Impact of refresher training on the outcomes of trachomatous trichiasis surgery.

BACKGROUND/AIMS: Trachomatous trichiasis (TT) is a severe consequence of chronic inflammation/conjunctival scarring resulting from trachoma, the leading infectious cause of blindness worldwide. Our prospective cohort study evaluated the effectiveness of refresher training (RT) for experienced surgeons (1-22 years) on the outcomes of upper lid (UL) TT surgery in rural Ethiopia. METHODS: Patients undergoing UL TT surgery in at least one eye by a participating surgeon were included. Patients were split into two cohorts: patients enrolled prior to (C1) and after (C2) RT. RT consisted of a 1-week programme with practice on a HEAD START mannequin and supportive supervision in live surgery by expert trainers. Data were collected at preoperative enrolment, and at 6-month and 12-month follow-up visits. The primary outcome was development of postoperative TT (PTT). A series of multivariate generalised estimating equations were fit to model PTT involving potential covariates of interest. RESULTS: A total of 261 eyes contributed by 173 patients were studied between 2017 and 2019. By 1-year postoperatively, 37/128 eyes (28.9%) in C1 and 22/133 eyes (16.5%) in C2 had developed PTT (p=0.03). Other than surgeon RT participation, no factors studied were associated with differences in PTT. CONCLUSION: Our results indicate a significant reduction in the risk of PTT after experienced surgeons' participation in RT as compared with eyes receiving surgery before RT. This observation suggests a significant potential benefit of the RT with HEAD START mannequin practice and supportive supervision during surgery, and suggests RT may be a valuable strategy to improve surgical outcomes.

A novel signalling screen demonstrates that CALR mutations activate essential MAPK signalling and facilitate megakaryocyte differentiation.

Most myeloproliferative neoplasm (MPN) patients lacking JAK2 mutations harbour somatic CALR mutations that are thought to activate cytokine signalling although the mechanism is unclear. To identify kinases important for survival of CALR-mutant cells, we developed a novel strategy (KISMET) that utilizes the full range of kinase selectivity data available from each inhibitor and thus takes advantage of off-target noise that limits conventional small-interfering RNA or inhibitor screens. KISMET successfully identified known essential kinases in haematopoietic and non-haematopoietic cell lines and identified the mitogen activated protein kinase (MAPK) pathway as required for growth of the CALR-mutated MARIMO cells. Expression of mutant CALR in murine or human haematopoietic cell lines was accompanied by myeloproliferative leukemia protein (MPL)-dependent activation of MAPK signalling, and MPN patients with CALR mutations showed increased MAPK activity in CD34 cells, platelets and megakaryocytes. Although CALR mutations resulted in protein instability and proteosomal degradation, mutant CALR was able to enhance megakaryopoiesis and pro-platelet production from human CD34+ progenitors. These data link aberrant MAPK activation to the MPN phenotype and identify it as a potential therapeutic target in CALR-mutant positive MPNs.

Neglected Tropical Diseases, Cross-Cutting Issues Workshop, 4-6 February 2015, