS

The study included 151 trauma patients. Of these, 62.3% were triaged correctly, 10.6% were overtriaged (2.6% critical overtriage), and 27.1% were undertriaged (4.0% critical undertriage). In the critically injured (immediate) category, the positive likelihood ratio (LR+) was 17.3 (95% CI 3.8-795), and the negative likelihood ratio (LR-) was 0.51 (95% CI 0.22-0.83). The probability of identifying a critically injured (immediate) patient was 17.3 times higher than the probability of identifying a severely (urgent) or minor (delayed) injured patient as immediate. Therefore, the rate of overtriage was very low. But every second patient who should have been classified as immediate was undertriaged by the EMS personnel. This undertriage was due to patients' suffering from head trauma, a well-known problem in the clinical context but a new problem in the triage context.

CONCLUSION

The results of our pilot study show that by using mSTaRT, patients designated as yellow (urgent) and green (delayed) will be accurately distinguished from red (immediate) patients; therefore, only a small number of patients will be overtriaged as red. However, some patients with severe head injury may not be initially assigned to the red category as required, resulting in undertriage. Consequently, modification of the mSTaRT procedures should be considered. A further identifier in the algorithm or checkpoint in the process should act as a safety net for catching severe head injury. A larger data set is required to further validate the mSTaRT algorithm. This will be acquired by means of a multicenter study.

Stability of Casein Micelles Cross-Linked by Transglutaminase

In this study, caseins micelles were internally cross-linked using the enzyme transglutaminase (TGase). The integrity of the micelles was examined on solubilization of micellar calcium phosphate (MCP) or on disruption of hydrophobic interactions and breakage of hydrogen bonds. The level of monomeric caseins, determined electrophoretically, decreased with increasing time of incubation with TGase at 30 degrees C; after incubation for 24 h, no monomeric beta- or kappa-caseins were detected, whereas only a small level of monomeric alphaS1-casein remained, suggesting near complete intramicellar cross-linking. The ability of casein micelles to maintain structural integrity on disruption of hydrophobic interactions (using urea, sodium dodecyl sulfate, or heating in the presence of ethanol), solubilization of MCP (using the calcium-chelating agent trisodium citrate) or high-pressure treatment was estimated by measurement of the L*-value of milk; i.e., the amount of back-scattered light. The amount of light scattered by casein micelles in noncross-linked milk was reduced by >95% on complete disruption of hydrophobic interactions or complete solubilization of MCP; treatment of milk with TGase increased the stability of casein micelles against disruption by all methods studied and stability increased progressively with incubation time. After 24 h of cross-linking, reductions in the extent of light scattering were still apparent in the presence of high levels of dissociating agents, possibly through citrate-induced removal of MCP nanoclusters from the micelles, or urea- or sodium dodecyl sulfate-induced increases in solvent refractive index, which reduce the extent of light-scattering.