[Chronic cough in adult patients-evidence-based approach]

Approximately 10% of the population suffer from a cough lasting longer than 8 weeks. Compared to acute cough, which usually occurs in the context of banal respiratory tract infections, the differential diagnoses of chronic cough require an increased use of diagnostic tests and thus a structured, evidence-based approach according to current international guidelines. A targeted history (smoking status, medication, previous diseases) and ENT status are always followed by chest x‑ray and pulmonary function tests before extended diagnostics. In the case of angiotensin-converting enzyme (ACE) inhibitor use and unremarkable physical examination, a drug discontinuation test can be carried out first. In case of inconspicuous findings, a disease entity that can be treated empirically such as upper airway cough syndrome is most likely. If the cough remains unexplained, cough suppression techniques, physiotherapy or speech therapy should be sought before off-label-use of medication.

Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search

Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective product information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.

Effects of acute exercise and training status on glucocorticoid-induced leucine zipper (GILZ) expression in human skeletal muscle

Interactions between statin therapy and physical exercise complicate effective cardiovascular prevention. Emerging evidence suggests that muscle strain related changes in the expression of the glucocorticoid-induced leucine zipper (GILZ) may be involved. Therefore, we measured GILZ mRNA expression levels in M. vastus lateralis samples of 32 healthy individuals before and after a standardized bout of strength or endurance exercise. Overall, we found a highly significant downregulation of GILZ after exercise training (p < 0.001). Within-subgroup changes were statistically significant only after strength training, supporting the role of muscle (as opposed to cardiocirculatory) strain. If confirmed, this may help fitting training recommendations and medication.

Evaluating H295R steroidogenesis assay data for robust interpretation

The in vitro H295R steroidogenesis assay (OECD TG 456) is used to determine a chemical's potential to interfere with steroid hormone synthesis/metabolism. As positive outcomes in this assay can trigger significant higher tiered testing, we compiled a stakeholder database of reference and test item H295R data to characterize assay outcomes. Information concerning whether a Level 5 reproductive toxicity study was triggered due to a positive outcome in the H295R assay was also included. Quality control acceptance criteria were not always achieved, suggesting this assay is challenging to conduct within the guideline specifications. Analysis of test item data demonstrated that pairwise significance testing to controls allowed for overly sensitive statistically significant positive outcomes, which likely contribute to the assay's high positive hit rate. Complementary interpretation criteria (e.g., 1.5-fold change threshold) markedly reduced the rate of equivocal and positive outcomes thus improving identification of robust positive effects in the assay. Finally, a case study (positive H295R outcome and no endocrine adversity in vivo) is presented, which suggests that stricter data interpretation criteria could refine necessary in vivo follow-up testing. Overall, the described additional criteria could improve H295R data interpretation and help inform on how to best leverage this assay for regulatory purposes.

Adenoid hypertrophy-​diagnosis and treatment: the new S2k guideline

Hyperplasia of the pharyngeal tonsils is to be considered pathologic when nasopharyngeal symptoms of mechanical obstruction and/or chronic inflammation occur. Chronic Eustachian tube dysfunction can result in various middle ear diseases such as conductive hearing loss, cholesteatoma, and recurrent acute otitis media. During examination, attention should be paid to the presence of adenoid facies (long face syndrome), with a permanently open mouth and visible tip of the tongue. In the case of severe symptoms and/or failure of conservative treatment, adenoidectomy is usually performed on an outpatient basis. Conventional curettage remains the established standard treatment in Germany. Histologic evaluation is indicated for clinical evidence of mucopolysaccharidoses. Due to the risk of hemorrhage, the preoperative bleeding questionnaire, which is obligatory before every pediatric surgery, is referred to. Recurrence of adenoids is possible despite correct adenoidectomy. Before discharge home, otorhinolaryngologic inspection of the nasopharynx for secondary bleeding should be performed and anesthesiologic clearance obtained.

Comparing genomes recovered from time-series metagenomes using long- and short-read sequencing technologies

BACKGROUND

Over the past years, sequencing technologies have expanded our ability to examine novel microbial metabolisms and diversity previously obscured by isolation approaches. Long-read sequencing promises to revolutionize the metagenomic field and recover less fragmented genomes from environmental samples. Nonetheless, how to best benefit from long-read sequencing and whether long-read sequencing can provide recovered genomes of similar characteristics as short-read approaches remains unclear.

RESULTS

We recovered metagenome-assembled genomes (MAGs) from the free-living fraction at four-time points during a spring bloom in the North Sea. The taxonomic composition of all MAGs recovered was comparable between technologies. However, differences consisted of higher sequencing depth for contigs and higher genome population diversity in short-read compared to long-read metagenomes. When pairing population genomes recovered from both sequencing approaches that shared ≥ 99% average nucleotide identity, long-read MAGs were composed of fewer contigs, a higher N50, and a higher number of predicted genes when compared to short-read MAGs. Moreover, 88% of the total long-read MAGs carried a 16S rRNA gene compared to only 23% of MAGs recovered from short-read metagenomes. Relative abundances for population genomes recovered using both technologies were similar, although disagreements were observed for high and low GC content MAGs.

