Pre-endoscopy SARS-CoV-2 testing strategy during COVID-19 pandemic: the care must go on.

BACKGROUND: In response to the COVID-19 pandemic, endoscopic societies initially recommended reduction of endoscopic procedures. In particular non-urgent endoscopies should be postponed. However, this might lead to unnecessary delay in diagnosing gastrointestinal conditions. METHODS: Retrospectively we analysed the gastrointestinal endoscopies performed at the Central Endoscopy Unit of Saarland University Medical Center during seven weeks from 23 March to 10 May 2020 and present our real-world single-centre experience with an individualized rtPCR-based pre-endoscopy SARS-CoV-2 testing strategy. We also present our experience with this strategy in 2021. RESULTS: Altogether 359 gastrointestinal endoscopies were performed in the initial period. The testing strategy enabled us to conservatively handle endoscopy programme reduction (44% reduction as compared 2019) during the first wave of the COVID-19 pandemic. The results of COVID-19 rtPCR from nasopharyngeal swabs were available in 89% of patients prior to endoscopies. Apart from six patients with known COVID-19, all other tested patients were negative. The frequencies of endoscopic therapies and clinically significant findings did not differ between patients with or without SARS-CoV-2 tests. In 2021 we were able to unrestrictedly perform all requested endoscopic procedures (> 5000 procedures) by applying the rtPCR-based pre-endoscopy SARS-CoV-2 testing strategy, regardless of next waves of COVID-19. Only two out-patients (1893 out-patient procedures) were tested positive in the year 2021. CONCLUSION: A structured pre-endoscopy SARS-CoV-2 testing strategy is feasible in the clinical routine of an endoscopy unit. rtPCR-based pre-endoscopy SARS-CoV-2 testing safely allowed unrestricted continuation of endoscopic procedures even in the presence of high incidence rates of COVID-19. Given the low frequency of positive tests, the absolute effect of pre-endoscopy testing on viral transmission may be low when FFP-2 masks are regularly used.

[Proposal for a Nationwide Johann-Peter Frank Cooperation Model under the National Leopoldina Initiative for Public Health and Global Health]. / Vorschlag für ein bundesweites Johann-Peter Frank Kooperationsmodell im Rahmen der nationalen Leopoldina-Initiative für Public Health und Global Health.

The discussion on the development of public health affairs was invigorated anew by the report on public health in Germany of Leopoldina/Acatech/Union of the German Academies of Sciences and Humanities of the year 2015. The report urges strengthening of public health and global health in Germany and addresses explicitly the Public Health Service (PHS). This indispensable inclusion of the PHS in further strategic planning offers for the first time an opportunity for a comprehensive and sustainable practice/policy transfer on the federal, state and community level, and also a chance for a sustainable network with modern academic public health institutions together with representation of medical specialization in public health at universities, that has been absent so far. A Johann-Peter Frank model for cooperation and stepwise modelling of this transition with the inclusion of the Academies for Public Health Service is presented.

[The EHEC O104:H4 outbreak in Germany 2011 - lessons learned?!]. / Der EHEC O104:H4 Ausbruch 2011 in Deutschland - Lektion gelernt?!

The EHEC O104:H4 outbreak 2011 in Germany provided numerous insights into the recognition and control of such epidemic situations. Food-borne outbreaks and their related dynamics may lead to a critical burden of disease and an eventual capacity overload of the medical care system. Possible difficulties in the microbiological diagnostics of new or significantly altered infectious agents may result in a delayed detection of the outbreak as well as the launching of interventional measures. Besides an early notification of the local public health office by the affected institutions, in which a complete electronic procedure and additional sentinel or surveillance instruments (e. g., in emergency departments of hospitals) may be of great help, an interdisciplinary cooperation of the local public health and food safety agencies is the key to an effective outbreak control. Corresponding organizations on the state and federal level should support the investigation process by microbiological diagnostics and advanced epidemiological analysis as well as examination of the food chains. Finally, successful crisis communication relies on "speaking with one voice" (not necessarily one person). Immediate, transparent, appropriate and honest information of the general public concerning the reasons, consequences and (counter-) measures of a crisis are the best means to keep the trust of the population and to counteract the otherwise inevitable speculations.

[Surveillance of hygiene by local public health authorities - recommendations (not only) for the public health service in Rhineland-Palatinate]. / Infektionshygienische Überwachung durch Gesundheitsämter - Empfehlungen (nicht nur) für den ÖGD in Rheinland-Pfalz.

Protection against communicable diseases and the prevention of their transmission require continuous surveillance by the public health service. There is also a need for targeting certain -hygiene standards and expert advice concerning their application, especially in institutions where medical interventions provide an increased risk for patients, staff and the public (e. g., intensive care units in hospitals or ambulatory dialysis centres). While the kind of institutions at risk is sufficiently governed in the German law (either at national or state level), the frequency of side visits as well the content and depth of surveillance activities lack adequate regulation. As the implementation of the national Protection against Infections Act in 2001 has enlarged the work load of local public health authorities without adequate staff compensation a risk-based strategy is required for efficient work scheduling. In Rhineland-Palatinate a task force of experts mandated by the ministry of health has developed recommendations on how often and with which expertise side visits should be performed. Based on published evidence and expert knowledge, an assessment of the institutional risk has been conducted leading to concrete patterns. High risk areas should be monitored every year, whereas three-year and five-year intervals are sufficient for institutions at middle or low risk respectively. This scheme represents a standard which should be applied by all public health departments in the state (and maybe also in other states). On the one hand the execution of this standard is expected to ascertain more transparency, predictability and comprehensibility for all involved parties. On the other hand the time and qualification pattern complements the general guidelines of the national steering committee for hospital hygiene and infectious disease protection (KRINKO). It is hoped that the combination of both elements will support the professional -dialogue between public health authorities and representatives of the affected institutions -leading to a common understanding of what communicable -disease protection is all about.

