Cholera Epidemic - Lusaka, Zambia, October 2017-May 2018.

On October 6, 2017, an outbreak of cholera was declared in Zambia after laboratory confirmation of Vibrio cholerae O1, biotype El Tor, serotype Ogawa, from stool specimens from two patients with acute watery diarrhea. The two patients had gone to a clinic in Lusaka, the capital city, on October 4. Cholera cases increased rapidly, from several hundred cases in early December 2017 to approximately 2,000 by early January 2018 (Figure). In collaboration with partners, the Zambia Ministry of Health (MoH) launched a multifaceted public health response that included increased chlorination of the Lusaka municipal water supply, provision of emergency water supplies, water quality monitoring and testing, enhanced surveillance, epidemiologic investigations, a cholera vaccination campaign, aggressive case management and health care worker training, and laboratory testing of clinical samples. In late December 2017, a number of water-related preventive actions were initiated, including increasing chlorine levels throughout the city's water distribution system and placing emergency tanks of chlorinated water in the most affected neighborhoods; cholera cases declined sharply in January 2018. During January 10-February 14, 2018, approximately 2 million doses of oral cholera vaccine were administered to Lusaka residents aged ≥1 year. However, in mid-March, heavy flooding and widespread water shortages occurred, leading to a resurgence of cholera. As of May 12, 2018, the outbreak had affected seven of the 10 provinces in Zambia, with 5,905 suspected cases and a case fatality rate (CFR) of 1.9%. Among the suspected cases, 5,414 (91.7%), including 98 deaths (CFR = 1.8%), occurred in Lusaka residents.

Punch and rescue technique for scleral fixation of dislocated single-piece intraocular lenses.

In-the-bag intraocular lens (IOL) dislocation is a well-known complication after cataract surgery. As the number of cataract surgeries performed annually continues to increase, so will the incidence of IOL dislocations requiring surgical correction. Described is a new technique for rescue and refixation of a single-piece acrylic IOL. In this method, a new instrument called the IOL punch is used to create a hole at the optic-haptic junction or along the border of the optic, which acts as an anchor point for centration and subsequent scleral fixation of a dislocated IOL. The IOL punch allows for precise intraocular manipulation of the IOL and is less invasive compared with popular scleral fixation methods. This innovative technique may decrease the risk for postoperative complications and allows patients to maintain or recover previous uncorrected visual acuity by circumventing the need for IOL explantation or exchange.

Characterization of Tbr2-expressing retinal ganglion cells.

The mammalian retina contains more than 40 retinal ganglion cell (RGC) subtypes based on their unique morphologies, functions, and molecular profiles. Among them, intrinsically photosensitive RGCs (ipRGCs) are the first specified RGC type emerging from a common retinal progenitor pool during development. Previous work has shown that T-box transcription factor T-brain 2 (Tbr2) is essential for the formation and maintenance of ipRGCs, and that Tbr2-expressing RGCs activate Opn4 expression upon native ipRGC ablation, suggesting that Tbr2+ RGCs contain a reservoir for ipRGCs. However, the identity of Tbr2+ RGCs has not been fully vetted. Here, using genetic sparse labeling and single cell recording, we showed that Tbr2-expressing retinal neurons include RGCs and a subset of GABAergic displaced amacrine cells (dACs). Most Tbr2+ RGCs are intrinsically photosensitive and morphologically resemble native ipRGCs with identical retinofugal projections. Tbr2+ RGCs also include a unique and rare Pou4f1-expressing OFF RGC subtype. Using a loss-of-function strategy, we have further demonstrated that Tbr2 is essential for the survival of these RGCs and dACs, as well as maintaining the expression of Opn4. These data set a strong foundation to study how Tbr2 regulates ipRGC development and survival, as well as the expression of molecular machinery regulating intrinsic photosensitivity.

A virtual COVID-19 ophthalmology rotation.

The coronavirus (COVID-19) pandemic temporarily suspended medical student involvement in clinical rotations, resulting in the need to develop virtual clinical experiences. The cancellation of clinical ophthalmology electives and away rotations reduces opportunities for exposure to the field, to network with faculty, conduct research, and prepare for residency applications. We review the literature and discuss the impact and consequences of COVID-19 on undergraduate medical education with an emphasis on ophthalmic undergraduate medical education. We also discuss innovative learning modalities used from medical schools around the world during the COVID-19 pandemic such as virtual didactics, online cases, and telehealth. Finally, we describe a novel, virtual neuro-ophthalmology elective created to educate medical students on neuro-ophthalmology foundational principles, provide research and presentation opportunities, and build relationships with faculty members. These innovative approaches represent a step forward in further improving medical education in ophthalmology during COVID-19 pandemic and beyond.