CONCLUSIONS

Our results highlight that short-read technologies recovered more MAGs and a higher number of species than long-read due to an overall higher sequencing depth. Long-read samples produced higher quality MAGs and similar species composition compared to short-read sequencing. Differences in the GC content recovered by each sequencing technology resulted in divergences in the diversity recovered and relative abundance of MAGs within the GC content boundaries.

[Adenoids-diagnosis and treatment: the new German S2k guideline]

Hyperplasia of the pharyngeal tonsils is to be considered pathologic when nasopharyngeal symptoms of mechanical obstruction and/or chronic inflammation occur. Chronic Eustachian tube dysfunction can result in various middle ear diseases such as conductive hearing loss, cholesteatoma, and recurrent acute otitis media. During examination, attention should be paid to the presence of adenoid facies (long face syndrome), with a permanently open mouth and visible tip of the tongue. In the case of severe symptoms and/or failure of conservative treatment, adenoidectomy is usually performed on an outpatient basis. Conventional curettage remains the established standard treatment in Germany. Histologic evaluation is indicated for clinical evidence of mucopolysaccharidoses. Due to the risk of hemorrhage, the preoperative bleeding questionnaire, which is obligatory before every pediatric surgery, is referred to. Recurrence of adenoids is possible despite correct adenoidectomy. Before discharge home, otorhinolaryngologic inspection of the nasopharynx for secondary bleeding should be performed and anesthesiologic clearance obtained.

[Development of quality standards for patients with rheumatoid arthritis for use in Germany]

Despite a qualitatively and structurally good care of patients with rheumatoid arthritis (RA) in Germany, there are still potentially amendable deficits in the quality of care. For this reason, the German Society for Rheumatology (DGRh) has therefore decided to ask a group of experts including various stakeholders to develop quality standards (QS) for the care of patients with RA in order to improve the quality of care. The QS are used to determine and quantitatively measure the quality of care, subject to relevance and feasibility. The recently published NICE and ASAS standards and a systematic literature search were used as the basis for development. A total of 8 QS, now published for the first time, were approved with the intention to measure and further optimize the quality of care for patients with RA in Germany.

[Acute and chronic cough - differential diagnosis and treatment]

Cough is a frequent reason for consultation in the general practitioner's office. Most of the time, the symptom is harmless and self-limiting, as in the case of a banal cold cough, for example - however, serious diseases such as malignancies can also be the cause. Evaluation is therefore not always easy. This article presents a targeted and appropriate approach and discusses which treatments are recommended and effective.Acute and chronic cough are differentiated according to the duration of symptoms (up to 8 weeks/longer than 8 weeks). The most common cause of acute cough is a self-limiting viral infection of the upper respiratory tract; the most important differential diagnosis is community-acquired pneumonia. If there are no defined warning signs (red flags), the history and clinical examination are sufficient to establish the diagnosis in the case of an acute cough; medication is not necessary. In the case of a chronic cough, a chest X-ray is usually ordered and then further investigations are carried out in accordance with the most probable suspected diagnosis; probationary therapies are an important part of the workup. Coughs that are refractory to treatment or unexplained require individualised treatment (pharmacological, including off-label, non-pharmacological) and regular re-evaluation.

[Acute Cough in Adult Patients]

Background

Acute cough (< 8 weeks) is a frequent complaint in family practice consultations. The most common cause are respiratory infections. The Guideline "Acute and chronic cough" of the German College of General Practitioners and Family Physicians (DEGAM) was updated in 2021 and contains recommendations for an evidence-based approach for the management of acute cough in primary care.

Methods

The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed by an interdisciplinary guideline committee and agreed by formal consensus.

Results

History-taking, exclusion of red flags and a physical examination are the basis of diagnostic evaluation. If an acute, uncomplicated bronchitis is likely, no laboratory tests, sputum diagnostics, or chest x-rays should be performed, and antibiotics should not be administered. Evidence based strategies to avoid antibiotic therapy (delayed prescribing, shared decision making, point-of-care-tests) can be used. There is inadequate evidence for the efficacy of antitussive or expectorant drugs against acute cough. The state of the evidence for phytotherapeutic agents is heterogeneous; clinical importance is minimal. COVID-19 should currently be considered in cases of acute respiratory symptoms. If specific symptoms or red flags occur, further diagnoses in the context of acute cough such as community-acquired pneumonia, influenza disease and exacerbations of chronic respiratory diseases (bronchial asthma, COPD) should be taken into consideration.

Conclusions

These evidence-based recommendations are intended to reduce the use of antibiotics to treat colds and acute bronchitis, for which they are not indicated. Further clinical trials of symptomatic treatments for cough should be performed in order to extend the evidence base.

Measurement of Lepton-Jet Correlation in Deep-Inelastic Scattering with the H1 Detector Using Machine Learning for Unfolding

The first measurement of lepton-jet momentum imbalance and azimuthal correlation in lepton-proton scattering at high momentum transfer is presented. These data, taken with the H1 detector at HERA, are corrected for detector effects using an unbinned machine learning algorithm (multifold), which considers eight observables simultaneously in this first application. The unfolded cross sections are compared with calculations performed within the context of collinear or transverse-momentum-dependent factorization in quantum chromodynamics as well as Monte Carlo event generators.

[Sore Throat - Guideline-based Diagnostics and Therapy]

Background

Sore throat is a common reason for consultation of family physicians. Acute sore throat (< 14 days) is usually triggered by infections of the pharynx. Less than 35 % of cases are caused by bacterial infections; nevertheless, antibiotics are prescribed far more often. Evidence-based guideline recommendations are available to reduce non-indicated administration of antibiotics in the treatment of sore throat.

