Migration: The aftershocks to the provision of healthcare

Migration is the “movement of people to a new area or country in order to find work or better living conditions” (Oxford dictionary). The term “migration” summarizes forced, reluctant and voluntary migration. Voluntary migration is a comparatively constant event. But reluctant and, in particular, forced migration have been subject to substantial change during the last years. At the end of 2016, more than 17.2 million refugees (+ 5.3 million Palestinians) were on the run outside their home countries. 55% of them fled from Syria (5.5 million), Afghanistan (2.5 million) and South Sudan (1.4 million), respectively. The top hosting countries were not, in fact, the Southern and Western European or North American, but some of the poorest countries in the world. With the refugees from countries where disorders of haemoglobin are very prevalent, the number of patients in the host countries significantly increased within a very short period of time. The extraordinary circumstances required rapid rethinking and adaption and, therefore, did not only pose a big challenge but, in some countries, also a big chance to improve care for patients suffering from hemoglobinopathies. Although there are certainly several trouble spots in the world, the Middle East crisis was and still is currently the most prominent one. There is a significant prevalence of thalassemia and sickle cell disease among the Syrian and Iraqi population and since the chronically ill were presumably those who left their home countries first, there was a dramatic increase in the prevalence of thalassaemia and sickle cell disease in the host countries. Many patients fled to Western and Northern European countries where hemoglobinopathies were very rare and where the healthcare systems were unable to cope with this sudden increase in patient numbers and complications. For example, disease characteristics were much more pronounced than doctors were used to. Complications occurred that physicians only knew from textbooks. In addition, virtually all families needed significant help in psychosocial matters and many refugees were severely traumatized

Digital Health Interventions (DHIs) to Support the Management of Children and Adolescents with Sickle‐Cell Disease

Sickle‐cell disease (SCD) is a very complex disorder alluding to all areas of medicine. Nevertheless, basic preventive and therapeutic interventions in patients suffering from SCD are extremely simple. However, in everyday life it is sometimes virtually impossible to motivate children and young adolescents to effectively self‐manage their disorder at an early stage. Digital health interventions (DHIs) provide new opportunities to support self‐management behaviours. DHIs may facilitate daily and recurrent routines such as drug intake or appointments along with helping the patients to better cope with their disease. This may be realized through mobile‐training programmes, disease‐specific social networks using secure communication channels, diaries, blogs and even games. Indeed, there are fascinating opportunities for modern disease‐training programmes to take advantage of several media that can be combined and didactically optimized to meet the individual needs and intellectual abilities of different patients. The technological progress is rapid, extremely dynamic and highly creative. Our chapter gives an overview of the multifarious world of DHIs with a focus on smartphone applications known as mobile health apps (mHealth apps). We elucidate the potential reasons why we think that numerous apps for SCD patients have not been successful and which app features developers should consider if they want to create a popular patient app

Technical and Legal Aspects of a German Pilot Study with 38,220 Participants

Sickle cell disease (SCD) does not occur in the indigenous German population, but with the increasing number of immigrants from countries at high risk for hemoglobinopathies, the question emerges whether or not a newborn screening program (NBS) for SCD disease should be initiated in Germany anyhow. We have recently shown that in Berlin, a city with a very large immigrant population, the incidence of SCD is considerable, but our findings are insufficient to make a decision for the country as a whole. In this paper we will show that a large body of epidemiological data can be generated in a relatively short period of time, with a very high degree of precision and at relatively little expense—a result that might motivate other working groups to start such a pilot project locally. We examined previously collected dried blood cards that were up to six months old, using high performance liquid chromatography (HPLC) as first method and capillary electrophoresis (CE) as second method. A single, part-time laboratory technician processed 38,220 samples in a period of 162 working days. The total costs per sample including all incidentals (as well as labor costs) were EUR 1.44

Studying boundary layer methane isotopy and vertical mixing processes at a rewetted peatland site using an unmanned aircraft system