An interstitial deletion at 3p21.3 results in the genetic fusion of MLH1 and ITGA9 in a Lynch syndrome family.

PURPOSE: Germline mutations in DNA mismatch repair genes, mainly MLH1 or MSH2, have been shown to predispose with high penetrance for the development of the clinical phenotype of hereditary nonpolyposis colorectal cancer (Lynch syndrome). Here, we describe the discovery and first functional characterization of a novel germline MLH1 mutant allele. EXPERIMENTAL DESIGN: A large kindred including 54 potential carriers was investigated at the molecular level by using different types of PCR experiments, gene cloning, transfection studies, Western blot experiments, and mismatch repair assays to identify and characterize a novel MLH1 mutant allele. Twenty-two of 54 putative carriers developed colon cancer or other tumors, including breast cancer. RESULTS: The identified MLH1 mutant allele emerged from an interstitial deletion on chromosome 3p21.3, leading to an in-frame fusion of MLH1 (exons 1-11) with ITGA9 (integrin alpha 9; exons 17-28). The deleted area has a size of about 400 kb; codes for LRRFIP2 (leucine-rich repeat in flightless interaction protein 2), GOLGA4 (Golgi autoantigen, golgin subfamily a, 4), and C3orf35/APRG1 (chromosome 3 open reading frame 35/AP20 region protein 1); and partly disrupts the AP20 region implicated in major epithelial malignancies. Tumor cells lost their second MLH1 allele. The MLH1*ITGA9 fusion protein provides no capability for DNA mismatch repair. Murine fibroblasts, expressing a doxycycline-inducible MLH1*ITGA9 fusion gene, exhibit a loss-of-contact inhibition phenotype. CONCLUSIONS: This is the first description of a functional gene fusion of the human MLH1 gene, resulting in the loss of mismatch repair capabilities. The MLH1*ITGA9 fusion allele, together with deletions of the AP20 region, presumably defines a novel subclass of Lynch syndrome patients, which results in an extended tumor spectrum known from hereditary nonpolyposis colorectal cancer and Muir-Torre syndrome patients.

A lecithin phosphatidylserine and phosphatidic acid complex (PAS) reduces symptoms of the premenstrual syndrome (PMS): Results of a randomized, placebo-controlled, double-blind clinical trial.

BACKGROUND & AIMS: Many women experience emotional and physical symptoms around the time of ovulation and more so before menstruation interfering with their daily normal life also known as premenstrual syndrome (PMS). Recent observational data suggest that supplementation with Lipogen's phosphatidylserine (PS) and phosphatidic acid (PA) complex (PAS) alleviates these PMS symptoms. The aim of this study was to confirm these observations on the effects of PAS on PMS symptom severity within a controlled clinical trial setting. METHODS: Forty women aged 18-45 years with a diagnosis of PMS were assigned to either take PAS (containing 400 mg PS & 400 mg PA per day) or a matching placebo. The study comprised 5 on-site visits including 1 baseline menstrual cycle followed by 3 treatment cycles. Treatment intake was controlled for by using an electronic device, the Medication Event Monitoring System (MEMS®). Primary outcome of the study was the PMS symptoms severity as assessed by using the Daily Record of Severity of Problems (DRSP). Further, SIPS questionnaire (a German version of the Premenstrual Symptoms Screening Tool (PSST)), salivary hormone levels (cortisol awakening response (CAR) and evening cortisol levels) as well as serum levels (cortisol, estradiol, progesterone and corticosteroid binding globulin (CBG)) were assessed. RESULTS: PMS symptoms as assessed by the DRSP Total score showed a significantly better improvement (p = 0.001) over a 3 cycles PAS intake as compared to placebo. In addition, PAS treated women reported a greater improvement in physical (p = 0.002) and depressive symptoms (p = 0.068). They also reported a lower reduction of productivity (p = 0.052) and a stronger decrease in interference with relationships with others (p = 0.099) compared to the placebo group. No other DRSP scale or item showed significant results. Likewise, the reduction in the number of subjects fulfilling PMS or premenstrual dysphoric disorder (PMDD) criteria as classified by the SIPS did not differ between the PAS and the placebo group. For the biomarkers, the salivary cortisol percentage increase of the CAR was significantly less pronounced in the follicular phase of cycle 4 than in the follicular phase of cycle 1 for subjects taking PAS when compared to subjects taking placebo (p = 0.018). Furthermore, the change of serum cortisol levels between visit 1 and visit 5 differed significantly between groups (p = 0.043). While serum cortisol levels of PAS treated females slightly decreased between visit 1 and visit 5, cortisol levels of females treated with placebo increased. For all other biomarkers, no treatment effects were observed over the 4 cycles study period. Overall, this study confirms that a daily intake of PAS, containing 400 mg PS and 400 mg PA, can be considered as safe. CONCLUSIONS: Results substantiate the efficacy of PAS in reducing symptoms of PMS. In view of the recent inclusion of severe PMS symptoms (PMDD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the positive results of this clinical study merits consideration of developing the PAS complex as a botanical drug for treatment of PMDD. CLINICAL TRIAL REGISTRATION: The study is registered at Deutsches Register Klinischer Studien with the registration number DRKS00009005.

Strengthening Healthcare Facilities Through Water, Sanitation, and Hygiene (WASH) Improvements: A Pilot Evaluation of "WASH FIT" in Togo.

Water, sanitation, and hygiene (WASH) services in healthcare facilities are essential to ensure quality health care and to facilitate infection, prevention, and control practices. They are critical to responding to outbreaks and preventing healthcare-associated infections and, therefore, critical to global health security. Many healthcare facilities in low- and middle-income settings have limited WASH services. One tool to address this issue is the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) Water and Sanitation for Health Facility Improvement Tool, or "WASH FIT." WASH FIT is a continuous improvement tool based on key WHO environmental health and infection, prevention, and control standards. While using WASH FIT, internal teams regularly perform self-assessments at their facilities, using up to 65 WASH indicators to develop and implement an improvement plan. The Ministry of Health and Social Protection (MSPS) in Togo, with support from WHO and the US Centers for Disease Control and Prevention (CDC), piloted this tool in 3 healthcare facilities. The pilot included facility assessments at 3 time points and in-depth interviews and document review 7 months after initiating WASH FIT. Facilities made improvements without significant external financial or material support. On average, pilot facilities improved from 18% of total indicators meeting standards at baseline to 44% after 7 months. Examples included improved drinking water supply, medical waste segregation, and increased soap at handwashing stations. Participants reported improvements in staff and patient satisfaction, hand hygiene, and occupational safety. Findings suggest that WASH FIT, coupled with training and supervision, may help facilities improve WASH services and practices, thus contributing to global health security. Based on these findings, the Togolese MSPS plans to scale up nationwide. Les services d'eau, d'assainissement, et d'hygiène (WASH) dans les établissements de santé sont essentiels pour assurer des soins de qualité et faciliter les pratiques de prévention et contrôle des infections. Ils sont essentiels pour répondre aux épidémies et prévenir les infections associées aux soins de santé, et donc à la sécurité sanitaire mondiale. De nombreux pays à revenu faible ou intermédiaire ont des services WASH limités dans les établissements de soins. Un outil récemment publié pour remédier cette situation est l'outil WASH FIT [Water and Sanitation for Health Facility Improvement Tool] de l'Organisation mondiale de la Santé (OMS) et le Fonds des Nations Unies (UNICEF) pour l'amélioration de l'eau et l'assainissement dans les formations sanitaires. WASH FIT est un outil d'amélioration continue basé sur les normes de l'OMS en matière de santé environnementale et de prévention et contrôle des infections. Lors de l'utilisation de WASH FIT, les équipes internes effectuent régulièrement des auto-évaluations dans leurs installations en utilisant jusqu'à 65 indicateurs pour élaborer et mettre en œuvre leur plan d'amélioration. Le ministère de la Santé et de la Protection Sociale (MSPS) du Togo, avec le soutien de l'OMS et les Centres pour le contrôle et la prévention des maladies (CDC), a fait un pilotage de cet outil dans 3 centres de santé. Ce pilotage comprenait 3 évaluations dans chaque formation sanitaire, des interviews approfondies, et une revue documentaire, 7 mois après l'initiation du WASH FIT. Les formations sanitaires ont réalisé des progrès, sans aide financière ou matérielle extérieure. En moyenne, les formations sanitaires sont passées de 18% des indicateurs atteignant les standards au départ, à 44% après 7 mois. Les exemples incluent l'approvisionnement en eau potable, le tri des déchets médicaux, et le savon aux points de lavage des mains. Les participants ont signalé des améliorations dans la satisfaction du personnel et des patients, l'hygiène des mains, et la sécurité au travail. Les résultats indiquent que WASH FIT, associé à la formation et à la supervision, pourrait être un outil pour aider les formations sanitaires à améliorer les services et pratiques WASH, contribuant ainsi à la sécurité sanitaire mondiale. Sur la base de ces résultats, le MSPS prévoit une extension à l'échelle nationale.

Reaeration in sewers.

The sewer system is a very dynamic system with an abundance of mass transfer processes and transformations. A key process is the mass exchange between the wastewater and the sewer atmosphere. An equation that describes the gas-liquid mass transfer under different hydrodynamic conditions is essential when sewer processes are to be quantified or modelled. In this work, a calibrated reaeration equation is proposed. It is based on the shear Reynolds and the Froude number to correct the increased gas-liquid interface roughness to higher flow rates. The equation was calibrated with previously published data and with new data. This data was obtained with a safe and environmentally friendly gas tracer method for gravity sewers based on the inert gas sulphur hexafluoride (SF6), a new method for the sewer system. Measurements were conducted in four channels under different conditions. The resulting equation will allow for more accurate simulations of the sewer system. Finally, the effect of reaeration with regard to the oxygen consuming processes for different hydrodynamic conditions is discussed.