Search Methods

Update of the clinical guideline "sore throat" of the German College of General Practitioners and Family Physicians (DEGAM) by means of a systematic search of the literature for international guidelines and systematic reviews.

Main Messages

After excluding red flags such as immunosuppression and severe systemic infections, acute sore throat is usually self-limiting with a mean duration of 7 days. Patients should be encouraged in self-management; ibuprofen and naproxen are recommended for symptomatic treatment. If antibiotics are considered, clinical scores (Centor, McIsaac, FeverPAIN) should be used to assess the risk of bacterial pharyngitis. At low risk (< 3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescription is an option; if high (> 3 points), antibiotics can be taken immediately. Even if scores suggestive a bacterial cause, the evidence suggests that antibiotic treatment only shortens the duration of symptoms modestly. Penicillin is the first choice (clarithromycin as an alternative). The antibiotic should be taken for 5-7 days.

Conclusions

In the absence of red flags, a regular use of symptomatic treatment will help to control discomfort. If administration of antibiotics is still considered a risk-adapted approach, using clinical scores is recommended.

Clinical Practice Guideline: Chronic Cough

BACKGROUND

Chronic cough, i.e., cough lasting longer than eight weeks, affects approximately 10% of the population and is a common reason for outpatient medical consultation. Its differential diagnosis is extensive, and it is generally evaluated in poorly structured fashion with a variety of diagnostic techniques. The German Clinical Practice Guideline on Acute and Chronic Cough was updated in 2021 and contains a description of the recommended stepwise, patient-centered, and evidence-based procedure for the management of chronic cough.

METHODS

The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed in an interdisciplinary manner and agreed upon by formal consensus. The target group consists of adult patients with cough.

RESULTS

History-taking, after the exclusion of red flags, should include questioning about smoking status, medications, and relevant present and past illnesses (COPD, asthma). Subsequent diagnostic testing should include a chest x-ray and pulmonary function tests. If the patient is taking an ACE inhibitor, a test of drug discontinuation can be carried out first. Radiologically detected pulmonary masses or evidence of rare diseases (interstitial lung diseases, bronchiectasis) are an indication for chest CT or for direct referral to an appropriate specialist. If the imaging studies and pulmonary function tests are normal, the patient is most likely suffering from a disease entity that can be treated empirically, such as upper airway cough syndrome or cough variant asthma. Any patient with an unexplained or refractory cough must receive proper patient education; individual therapeutic trials of physiotherapeutic or speechtherapeutic methods are possible, as is the off-label use of gabapentin or morphine.

CONCLUSION

Chronic cough should be evaluated according to an established diagnostic algorithm in collaboration with specialists. Treatments such as inhaled corticosteroids should be tested exhaustively in accordance with the guidelines, and the possibility of multiple causes as well as the role of patient compliance should be kept in mind before a diagnosis of unexplained or intractable cough is assigned.

In situ visualization of glycoside hydrolase family 92 genes in marine flavobacteria

Gene clusters rich in carbohydrate-active enzymes within Flavobacteriia genera provide a competitiveness for their hosts to degrade diatom-derived polysaccharides. One such widely distributed polysaccharide is glucuronomannan, a main cell wall component of diatoms. A conserved gene cluster putatively degrading glucuronomannan was found previously among various flavobacterial taxa in marine metagenomes. Here, we aimed to visualize two glycoside hydrolase family 92 genes coding for α-mannosidases with fluorescently-labeled polynucleotide probes using direct-geneFISH. Reliable in situ localization of single-copy genes was achieved with an efficiency up to 74% not only in the flavobacterial strains Polaribacter Hel1_33_49 and Formosa Hel1_33_131 but also in planktonic samples from the North Sea. In combination with high-resolution microscopy, direct-geneFISH gave visual evidence of the contrasting lifestyles of closely related Polaribacter species in those samples and allowed for the determination of gene distribution among attached and free-living cells. We also detected highly similar GH92 genes in yet unidentified taxa by broadening probe specificities, enabling a visualization of the functional trait in subpopulations across the borders of species and genera. Such a quantitative insight into the niche separation of flavobacterial taxa complements our understanding of the ecology of polysaccharide-degrading bacteria beyond omics-based techniques on a single-cell level.

Influence of physical activity on periodontal health in patients with type 2 diabetes mellitus. A blinded, randomized, controlled trial

Objectives

The aim was to investigate the effect of physical activity on periodontal health and HbA1c levels in patients with type 2 diabetes mellitus (T2DM) over a period of 6 months.

Materials and methods

Thirty-seven patients with non-insulin-dependent T2DM were included in the study. The intervention group (n=20) performed physical activity over a period of 6 months. The control group (n=17) did not receive any intervention. Baseline and final examinations included dental parameters and concentrations of glycosylated hemoglobin (HbA1c) and high-sensitivity C-reactive protein (hsCRP).

Results

Physical activity showed a positive effect on periodontal health. Both the BOP (p= 0.005) and the severity of periodontitis (p= 0.001) were significantly reduced in the intervention group compared to the control group. Furthermore, HbA1c levels were reduced (p= 0.010) significantly in the intervention group while hsCRP levels significantly increased in the control group (p= 0.04).