[Infection surveillance in North Rhine-Westphalia--standard reports, barometer and early warning system]. / Infektionssurveillance in NRW--Standardberichte, Barometer und Frühwarnsystem.

The increasing significance of communicable diseases requires new surveillance tools. Modern electronic instruments in analysis and communication replace the former "handbased" statistics and allow the development of early warning systems. In North Rhine-Westphalia (NRW) the Institute of Public Health started an approach to develop a modular surveillance system prior to the the implementation of the new German infectious disease protection act. The first module called "Automated infectious disease notifications and information system (AIM+)" generates various standard hypertext reports which are published as "Infectious disease reports NRW" on the internet (www.loegd.nrw.de). In addition the infectious disease information is linked with a geographical information system (GIS) giving spatial and temporal patterns. The second module called "Infectious disease barometer NRW" offers a quick actual overview highlighting several selected diseases. It can be electronically sent out to any interested person. The third module "Early warning system" realizes an effective early detection system by combining six statistical procedures with a total of 11 separate methods. In case of detecting clusters and outbreaks it automatically generates warning reports to the responsible parties. All three modules together improve the epidemiological surveillance of the population in NRW, support the translation of information to prevention and control measures, and therefore strengthen epidemiological policy-making.

Angiogenesis and microvascularization after cryothermia-induced myocardial infarction: a quantitative fluorescence microscopic study in rats.

OBJECTIVE: Microvascularization of infarcted myocardial tissue may be a prerequisite for successful therapeutic interventions, including cardiomyoblast or satellite cell transplantation. Because little is known on microvascular restitution within infarcted tissue, we studied angiogenesis and microvascularization after cryothermia-induced myocardial infarction using intravital fluorescence microscopic techniques. METHODS: In anesthetized, orally intubated and ventilated Sprague-Dawley rats (n = 20), a sternotomy was performed and a standardized cryolesion was induced to the right ventricle by freezing for 5 min to -160 degrees C. Myocardial angiogenesis and microvascularization were analyzed quantitatively after rethoracotomy on days 7 (n = 6) or 28 (n = 8). Sham-operated animals (n = 6) served as controls. RESULTS: Seven days after cryothermia, the central tissue area of the injured myocardium (28.4 +/- 9.2 mm2) was characterized by complete lack of capillary perfusion, while the periphery of the cryolesion (27.6 +/- 5.7 mm2) revealed a heterogeneous capillary perfusion pattern with a density of 300.9 +/- 38.9 cm-1. Adjacent myocardial tissue showed intact capillary perfusion (density: 563.0 +/- 44.4 cm-1) comparable with that of sham-operated controls. After 28 d the area with lack of capillary perfusion was found significantly reduced to 7.3 +/- 3.7 mm2 (P < 0.05); however, it was still surrounded by a heterogeneously perfused area of myocardial tissue of 57.7 +/- 19.2 mm2 (density: 271.1 +/- 52.7 cm-1), indicating partial restitution of capillary perfusion. Although at day 7 within the central zone of the cryolesions, capillary perfusion was completely shut down, perfusion of microvessels larger than capillaries, i.e., arterioles and venules, were found maintained, however, with a density markedly lower (1.96 +/- 1.04 mm-1) when compared with that of sham-controls (4.28 +/- 1.52 mm-1). After 28 d the number of these larger-sized microvessels increased significantly with values of density even higher compared with those observed in controls (6.89 +/- 1.71 mm-1; P < 0.05), indicating new vessel formation. CONCLUSIONS: Our study indicates partial restitution and function of the microvascular network within infarcted myocardial tissue, which may serve as an appropriate prerequisite for successful application of novel therapeutic strategies to improve myocardial function.

In vivo analysis of microvascular injury after myocardial cryothermia.

We studied microvascular injury after myocardial cryothermia in rats using intravital fluorescence microscopic techniques. Cryolesions were induced to the right ventricle by freezing with -160 degrees C (probe diameter: 5 mm) for a total of 5 min. Fluorescence microscopy was performed at 15, 30, 60, 90, and 120 min as well as at 3 and 7 days after cryothermia. Analysis of the epicardial microvasculature 15 min after cryothermia revealed an area of 24.6 +/- 3.8 mm2 of nonperfused tissue, which was reduced to 5.3 +/- 1.5 mm2 (P < 0.05) after the initial 2-h observation period. Vital microscopic images of reperfused tissue characteristically demonstrated extravasation of the macromolecular fluorescent tracer FITC-dextran (21.7 +/- 3.4 mm2), suggesting substantial loss of endothelial integrity. In vivo propidium iodide staining confirmed membrane damage of microvascular endothelial cells. Three days after cryoinjury the area of nonperfused tissue was reduced further to 1.1 +/- 0.4 mm2 in the center of the lesion, while the area of perfused tissue with disruption of endothelial integrity was found significantly increased to 47.4 +/- 5.9 mm2 (P < 0.05) toward the periphery. Analysis at 7 days revealed endothelial repair at the periphery of the cryolesion, but now a central necrotic area was found demarcated (nonperfused), presenting with a size (26.0 +/- 3.5 mm2) similar to that shown during the very early (15 min) reperfusion period. Our study demonstrates recovery of microvascular perfusion during the first hours and days after myocardial cryothermia. This is, however, associated with endothelial injury, i.e., damage of plasma membrane and loss of barrier function. Infarction with capillary perfusion failure is evident at 7 days with a size which strikingly corresponds to the sizeof nonperfused tissue observed immediately after cryointervention.