Personal Identity and Self-Interpretation & Natural Right and Natural Emotions

Collection of papers presented at the 2nd and 3rd Budapest Seminar in Early Modern Philosoph

Contamination of surgical mask during aerosol-producing dental treatments

Objectives Surgical masks are usually contaminated during dental treatment. So far it has not been investigated whether a surgical mask itself can be a source of microbial transmission. The aim of this study was therefore to investigate the microbiological contamination of surgical masks during dental treatment and the transfer of microorganisms from the mask to the hands. Materials and methods Five dental treatment modalities were studied: carious cavity preparation (P-caries, n = 10), tooth substance preparation (P-tooth, n = 10), trepanation and root canal treatment (P-endo, n = 10), supragingival ultrasonic application (US-supra, n = 10), and subgingival periodontal ultrasonic instrumentation (US-sub, n = 10). Bacterial contamination of mask and gloves worn during treatment was tested by imprinting on agar plates. Additionally, before masks were tested, their outer surface was touched with a new sterile glove. This glove was also imprinted on agar. Bacteria were identified by MALDI TOF mass spectrometry. Colony-forming units (CFU) were scored: score 0: 0 CFU, score 1:  102 CFU, score 3: dense microbial growth. Results All masks and all gloves used during treatment displayed bacterial contamination (sample scores 0/1/2/3: masks 0/46/3/1 and gloves 0/31/10/9). After touching the masks with new sterile gloves, microorganisms were recovered with the following contamination scores: P-caries: 4/6/0/0, P-tooth: 2/8/0/0: P-endo: 7/3/0/0, US-supra: 0/9/1/0, US-sub: 2/8/0/0. No statistically significant differences were detected between the treatment modalities. Streptococci spp. and Staphylococci spp. representing the oral and cutaneous flora dominated. Conclusions Surgical masks are contaminated after aerosol-producing dental treatment procedures. Used masks have a potential to be a source of bacterial contamination of the hands. Clinical relevance Dental staff should avoid touching the outer surface of masks with their hands to prevent transmission of pathogens. It is recommendable to change the mask after each treated patient followed by hand disinfection

Study on simplified model for estimating evaporation from reservoirs

In this study, the Linacre evaporation model was tested for its accuracy using daily, weekly and monthly records. The records were collected from class A evaporation pan installed at Algardabiya Reservoir, Sirt, Libya. The records for three years were used to calibrate and validate the model. Statistical tests show that the model gives a reasonable accuracy. The errors in the model prediction are 5.8%, 8% and 8.5% for weekly, monthly and daily prediction respectively. Thus, the Linacre model can be used when the available meteorological data is limited (air temperature only) and for all types of record such as daily, weekly and monthly

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Determination of the microbial contamination of the unprotected facial regions and the dental oro-nasal protective mask