Conclusions

Within the limitations of this randomized, controlled trial, physical activity over a period of 6 months is a health-promoting measure for patients with T2DM and improves both periodontal health and HbA1c concentrations.

Clinical Practice Guideline: Sore Throat

BACKGROUND

Sore throat is a common reason for consultation of primary care physicians, pediatricians, and ENT specialists. The updated German clinical practice guideline on sore throat provides evidence-based recommendations for treatment in the German healthcare system.

METHODS

Guideline revision by means of a systematic search of the literature for international guidelines and systematic reviews. All recommendations resulted from interdisciplinary cooperation and were agreed by formal consensus. The updated guideline applies to patients aged 3 years and over.

RESULTS

In the absence of red flags such as immunosuppression, severe comorbidity, or severe systemic infection, acute sore throat is predominantly self-limiting. The mean duration is 7 days. Chronic sore throat usually has noninfectious causes. Laboratory tests are not routinely necessary. Apart from non-pharmacological self-management, ibuprofen and naproxen are recommended for symptomatic treatment. Scores can be used to assess the risk of bacterial pharyngitis: one point each is assigned for tonsil lesions, palpable cervical lymph nodes, patient age, disease course, and elevated temperature. If the risk is low (<3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescribing is recommended; if high (>3 points), antibiotics can be taken immediately. Penicillin remains the first choice, with clarithromycin as an alternative for those who do not tolerate penicillin. The antibiotic should be taken for 5-7 days.

CONCLUSION

After the exclusion of red flags, antibiotic treatment is unnecessary in many cases of acute sore throat. If administration of antibiotics is still considered in spite of consultation on the usual course of tonsillopharyngitis and the low risk of complications, a risk-adapted approach using clinical scores is recommended.

Musculoskeletal disorders and level of physical activity in welders

BACKGROUND

Welders demonstrate a high prevalence of musculoskeletal disorders (MSDs), as indicated by high rates of illness-related absenteeism. Leisure time physical activity (LTPA) could be a preventive strategy. However, little is known about LTPA prevalence and its association with MSDs among welders.

AIMS

The aim of this study was to analyse the prevalence of MSD and LTPA levels among welders and to identify risk factors for the main disorder of low back pain (LBP).

METHODS

The following data were collected from 145 welders from 34 companies in the German steel industry: individual factors (demographics, health behaviour), job-related factors (welding process, welding hours per day, employment years, shift work, ergonomic tools) and MSD (Nordic questionnaire). LTPA (International Physical Activity Questionnaire) was calculated to determine the metabolic equivalent of task (MET) per week as an objective measure of energy expenditure. Prevalence and multivariate regression analysis were calculated to determine odds ratios (ORs).

RESULTS

The 12-month prevalence of LBP was 71%, for neck pain 61% and for shoulder pain 55%. Forty-two per cent of the participants accumulated <600 MET/week. The multivariate regression model revealed LTPA <600 MET/week (OR 3.4, 95% CI 1.05-10.85) and neck pain in the previous 12 months (OR 5.2, 95% CI 2.02-13.56) to be significantly associated with LBP.

CONCLUSIONS

The results show a high prevalence of MSDs and thus a strong requirement for intervention. Therefore, LTPA should be prioritized and employers should encourage access to regular activity.

EFFECTS OF ZIZIPHUS JUJUBE SUPPLEMENTATION ON PRO- AND ANTI-APOPTOTIC PROTEIN EXPRESSION IN NEUTROPHILS AFTER RESISTANCE EXERCISE

Introduction. It is suggested that jujube might have beneficial effects on exercise-induced immune perturbations, specifically on neutrophils apoptosis regulation, but its cellular mechanism is unclear. Aim. The aim of this study was to investigate the acute effect of Ziziphus jujuba administration on pro- and anti-apoptotic protein levels in human neutrophils in response to a session of circuit resistance exercise (Ex). Material and Methods. Participants completed an Ex (75 % 1RM, 9 exercises, 3 sets). While one group received a placebo, the other group (Zj) was supplemented daily with jujube (0.5 gr/kg body weight suspended in 2.5cc distilled water) one hour before Ex. Results. Ex increased the neutrophil level of [Ca2+]i, calpain-1 and caspase-3 (p < 0.05) while a reduction of calpastatin and XIAP were observed (p < 0.05). Zj either suppressed the [Ca2+]i or reversed the calpastatin, calpain-1, XIAP, and caspase-3 responses (p < 0.01). Conclusions. The data indicate that a single session of intensive Ex induced apoptotic signaling in human neutrophils with the involvement of [Ca2+]i-calpastatin-calpain axis upstream caspase-3. Acute administration of jujube solution before exercise attenuated these effects probably by providing energy sources for neutrophils or by functioning as antioxidants.