The combination of two well-established methods, of quadrocopter-borne air sampling and methane isotopic analyses, is applied to determine the source process of methane at different altitudes and to study mixing processes. A proof-of-concept study was performed to demonstrate the capabilities of quadrocopter air sampling for subsequently analysing the methane isotopic composition δ13C in the laboratory. The advantage of the system compared to classical sampling on the ground and at tall towers is the flexibility concerning sampling location, and in particular the flexible choice of sampling altitude, allowing the study of the layering and mixing of air masses with potentially different spatial origin of air masses and methane. Boundary layer mixing processes and the methane isotopic composition were studied at Polder Zarnekow in Mecklenburg–West Pomerania in the north-east of Germany, which has become a strong source of biogenically produced methane after rewetting the drained and degraded peatland. Methane fluxes are measured continuously at the site. They show high emissions from May to September, and a strong diurnal variability. For two case studies on 23 May and 5 September 2018, vertical profiles of temperature and humidity were recorded up to an altitude of 650 and 1000 m, respectively, during the morning transition. Air samples were taken at different altitudes and analysed in the laboratory for methane isotopic composition. The values showed a different isotopic composition in the vertical distribution during stable conditions in the morning (delta values of −51.5 ‰ below the temperature inversion at an altitude of 150 m on 23 May 2018 and at an altitude of 50 m on 5 September 2018, delta values of −50.1 ‰ above). After the onset of turbulent mixing, the isotopic composition was the same throughout the vertical column with a mean delta value of −49.9 ± 0.45 ‰. The systematically more negative delta values occurred only as long as the nocturnal temperature inversion was present. During the September study, water samples were analysed as well for methane concentration and isotopic composition in order to provide a link between surface and atmosphere. The water samples reveal high variability on horizontal scales of a few tens of metres for this particular case. The airborne sampling system and consecutive analysis chain were shown to provide reliable and reproducible results for two samples obtained simultaneously. The method presents a powerful tool for distinguishing the source process of methane at different altitudes. The isotopic composition showed clearly depleted delta values directly above a biological methane source when vertical mixing was hampered by a temperature inversion, and different delta values above, where the air masses originate from a different footprint area. The vertical distribution of methane isotopic composition can serve as tracer for mixing processes of methane within the atmospheric boundary layer

Unmanned Aerial Systems for Investigating the Polar Atmospheric Boundary Layer—Technical Challenges and Examples of Applications

Unmanned aerial systems (UAS) fill a gap in high-resolution observations of meteorological parameters on small scales in the atmospheric boundary layer (ABL). Especially in the remote polar areas, there is a strong need for such detailed observations with different research foci. In this study, three systems are presented which have been adapted to the particular needs for operating in harsh polar environments: The fixed-wing aircraft M^2AV with a mass of 6 kg, the quadrocopter ALICE with a mass of 19 kg, and the fixed-wing aircraft ALADINA with a mass of almost 25 kg. For all three systems, their particular modifications for polar operations are documented, in particular the insulation and heating requirements for low temperatures. Each system has completed meteorological observations under challenging conditions, including take-off and landing on the ice surface, low temperatures (down to −28 °C), icing, and, for the quadrocopter, under the impact of the rotor downwash. The influence on the measured parameters is addressed here in the form of numerical simulations and spectral data analysis. Furthermore, results from several case studies are discussed: With the M^2AV, low-level flights above leads in Antarctic sea ice were performed to study the impact of areas of open water within ice surfaces on the ABL, and a comparison with simulations was performed. ALICE was used to study the small-scale structure and short-term variability of the ABL during a cruise of RV Polarstern to the 79°N glacier in Greenland. With ALADINA, aerosol measurements of different size classes were performed in Ny-Ålesund, Svalbard, in highly complex terrain. In particular, very small, freshly formed particles are difficult to monitor and require the active control of temperature inside the instruments. The main aim of the article is to demonstrate the potential of UAS for ABL studies in polar environments, and to provide practical advice for future research activities with similar systems

Unmanned Aerial Systems for Investigating the Polar Atmospheric Boundary Layer—Technical Challenges and Examples of Applications