In der Zahnmedizin stellt die horizontale und vertikale Übertragung von Mikroorganismen ein Risiko sowohl für Patienten als auch für medizinisches Personal dar. In den vergangenen Jahren und der aktuellen Pandemie wurden durch die breite Anwendung von Schutzkleidung dieser Problematik Rechnung getragen. Für Körperbekleidung, Handschuhe und Schutzbrillen bestehen allgemein akzeptierte Regeln. Zusätzlich schützen die Mund-Nasen-Schutzmaske vor Infektionen über die Atemwege. Im regelhaften zahnmedizinischen Behandlungsablauf werden jedoch einzelne Hautareale des medizinischen Personals nicht vollständig abgedeckt. Dies sind typischerweise die Unterarmregionen und die Stirn. Während Unterarme im Rahmen der Händedesinfektion mehrfach täglich gereinigt werden, bleibt die Stirn unberücksichtigt. Die Zielstellung der vorgestellten Pilotstudie war die Bestimmung der mikrobiellen Kontamination der Stirnflächen der Zahnmediziner mit den aus der Mundhöhle stammenden Spezies und die Gegenüberstellung der mikrobiellen Kontamination der ungeschützten Stirnfläche und der zahnärztlichen Mund-Nasen-Schutzmaske verursacht durch orale Spezies. Dazu erfolgte der qualitative und quantitative Nachweis durch Aerosol und Flüssigkeitstropfen aus der Mundhöhle versprengter Keime auf die Haut der Stirnflächen und die Mund-Nasen- Schutzmasken. Für die Studie wurden typische aerosolproduzierende, konservierend und parodontologische Therapieschritte an der Klinik für Zahnerhaltung, Parodontologie und Präventive Zahnheilkunde des Universitätsklinikums des Saarlandes untersucht. Im Vorfeld der Behandlung wurden Abstriche von der Stirn der Zahnmediziner mittels eines sterilem Nylon-Flockfaser- Abstrichtupfers genommen. Dieser Vorgang wurde 60 - 90 Minuten nach Behandlungsbeginn wiederholt. Die durch den Stirnabstich gewonnene Keime wurden anschließend mittels Dreiösenausstrich jeweils auf eine Trypticase Soja-Agarplatte (TSA-Platte) und eine Columbia Agarplatte ausgebracht, welche sowohl unter aeroben als auch anaeroben Bedingungen kultiviert wurden. Um die Kontamination der Mund-Nasen-Schutzmasken im Vergleich zu den Stirnflächen nach erfolgten Therapieschritten vergleichen zu können, wurden die keimbesiedelten äußere Oberflächen der während der Behandlung vom jeweiligen Probanden getragenen chirurgischen Mund-Nasen- Schutzmasken ebenfalls nach 60 - 90 Minuten Behandlungszeit mit einer TSA - und eine Columbia Agarplatte in direkten Kontakt gebracht. Diese wurden wiederum aerob und anearob im Wärmeschrank für 48 Stunden bei 36ºC ± 2ºC kultiviert. Nach der Kultivierung wurden die dann optisch unterscheidbaren Phänotypen mittels Flugzeitmassenspektrometrie (MALDI TOF - MS) identifiziert. Es konnte nachgewiesen werden, dass obligate und fakultative orale Spezies sowohl auf den Stirnflächen der Probanden als auch auf den Mund-Nasen-Schutzmasken aufgefunden werden konnten. Orale Spezies wurden auf 75% der chirurgischen Masken und auf 30 % der Stirnflächen nachgewiesen. Damit lag die Wahrscheinlichkeit für eine positive Besiedlung mit denen aus der Mundhöhle versprengten Mikroorganismen auf der Mund-Nasen-Schutzmaske um das 2,5 fache höher im Vergleich zur Stirnfläche der Probanden. Obligate orale Bakterien wurden auf der Stirnhaut (n = 4) und auf den Mund-Nasen-Schutzmasken (n = 17) nach der Behandlung gefunden. Die Zusammensetzung der oralen Spezies aus obligat oralen, fakultativ oralen und deren Kombination war auf den Stirnflächen und Mund-Nasen-Schutzmasken weitgehend vergleichbar. Dabei wurden sowohl auf den Stirnflächen als auch auf den Mund-Nasen-Schutzmasken folgende Mikroorganismen aufgefunden: Staphylococcus epidermidis, Staphylococcus capitis, Streptococcus oralis, alpha – hämolysierende Streptokokken, Acinetobacter lwoffii und Staphylococcus hominis. Auf 2 (3 %) Stirnflächen konnten bereits vor der Behandlung obligat den Mundhöhlenspezies zuzuordnende Mikroorganismen aufgefunden werden. Weiter konnten vor und nach der Behandlung Mikroorganismen aus anderen Körperregionen (Staphylococcus saprophyticus) auf den Stirnflächen aufgefunden werden. Auf den Mund-Nasen-Schutzmasken wurden nach der Behandlung auf einer Probe eine Clostridium Spezies (obligat anaerober), auf einer anderen Probe Escherichia coli (fakultativ anaerob), auf jeweils einer Probe Staphylococcus haemolyticus und Leclercia adecarboxylata und auf weiteren 4 Proben Staphylococcus saprophyticus identifiziert. Staphylococcus aureus wurden auf 4 Stirnflächen vor, auf 3 Stirnflächen nach der Behandlung und auf 3 Mund- Nasen-Schutzmasken aufgefunden. Ein Methicillin-resistenter S. aureus (MRSA) Nachweis konnte für keinen der aufgefundenen S. aureus erbracht werden. Es wird vermutet, dass natürliche Abwehrmechanismen der Haut eine Neubesiedlung behindern oder einzelne Mikroorganismen nach erfolgter Kontamination eliminieren. Um sowohl das Risikopotenzial im Hinblick auf die Möglichkeit einer bakteriellen und viralen Kontamination besser abschätzen zu können und um konkrete Handlungsanweisungen zu formulieren, müssen zu der behandelten Fragestellung weitere Studien durchgeführt werden. Dabei könnte z.B. die Verbreitungsgefahr einer auf der Stirn bestehenden bakteriellen oder viralen Kontamination in die Augen durch Schwitzen untersucht werden. Die Ergebnisse dieser Pilotstudie bestätigen, dass Aerosol- und Flüssigkeitstropfen freisetzende zahnmedizinisch therapeutische Maßnahmen ein Kontaminationsrisiko für die ungeschützten Hautareale und die Mund-Nasen-Schutzmaske des Behandlungsteams darstellen. Gesichtsschutzschilde können die Übertragung von Tröpfchen reduzieren, aber Aerosole nicht einschränken, da diese in den Luftströmungen transportiert werden. Es wird empfohlen, dass die ungeschützte Stirnfläche bei der persönlichen Hygiene, z.B. durch die Nutzung desinfizierender Präparate, die für die Anwendung auf der Gesichtshaut geeignet sind, stärkere