[Delegation of medical tasks in rheumatology]

Modern rheumatology enables better and earlier diagnosis and therapy of inflammatory rheumatic system diseases. At the same time, the requirements for the care of rheumatologic patients have risen considerably for non-medical assistant professions and specialists for nursing professions. Since 2006 there has been established an education curriculum "Rheumatological Specialist Assistant DGRh-BDRh" (RFA) with the training to become a "Rheumatological Specialist Assistant (DGRh-BDRh)". In Europe and in parallel in Germany, assistant professions are increasingly involved in the early detection and care of patients with rheumatic diseases and entrusted with tasks.In this work, the overarching principles for delegation of medical tasks to RFA and recommendations for the delegation are published by the Commission for Delegation of the German Society for Rheumatology (DGRh). These recommendations are based on the requirements of the German Medical Association and have been legally evaluated. With the extension of the training of the RFA board certification is aimed for "MFA for Rheumatology". These recommendations enable more transparency and security for delegating doctors and the delegated RFA's.

[Safety management of the treatment with antimalarial drugs in rheumatology. Interdisciplinary recommendations based on a systematic literature search]

BACKGROUND

Antimalarial medication (AM) plays an important role in the treatment of rheumatic diseases.

OBJECTIVE

Updated evidence-based recommendations on the safety management of rheumatological treatment with AM are presented.

METHODS

A systematic literature search in the databases Medline (PubMed) and Cochrane identified 1160 studies on the safety of treatment with AM in rheumatology. In addition, a manual search was carried out and 67 publications considered to be particularly relevant by the authors were analyzed in more detail. These publications served as a basis for consensus-based recommendations.

RESULTS

Treatment with AM in rheumatology should be carried out with hydroxychloroquine (HCQ) with a dosage not exceeding 5 mg/kg body weight/day. Patients should undergo a basic ophthalmological examination within the first 6 months of AM treatment. Pre-existing maculopathy, renal insufficiency (glomerular filtration rate, GFR <60 ml/min), tamoxifen comedication, a daily dose of >5 mg/kg HCQ or treatment with chloroquine (CQ) show an increased risk for AM-induced retinopathy. These patients should undergo an annual ophthalmological check from the beginning of the treatment, whereas patients with no risk factors are recommended to start this only after 5 years of taking the medication. The ophthalmological examination should comprise at least both an appropriate subjective and an objective method and these are usually an automated visual field test and optical coherence tomography (OCT). A visual field test revealing a parafoveal sensitivity loss and an OCT showing a parafoveal circumscribed loss of the photoreceptor layer or focal interruptions of the structural line of the outer segment are signs of a possible AM retinopathy. Determination of creatine kinase (CK) and lactate dehydrogenase (LDH) in blood is appropriate to screen for cardiomyopathy and myopathy and should be checked before starting the treatment and then ca. every 3 months. The use of cardiac biomarkers, such as brain natriuretic peptide (BNP) or troponin in serum, electrocardiograph (ECG) or cardiac imaging should be considered depending on the situation. An intake of HCQ is safe during pregnancy and breastfeeding according to the current state of knowledge and is protective for mother and child in patients with systemic lupus erythematosus.

CONCLUSION

The updated recommendations on AM treatment in rheumatology in particular include a more rigorous measuring of doses, risk stratification in monitoring and defined ophthalmological examination methods to detect a possible retinopathy.

[SARS-CoV-2 & rheumatic disease : Consequences of the SARS-CoV-2 pandemic for patients with inflammatory rheumatic diseases. A comparison of the recommendations for action of rheumatological societies and risk assessment of different antirheumatic treatments]

The recommendations of the German Society of Rheumatology (DGRh) update, which update and expand the guidance on the management of patients with inflammatory rheumatic diseases in view of SARS-CoV‑2 created at the beginning of the COVID-19 pandemic, correspond in many points with the recommendations for action of the American (ACR) and European (EULAR) societies, but also differ in some points. Therefore, this article discusses the core recommendations of the DGRh update on the prevention of SARS-CoV-2/COVID-19, the risk assessment for inflammatory rheumatic diseases and the use of antirheumatic treatments in the context and in comparison to the ACR and EULAR recommendations, and provides an overview of the risk assessment of individual antirheumatic drugs.

Candidatus Abditibacter, a novel genus within the Cryomorphaceae, thriving in the North Sea

Coastal phytoplankton blooms are frequently followed by successive blooms of heterotrophic bacterial clades. The class Flavobacteriia within the Bacteroidetes has been shown to play an important role in the degradation of high molecular weight substrates that become available in the later stages of such blooms. One of the flavobacterial clades repeatedly observed over the course of several years during phytoplankton blooms off the coast of Helgoland, North Sea, is Vis6. This genus-level clade belongs to the family Cryomorphaceae and has been resistant to cultivation to date. Based on metagenome assembled genomes, comparative 16S rRNA gene sequence analyses and fluorescence in situ hybridization, we here propose a novel candidate genus Abditibacter, comprising three novel species Candidatus Abditibacter vernus, Candidatus Abditibacter forsetii and Candidatus Abditibacter autumni. While the small genomes of the three novel photoheterotrophic species encode highly similar gene repertoires, including genes for degradation of proteins and algal storage polysaccharides such as laminarin, two of them - Ca. A. vernus and Ca. A. forsetii - seem to have a preference for spring blooms, while Ca. A. autumni almost exclusively occurs in late summer and autumn.

Effects of Escherichia coli strain Nissle 1917 on exercise-induced disruption of gastrointestinal integrity

PURPOSE

The aim of the current study was to investigate the effects of the probiotic Escherichia coli strain Nissle 1917 (EcN) on the exercise-induced disruption of gastrointestinal (GI) integrity and the associated release of damage and inflammatory markers.