Unmanned aerial systems (UAS) fill a gap in high-resolution observations of meteorological parameters on small scales in the atmospheric boundary layer (ABL). Especially in the remote polar areas, there is a strong need for such detailed observations with different research foci. In this study, three systems are presented which have been adapted to the particular needs for operating in harsh polar environments: The fixed-wing aircraft M2AV with a mass of 6 kg, the quadrocopter ALICE with a mass of 19 kg, and the fixed-wing aircraft ALADINA with a mass of almost 25 kg. For all three systems, their particular modifications for polar operations are documented, in particular the insulation and heating requirements for low temperatures. Each system has completed meteorological observations under challenging conditions, including take-offand landing on the ice surface, low temperatures (down to-28 °C), icing, and, for the quadrocopter, under the impact of the rotor downwash. The influence on the measured parameters is addressed here in the form of numerical simulations and spectral data analysis. Furthermore, results from several case studies are discussed: With the M2AV, low-level flights above leads in Antarctic sea ice were performed to study the impact of areas of open water within ice surfaces on the ABL, and a comparison with simulations was performed. ALICE was used to study the small-scale structure and short-term variability of the ABL during a cruise of RV Polarstern to the 79° N glacier in Greenland. With ALADINA, aerosol measurements of different size classes were performed in Ny-Alesund, Svalbard, in highly complex terrain. In particular, very small, freshly formed particles are difficult to monitor and require the active control of temperature inside the instruments. The main aim of the article is to demonstrate the potential of UAS for ABL studies in polar environments, and to provide practical advice for future research activities with similar systems. © 2020 by the authors

High-sensitivity microsatellite instability assessment for the detection of mismatch repair defects in normal tissue of biallelic germline mismatch repair mutation carriers

Introduction: Lynch syndrome (LS) and constitutional mismatch repair deficiency (CMMRD) are hereditary cancer syndromes associated with mismatch repair (MMR) deficiency. Tumours show microsatellite instability (MSI), also reported at low levels in non-neoplastic tissues. Our aim was to evaluate the performance of high-sensitivity MSI (hs-MSI) assessment for the identification of LS and CMMRD in non-neoplastic tissues. Materials and methods: Blood DNA samples from 131 individuals were grouped into three cohorts: baseline (22 controls), training (11 CMMRD, 48 LS and 15 controls) and validation (18 CMMRD and 18 controls). Custom next generation sequencing panel and bioinformatics pipeline were used to detect insertions and deletions in microsatellite markers. An hs-MSI score was calculated representing the percentage of unstable markers. Results: The hs-MSI score was significantly higher in CMMRD blood samples when compared with controls in the training cohort (p<0.001). This finding was confirmed in the validation set, reaching 100% specificity and sensitivity. Higher hs-MSI scores were detected in biallelic MSH2 carriers (n=5) compared with MSH6 carriers (n=15). The hs-MSI analysis did not detect a difference between LS and control blood samples (p=0.564). Conclusions: The hs-MSI approach is a valuable tool for CMMRD diagnosis, especially in suspected patients harbouring MMR variants of unknown significance or non-detected biallelic germline mutations. Keywords: constitutional mismatch repair deficiency; highly sensitive methodologies; lynch syndrome; microsatellite instability; next generation sequencing

Antimicrobial use in pediatric oncology and hematology in Germany and Austria, 2020/2021: a cross-sectional, multi-center point-prevalence study with a multi-step qualitative adjudication process