Berücksichtigung finden. Die chirurgische Mund-Nasen- Schutzmaske sollte nach jedem Patienten gewechselt werden. Auch das Herabziehen der Mund-Nasen- Schutzmaske unter Berührung der Außenflächen der Schutzmaske, z.B. in Behandlungspausen ohne anstehenden Patientenwechsel, ist zu unterlassen.In dentistry, the horizontal and vertical transmission of microorganisms poses a risk to both patients and medical staff. In recent years and the current pandemic, the widespread use of protective clothing has addressed this issue. Generally, accepted rules exist for body clothing, gloves and protective eyewear. In addition, the mouth-nose protective mask blocks the infections via the respiratory tract. In the regular dental treatment process, however, individual skin areas of the medical staff are not fully covered. These are typically the forearm regions and the forehead. While forearms are cleaned several times a day as part of hand disinfection, the forehead remains unconsidered. The objective of the pilot study presented was to determine the microbial contamination of the forehead surfaces of dentists with species originating from the oral cavity and to compare the microbial contamination of the unprotected forehead surface and the dental mouth-nose protective mask caused by oral species. For this purpose, qualitative and quantitative detection of germs dispersed by aerosol and liquid droplets from the oral cavity onto the skin of the forehead surfaces and the oral-nasal protective masks were carried out. For the study, typical aerosol-producing, conservative and periodontal therapy steps were investigated at the Clinic for Dental Preservation, Periodontology and Preventive Dentistry of Saarland University Hospital. Prior to treatment, swabs were taken from the dentists' foreheads using a sterile nylon flock fibre swab. This procedure was repeated 60-90 minutes after the start of treatment. The germs obtained from the forehead swab were then spread onto a trypticase soy agar plate (TSA plate) and a Columbia agar plate respectively, which were cultured under both aerobic and anaerobic conditions, using a three-eye smear. In order to compare the contamination of the oral-nasal protective masks in comparison to the frontal surfaces after therapy, the germ-populated outer surfaces of the surgical oralnasal protective masks worn by the respective test person during treatment were also brought into direct contact with a TSA plate and a Columbia agar plate after 60 - 90 minutes of treatment. These were again cultured aerobically and anearobically for 48 hours at 36ºC ± 2ºC. After cultivation, optically distinguishable phenotypes were identified by time-of-flight mass spectrometry (MALDI TOF - MS). Obligate and facultative oral species were found on the forehead of the test persons as well as on the surgical face masks masks. Oral species were detected on 75% of the surgical masks and on 30% of the forehead surfaces. Thus, the probability of positive colonization with microorganisms dispersed from the oral cavity was 2.5 times higher on the oral-nasal protective mask compared to the forehead surface of the dental masks. Obligate oral bacteria were found on the forehead skin (n = 4) and on the mouth-nose protective masks (n = 17) after treatment. The oral species composition of obligate oral, facultative oral, and their combination was largely comparable on the forehead surfaces and oral-nasal protective masks. The following microorganisms were found on both the forehead surfaces and the oral-nasal protective masks: Staphylococcus epidermidis, Staphylococcus capitis, Streptococcus oralis, alpha - hemolytic streptococci, Acinetobacter lwoffii, and Staphylococcus hominis. On 2 (3 %) forehead surfaces, microorganisms obligatory associated with the oral cavity species could already be found before treatment. Furthermore, microorganisms from other body regions (Staphylococcus saprophyticus) were found on the forehead surfaces before and after treatment. On the mouth-nose masks after treatment, a Clostridium species (obligate anaerobic) was identified on one sample, Escherichia coli (facultative anaerobic) on another sample, Staphylococcus haemolyticus and Leclercia adecarboxylata on one sample each, and Staphylococcus saprophyticus on a further 4 samples. Staphylococcus aureus was found on 4 forehead surfaces before treatment, on 3 forehead surfaces after treatment, and on 3 oral-nasal masks. Methicillin-resistant S. aureus (MRSA) detection was not detected for any of the S. aureus encountered. It is assumed that natural defense mechanisms of the skin prevent recolonization or eliminate individual microorganisms after contamination. In order to be able to better assess the risk potential with regard to the possibility of bacterial and viral contamination and to formulate concrete instructions for action, further studies must be carried out on the issue addressed. For example, the risk of spreading bacterial or viral contamination existing on the forehead into the eyes through sweating could be investigated. The results of this pilot study confirm that aerosol and liquid droplet-releasing dental therapeutic procedures pose a contamination risk to the unprotected skin areas and the mouth-nose protective mask of dental professionals. Face shields can reduce droplet transmission but cannot limit aerosols as they are transported in air currents. It is recommended that greater consideration be given to the unprotected frontal surface in personal hygiene, e.g., through the use of disinfectant preparations suitable for use on facial skin. The surgical protective mouth-nose mask should be changed after each patient. Pulling down the mouth-nose-protective mask while touching the outer surfaces of the protective mask, e.g. during treatment breaks without a pending patient change, should also be refrained from