METHODS

After a pre-performance test, 19 untrained subjects (aged 18-35 years) passed two identical exhaustive treadmill exercise tests in an intensity corresponding to 60-80% VO_2max in a test-retest design. The exercise tests were separated by a time period of 4 weeks. During this period, all subjects ingested 5 ml of an EcN suspension daily. Serum samples were taken before, immediately following and 3 h after both exercise tests. They were analyzed for indicators of GI integrity (zonulin; claudin-3; LPS), various damage and redox markers (I-FABP, GOT; GPT; TBARS) and inflammatory parameters (hsCRP; leucocytes). GI complaints were evaluated by a questionnaire.

RESULTS

The intake of EcN resulted in a significantly lower increase in I-FABP and TBARS after exercise (p < 0.05). In contrast, no effect of EcN supplementation was found for hsCRP and leucocyte numbers. Similarly, no differences were found for levels of zonulin and claudin-3. Exercise-associated GI complaints were not affected by the probiotic supplement.

CONCLUSION

The probiotic EcN reduced the exercise-associated increase in oxidative stress. This antioxidative mechanism probably leads to a reduction of GI epithelial damage after exhaustive exercise. The lack of EcN effects on other markers of GI permeability and systemic inflammation is most likely due to an inadequate exercise load, with rather small and insignificant exercise effects on these parameters.

[Current guidance of the German Society of Rheumatology for the care of patients with rheumatic diseases during the SARS-CoV-2/Covid 19 pandemic]

In der aktuellen SARS-CoV-2 Pandemie bestehen viele Fragen mit Blick auf die sichere Behandlung von Patienten mit entzündlich-rheumatischen Erkrankungen. Auf viele dieser Fragen gibt es zur Zeit noch keine evidenzbasierte Antwort und das macht die Betreuung der Patienten nicht leicht. Die Deutsche Gesellschaft für Rheumatologie e. V. (DGRh) will mit diesen ersten Empfehlungen Hilfestellung für spezielle Belange in der Betreuung von Rheumapatienten angesichts der aktuellen Bedrohung durch SARS-CoV-2 geben. Um den dynamischen weltweiten Erkenntnisgewinn für unsere Patienten zu nutzen, werden die Empfehlungen regelmäßig aktualisiert. Die aktualisierten Versionen der Empfehlungen werden auf der Homepage der DGRh hinterlegt.

Obesity prevention - is school an effective place? A systematic review

Background

Juvenile and childhood obesity or overweight are associated with various secondary diseases and physical limitations, as well as with the effects of discrimination and social exclusion. The early prevention of obesity remains a key area of action worldwide. Schools are considered as a classical setting. The analysis focuses on the effectiveness of interventions, the identification of effective components and conditions as well as barriers. The aim is to provide a differentiated presentation of the current study situation.

Methods

The systematic literature search in eleven databases included studies in English and German published in 1990 to 2015. A control group and posttest data were obligatory. Evaluated outcome measures must map effects on the prevalence of obesity (e.g., BMI, body fat percentage, waist-to-hip ratio). Included full texts were evaluated with the instrument ROBINS-I. Due to the heterogeneity of studies (especially in terms of design, intervention and outcomes) results were analysed qualitatively.

Results

48 primary studies were included of which most studies report data on changes in mean BMI over time, and show predominantly (small) effects in favour of the intervention. Almost all identified interventions include behavioral measures, most of them combine the fields of nutrition and physical activity, with behavioral prevention being overrepresented in particular in activities addressing nutrition.

Conclusions

The results allow the conclusion, that school-based measures to prevent obesity are effective in terms of anthropometric outcome measures, but to a limited extent. There is clear evidence that the effects achieved tend to be maintained beyond the intervention. There are also clear indications for the cost-effectiveness of school-based obesity prevention. The studies from this field of research have clearly gained in quality over the years and are now flanked by health economic analyses.

Funded by DIMDI

Key messages

School-based measures to prevent obesity are effective in terms of anthropometric outcome measures, but to a limited extent. In order to fully realize its potential, school-based measures to prevent obesity should be accompanied by interventions at other levels, like the health-promoting design of living environments.

Niche differentiation among annually recurrent coastal Marine Group II Euryarchaeota

Since the discovery of archaeoplankton in 1992, the euryarchaeotal Marine Group II (MGII) remains uncultured and less understood than other planktonic archaea. We characterized the seasonal dynamics of MGII populations in the southern North Sea on a genomic and microscopic level over the course of four years. We recovered 34 metagenome-assembled genomes (MAGs) of MGIIa and MGIIb that corroborated proteorhodopsin-based photoheterotrophic lifestyles. However, MGIIa and MGIIb MAG genome sizes differed considerably (~1.9 vs. ~1.4 Mbp), as did their transporter, peptidase, flagella and sulfate assimilation gene repertoires. MGIIb populations were characteristic of winter samples, whereas MGIIa accounted for up to 23% of the community at the beginning of summer. Both clades consisted of annually recurring, sequence-discrete populations with low intra-population sequence diversity. Oligotyping of filtered cell-size fractions and microscopy consistently suggested that MGII cells were predominantly free-living. Cells were coccoid and ~0.7 µm in diameter, likely resulting in grazing avoidance. Based on multiple lines of evidence, we propose distinct niche adaptations of MGIIa and MGIIb Euryarchaeota populations that are characteristic of summer and winter conditions in the coastal North Sea.