Background Due to the high risk of severe infection among pediatric hematology and oncology patients, antimicrobial use is particularly high. With our study, we quantitatively and qualitatively evaluated, based on institutional standards and national guidelines, antimicrobial usage by employing a point-prevalence survey with a multi-step, expert panel approach. We analyzed reasons for inappropriate antimicrobial usage. Methods This cross-sectional study was conducted at 30 pediatric hematology and oncology centers in 2020 and 2021. Centers affiliated to the German Society for Pediatric Oncology and Hematology were invited to join, and an existing institutional standard was a prerequisite to participate. We included hematologic/oncologic inpatients under 19 years old, who had a systemic antimicrobial treatment on the day of the point prevalence survey. In addition to a one-day, point-prevalence survey, external experts individually assessed the appropriateness of each therapy. This step was followed by an expert panel adjudication based upon the participating centers’ institutional standards, as well as upon national guidelines. We analyzed antimicrobial prevalence rate, along with the rate of appropriate, inappropriate, and indeterminate antimicrobial therapies with regard to institutional and national guidelines. We compared the results of academic and non-academic centers, and performed a multinomial logistic regression using center- and patient-related data to identify variables that predict inappropriate therapy. Findings At the time of the study, a total of 342 patients were hospitalized at 30 hospitals, of whom 320 were included for the calculation of the antimicrobial prevalence rate. The overall antimicrobial prevalence rate was 44.4% (142/320; range 11.1–78.6%) with a median antimicrobial prevalence rate per center of 44.5% (95% confidence interval [CI] 35.9–49.9). Antimicrobial prevalence rate was significantly higher (p < 0.001) at academic centers (median 50.0%; 95% CI 41.2–55.2) compared to non-academic centers (median 20.0%; 95% CI 11.0–32.4). After expert panel adjudication, 33.8% (48/142) of all therapies were labelled inappropriate based upon institutional standards, with a higher rate (47.9% [68/142]) when national guidelines were taken into consideration. The most frequent reasons for inappropriate therapy were incorrect dosage (26.2% [37/141]) and (de-)escalation/spectrum-related errors (20.6% [29/141]). Multinomial, logistic regression yielded the number of antimicrobial drugs (odds ratio, OR, 3.13, 95% CI 1.76–5.54, p < 0.001), the diagnosis febrile neutropenia (OR 0.18, 95% CI 0.06–0.51, p = 0.0015), and an existing pediatric antimicrobial stewardship program (OR 0.35, 95% CI 0.15–0.84, p = 0.019) as predictors of inappropriate therapy. Our analysis revealed no evidence of a difference between academic and non-academic centers regarding appropriate usage. Interpretation Our study revealed there to be high levels of antimicrobial usage at German and Austrian pediatric oncology and hematology centers with a significant higher number at academic centers. Incorrect dosing was shown to be the most frequent reason for inappropriate usage. Diagnosis of febrile neutropenia and antimicrobial stewardship programs were associated with a lower likelihood of inappropriate therapy. These findings suggest the importance of febrile neutropenia guidelines and guidelines compliance, as well as the need for regular antibiotic stewardship counselling at pediatric oncology and hematology centers. Funding European Society of Clinical Microbiology and Infectious Diseases, Deutsche Gesellschaft für Pädiatrische Infektiologie, Deutsche Gesellschaft für Krankenhaushygiene, Stiftung Kreissparkasse Saarbrücken

Posttranscriptional silencing of ETV6/RUNX1 by lentiviral transduction with the ribozyme buRZ28