Zooming into temperature conditions in the city of Leipzig: how do urban built and green structures influence earth surface temperatures in the city?

Urban landscape and land-use structure, particularly that of built space, were found to have a significant impact on environmental exposures, e.g., on the level and spatial distribution of particle and noise exposure in cities. Climate change will increase the frequency, duration and intensity of heat waves. Hence, the question arises: how do urban structures affect the shape and intensity of urban temperature conditions? To answer this question, multiple urban structures have been quantified in terms of their structural patterns and configuration using the landscape metric (LSM) approach. The results of a linear regression analysis showed that both the edge density and patch size ratio are significantly correlated with the spread and intensity of temperatures across all urban built structures. The analysis shows that the higher the proportion and structural complexity of the built area, the higher are the morning and evening surface temperatures. LSMs were found to be very well suited as analysis models of the site-specific temperature impact beyond the aggregate city level. Hence, they may serve as a planning tool for urban adaptation measures to climate change.

SDHB loss predicts malignancy in pheochromocytomas/sympathethic paragangliomas, but not through hypoxia signalling.

Prediction of malignant behaviour of pheochromocytomas/sympathetic paragangliomas (PCCs/PGLs) is very difficult if not impossible on a histopathological basis. In a familial setting, it is well known that succinate dehydrogenase subunit B (SDHB)-associated PCC/PGL very often metastasise. Recently, absence of SDHB expression as measured through immunohistochemistry was shown to be an excellent indicator of the presence of an SDH germline mutation in PCC/PGL. SDHB loss is believed to lead to tumour formation by activation of hypoxia signals. To clarify the potential use of SDHB immunohistochemistry as a marker of malignancy in PCC/PGL and its association with classic hypoxia signalling we examined SDHB, hypoxia inducible factor-1α (Hif-1α) and its targets CA-9 and GLUT-1 expression on protein level using immunohistochemistry on a tissue micro array on a series of familial and sporadic tumours of 115 patients. Survival data was available for 66 patients. SDHB protein expression was lost in the tumour tissue of 12 of 99 patients. Of those 12 patients, 5 had an SDHB germline mutation, in 4 patients no germline mutation was detected and mutational status remained unknown in parts in 3 patients. Loss of SDHB expression was not associated with increased classic hypoxia signalling as detected by Hif-1α, CA-9 or GLUT-1 staining. Loss of SDHB expression was associated with an adverse outcome. The lack of correlation of SDHB loss with classic hypoxia signals argues against the current hypoxia hypothesis in malignant PCC/PGL. We suggest SDHB protein loss as a marker of adverse outcome both in sporadic and in familial PCC/PGL.

BAX and caspase-5 frameshift mutations and spontaneous apoptosis in colorectal cancer with microsatellite instability.

BACKGROUND AND AIMS: Hereditary nonpolyposis colorectal cancer (HNPCC) and a subset of sporadic colorectal cancers are characterized by microsatellite instability (MSI) and inactivating frameshift mutations of target genes. Inactivation of BAX, caspase-5 ( cas-5), and other genes coding for pro-apoptotic proteins might contribute to tumor progression by enhancing escape from apoptosis. The aim of this study was to further characterize the role of BAX and cas-5 inactivation for spontaneous apoptosis. METHODS: Twenty-five colorectal cancers with MSI were analyzed for frameshift mutations in the BAX (G)8 and cas-5 (A)10 tract by fluorescence PCR, cloning, and sequencing. The rate of spontaneous apoptosis was examined by in situ DNA nick end-labeling. The results were compared with 25 stage-matched microsatellite stable (MSS) colorectal cancers. RESULTS: In colorectal cancer with MSI frameshift mutations in BAX and cas-5 were present in 16 of 25 (64%) and in 12 of 25 (48%) tumors, respectively, whereas neither mutant BAX nor cas-5 alleles were detected in all stage-matched sporadic MSS colorectal cancer. Tumors with MSI showed a higher apoptotic rate than MSS tumors (2.5+/-1.0 vs. 2.1+/-0.7; p <0.05), whereas the presence of BAX or cas-5 frameshift mutations had only minor influence on this finding (2.4+/-1.1% and 2.5+/-0.9%, respectively). CONCLUSION: Mismatch-repair deficiency itself is associated with increased spontaneous apoptosis, not further accelerated by either inactivating BAX or cas-5 frameshift mutations.