In marine Bacteroidetes the bulk of glycan degradation during algae blooms is mediated by few clades using a restricted set of genes

We investigated Bacteroidetes during spring algae blooms in the southern North Sea in 2010–2012 using a time series of 38 deeply sequenced metagenomes. Initial partitioning yielded 6455 bins, from which we extracted 3101 metagenome-assembled genomes (MAGs) including 1286 Bacteroidetes MAGs covering ~120 mostly uncultivated species. We identified 13 dominant, recurrent Bacteroidetes clades carrying a restricted set of conserved polysaccharide utilization loci (PULs) that likely mediate the bulk of bacteroidetal algal polysaccharide degradation. The majority of PULs were predicted to target the diatom storage polysaccharide laminarin, alpha-glucans, alpha-mannose-rich substrates, and sulfated xylans. Metaproteomics at 14 selected points in time revealed expression of SusC-like proteins from PULs targeting all of these substrates. Analyses of abundant key players and their PUL repertoires over time furthermore suggested that fewer and simpler polysaccharides dominated early bloom stages, and that more complex polysaccharides became available as blooms progressed.

Classical biological control of the African citrus psyllid Trioza erytreae, a major threat to the European citrus industry

Citrus greening or huanglongbing (HLB) is the main threat to the European citrus industry since one of its vectors, the African citrus psyllid, Trioza erytreae, has recently become established in mainland Europe. In this context, classical biological control programmes should be implemented to reduce the spread of the psyllid. The aims of this study were to: i) disentangle the parasitoid complex of T. erytreae combining morphological and molecular characterization; and ii) to study the biology of its main parasitoids in its area of origin in South Africa for their future importation into Europe. The main citrus producing areas of South Africa were surveyed during 2017. In contrast to previous studies, the parasitoid complex of T. erytreae included three species of primary parasitoids: Tamarixia dryi, Psyllaephagus pulvinatus and another parasitoid of the genus Tamarixia. Molecular analysis showed that it is a new species closely related to T. dryi. Tamarixia dryi was the most abundant parasitoid but its relative abundance varied among sampling sites. The sex ratio (males/females) of T. dryi and Tamarixia sp. decreased with T. erytreae size and became female biased when psyllid nymphs were larger than 0.6 and 1.2 mm², respectively. These parasitoids were attacked by three species of hyperparasitoids, Aphidencyrtus cassatus, Marietta javensis and a species of the genus Aphanogmus. Aphidencyrtus cassatus, the most abundant hyperparasitoid, tended to emerge from large nymphs, and adult females lived as long as those of T. dryi. The implications of these results are discussed within the framework of the introduction of T. dryi into Europe.

[Pharmacological treatment of rheumatoid arthritis and its comorbidities]

Due to therapeutic advances, rheumatoid arthritis (RA) today has developed into a satisfactorily treatable disease in most cases, with remission being the target of treatment. Early diagnosis with immediate treatment initiation following treat-to-target strategy is the key to a favorable long-term outcome. A guideline-directed treatment algorithm determines the use of conventional synthetic disease-modifying anti-rheumatic drugs (DMARD; e.g., methotrexate), biological DMARD, and targeted oral DMARD (Janus kinase inhibitors). Comorbidities-in particular cardiovascular and interstitial lung disease-affect 80% of RA patients and represent the leading causes for mortality. The choice of drug treatment is influenced by the presence of comorbidities.

Consistency in microbiomes in cultures of Alexandrium species isolated from brackish and marine waters

Phytoplankton and bacteria interactions have a significant role in aquatic ecosystem functioning. Associations can range from mutualistic to parasitic, shaping biogeochemical cycles and having a direct influence on phytoplankton growth. How variations in phenotype and sampling location, affect the phytoplankton microbiome is largely unknown. A high-resolution characterization of the bacterial community in cultures of the dinoflagellate Alexandrium was performed on strains isolated from different geographical locations and at varying anthropogenic impact levels. Microbiomes of Baltic Sea Alexandrium ostenfeldii isolates were dominated by Betaproteobacteria and were consistent over phenotypic and genotypic Alexandrium strain variation, resulting in identification of an A. ostenfeldii core microbiome. Comparisons with in situ bacterial communities showed that taxa found in this A. ostenfeldii core were specifically associated to dinoflagellate dynamics in the Baltic Sea. Microbiomes of Alexandrium tamarense and minutum, isolated from the Mediterranean Sea, differed from those of A. ostenfeldii in bacterial diversity and composition but displayed high consistency, and a core set of bacterial taxa was identified. This indicates that Alexandrium isolates with diverse phenotypes host predictable, species-specific, core microbiomes reflecting the abiotic conditions from which they were isolated. These findings enable in-depth studies of potential interactions occurring between Alexandrium and specific bacterial taxa.

[Biologics and further new drugs for rheumatic diseases since 2000]

BACKGROUND

Rheumatoid arthritis (RA), psoriatic arthritis and axial spondyloarthritis are severe diseases, which without adequate treatment lead to extremely reduced mobility, functional status and quality of life.

OBJECTIVE

The effects of biologics and further new antirheumatic drugs on the burden of disease.

METHODS

Evaluation of study results and register data dealing with the efficacy and safety of these drugs.