Die Transkriptionsfaktoren ETV6 und RUNX1 sind essenzielle Regulatoren der Häma-topoese. Durch die kryptische chromosomale Translokation t(12;21)(p13;q22), die bei ca. 25% der akuten lymphoblastischen Leukämien (ALL) im Kindesalter nachweisbar ist, entsteht das Fusionsgen ETV6/RUNX1, das zur Bildung eines aberranten Fusionspro-teins führt. Essenzielle regulatorische Funktionen beider Transkriptionsfaktoren werden dadurch nachhaltig gestört. Die exakten Bedeutungen von ETV6 und RUNX1 in der Hämatopoese sind noch nicht abschließend geklärt. Ebenso ist die Rolle des Fusions-proteins in der Leukämogenese bislang unklar. In verschiedenen Studien wurde versucht, die Expression des Fusionstranskriptes mit Hilfe von RNA- Interferenzstrategien posttranskriptionell zu unterdrücken. Dies gelang nur mit begrenztem Erfolg. Das liegt wahrscheinlich daran, dass siRNA-basierte Eingriffe in die Genregulation nur dann spezifisch sein können, wenn die verwendete siRNA exakt den ETV6/RUNX1-Fusionsbereich als Ziel hat. Alle anderen Sequenzen kommen nicht nur im Fusionsgen sondern auch im zweiten ETV6- bzw. im zweiten RUNX1-Allel vor. Im Fusionsbereich bietet sich aber kein optimales siRNA-Ziel. Hammerhead-Ribozyme sind sehr kurze, katalytisch wirksame RNA-Moleküle, die in der Lage sind, definierte RNA-Sequenzen zu schneiden. Sie sind damit potenziell ebenso geeignet, die Expression von Genen posttranskriptionell zu regulieren wie inter-ferierende RNA-Moleküle. Für Ribozyme gelten zwar grundsätzlich die gleichen Ein-schränkungen wie für siRNA. Aufgrund des gänzlich unterschiedlichen Wirkmechanis-mus gelang einer koreanischen Arbeitsgruppe aber dennoch ein Ribozym mit Wirksam-keit gegen ETV6/RUNX1 zu identifizieren. Das Einbringen regulatorisch wirksamer RNA- Entitäten durch lentivirale Transduktion hat den wesentlichen Vorteil, dass der entsprechende Nukleinsäureabschnitt stabil in das Genom der Zielzelle integriert wird und deswegen nicht in zukünftigen Zellteilungen verloren geht. Außerdem können zusätzliche Sequenzen in die Zielzellen eingebracht werden, die wiederum die Expression des regulatorisch wirksamen RNA-Moleküls be- einflussen. Dadurch lassen sich Regulationseffekte gewissermaßen an- und abschalten. Im Rahmen dieser Dissertation wurde das bekannte, die Expression von ETV6/RUNX1 posttranskriptionell beeinflussende Hammerhead-Ribozym mit der Bezeichnung buRz28 lentiviral in eine selbst generierte ETV6/RUNX1-exprimierende Modellzelllinie eingebracht und untersucht, ob das lentiviral transferierte Ribozym ebenso wirksam ist wie das episomal durch Transfektion eingebrachtes Ribozym. Es konnte gezeigt werden, ➢ dass die Modellzelllinie HT-1080 nach Transduktion mit einem selbst klonierten lentiviralen Vektor stabil ETV6/RUNX1 exprimiert, ➢ dass sich die ETV6/RUNX1 exprimierenden HT-1080-Zellen lentiviral mit dem Ribozym buRz28 transduzieren ließen, ➢ und dass das lentiviral eingebrachte Ribozym buRz28 zu einer posttranskriptio-nellen Herabregulierung der Genexpression führt. Die in dieser Arbeit verwendete Methodik ist sehr innovativ. Bislang gibt es kaum Publi-kationen zu lentiviral vermitteltem Ribozymtransfer. Diese Technik könnte sich als gute Alternative zur posttranskriptionellen Genexpressionshemmung erweisen, insbesondere dann, wenn die Zielsequenz kein geeignetes Ziel für siRNA bietet.The transcription factors ETV6 and RUNX1 are essential regulators of haematopoiesis. The cryptic translocation t(12;21)(p13;q22) found in about 25% of childhood acute lymphoblastic leukaemia, results in the fusion gene ETV6/RUNX1, which gives rise to an aberrant fusion protein and causes significant alterations of essential regulatory tasks of both transcription factors. However, to date, the exact relevance of ETV6 and RUNX1 in haematopoiesis and leukaemogenesis is not clear. Several studies aimed at the posttranscriptional inhibition of the fusion transcript by means of RNA interference with limited success. siRNA based interference of gene regulation is only specific, if it targets the ETV6/RUNX1 fusion region exactly. Any other sequence is not only part of the fusion gene, but also of the second ETV6 or RUNX1 allele, respectively. However, the fusion region does provide an optimal target for siRNA. Hammerhead ribozymes are very short RNA molecules with catalytic activity able to cut defined RNA sequences. Hence, they are potentially as suitable to regulate gene expression poststranscriptionally as are interfering RNA molecules. Anyway, the same restrictions apply for ribozymes as do for siRNA. Nevertheless, due to a completely different mechanism of action, a Korean group was able to identify a ribozyme with activity against ETV6/RUNX1. Delivery of regulatory RNA entities by lentiviral transduction has the significant advantage of stable integration of the respective nucleic acid into the host cell genome. Thus, the sequence does not get lost during future divisions of the cell. Moreover, additional sequences can be co-delivered, which may control the expression of regulatory RNA molecules. Thereby, regulatory effects can be switched on and off. In this dissertation, the hammerhead ribozyme buRZ28, which was known to inhibit the expression of ETV6/RUNX1 posttranscriptionally, was delivered lentivirally into a self-generated ETV6/RUNX1 expressing model cell line. Subsequently, it was studied if the lentiviral transfer of the ribozyme was as effective as the introduction of the ribozyme in an episomal manner. It could be demonstrated, that (a) the model cell line HT-1080 stably expressed ETV6/RUNX1 after transduction with a self-designed lentiviral vector, that (b) ETV6/RUNX1 expressing HT-1080 cells could be transduced lentivirally with the ribozyme buRz28 and that (c) lentivirally transferred buRz28 was able to silence gene expression posttranscriptionally. The methodology used in this work is very innovative. To date, there is hardy any publication on lentiviral ribozyme transfer. This technique could be a suitable alternative in studies of posttranscriptional gene expression, which is particular true, if there is no appropriate target for siRNA in the respective sequence