RESULTS

Biologics have been proven to dramatically improve the outcome of all three diseases and contributed to the fact that remission is a realistic target today. In addition, the cardiovascular risk and mortality in RA have been reduced and structural damage is considerably blocked by biologics. Recently Janus kinase (JAK) inhibitors contributed to the treatment possibilities in the same way. Biologics as well as JAK inhibitors offer an excellent safety profile and tolerability with infections being the most important risk.

CONCLUSION

With the availability of biologics and additional new drugs all three diseases have lost the status of difficult to treat diseases. Their usage according to the guidelines ensures that the burden of disease can been minimalized in most cases. The benefit-risk profile of these drugs has been shown to be excellent.

Polysaccharide utilization loci of North Sea Flavobacteriia as basis for using SusC/D-protein expression for predicting major phytoplankton glycans

Marine algae convert a substantial fraction of fixed carbon dioxide into various polysaccharides. Flavobacteriia that are specialized on algal polysaccharide degradation feature genomic clusters termed polysaccharide utilization loci (PULs). As knowledge on extant PUL diversity is sparse, we sequenced the genomes of 53 North Sea Flavobacteriia and obtained 400 PULs. Bioinformatic PUL annotations suggest usage of a large array of polysaccharides, including laminarin, α-glucans, and alginate as well as mannose-, fucose-, and xylose-rich substrates. Many of the PULs exhibit new genetic architectures and suggest substrates rarely described for marine environments. The isolates’ PUL repertoires often differed considerably within genera, corroborating ecological niche-associated glycan partitioning. Polysaccharide uptake in Flavobacteriia is mediated by SusCD-like transporter complexes. Respective protein trees revealed clustering according to polysaccharide specificities predicted by PUL annotations. Using the trees, we analyzed expression of SusC/D homologs in multiyear phytoplankton bloom-associated metaproteomes and found indications for profound changes in microbial utilization of laminarin, α-glucans, β-mannan, and sulfated xylan. We hence suggest the suitability of SusC/D-like transporter protein expression within heterotrophic bacteria as a proxy for the temporal utilization of discrete polysaccharides.

[Rheumatoid symptoms in patients with hematologic neoplasms]

Paraneoplastic syndromes in lymphatic or myeloid neoplasms can present with musculoskeletal symptoms, vasculitis-like or febrile symptoms. Hematologic diseases are also associated with rheumatic diseases whereas inflammatory rheumatic diseases are often associated with an increased risk for lymphoproliferative disease. Atypical disease characteristics, lack of disease-specific antibodies or therapeutic response are red flags for diagnosing paraneoplastic or coexistent malignant diseases. New onset of systemic symptoms, worsening of general condition, night sweats or weight loss need to be considered during follow-up and differential diagnostics. This article focuses on musculoskeletal, vasculitis-like and systemic signs of lymphatic or myeloid neoplasms either because of coexistency, tumor association or paraneoplastic disease.

Determination of the strong coupling constant α s ( m Z ) in next-to-next-to-leading order QCD using H1 jet cross section measurements: H1 Collaboration

The strong coupling constant α s is determined from inclusive jet and dijet cross sections in neutral-current deep-inelastic ep scattering (DIS) measured at HERA by the H1 collaboration using next-to-next-to-leading order (NNLO) QCD predictions. The dependence of the NNLO predictions and of the resulting value ofα s ( m Z ) at the Z-boson mass m Z are studied as a function of the choice of the renormalisation and factorisation scales. Using inclusive jet and dijet data together, the strong coupling constant is determined to beα s ( m Z ) = 0.1157 ( 20 ) exp ( 29 ) th . Complementary,α s ( m Z ) is determined together with parton distribution functions of the proton (PDFs) from jet and inclusive DIS data measured by the H1 experiment. The valueα s ( m Z ) = 0.1142 ( 28 ) tot obtained is consistent with the determination from jet data alone. The impact of the jet data on the PDFs is studied. The running of the strong coupling is tested at different values of the renormalisation scale and the results are found to be in agreement with expectations.

[Management of rheumatoid arthritis]

Rheumatoid arthritis is the most common inflammatory rheumatic disease. Due to the destruction of joints in the course of the disease it leads to significant morbidity in affected patients. The quality of life and even life expectancy can be severely impaired. Early diagnosis and early initiation of treatment is a decisive step towards a more benign course of the disease. New classification criteria have been published in order to help in early diagnosis. Methods of imaging, such as ultrasound and magnetic resonance imaging help in the detection of synovitis, which is the major pathomorphological manifestation of arthritis and should be identified without any doubt. Treatment follows the rule of treat to target with the aim of achieving remission or if this is not realistic, at least the lowest possible level of disease activity. The first and perhaps most important step in therapy is the initiation of methotrexate or if contraindications are present, another disease-modifying antirheumatic drug (DMARD) as soon as the diagnosis is made. Initial addition of glucocorticoids is recommended, which should be reduced in dose and terminated as soon as possible. Furthermore, either the combination of different DMARDs or the start of biologic DMARDs, such as tumor necrosis factor alpha (TNF-alpha) inhibitors or second generation biologic DMARDs is possible as a treatment option. The treatment follows the rule of shared decision-making and is the standard to treat comorbidities, the use an interdisciplinary approach and to treat functional deficits by rehabilitation measures, such as physiotherapy.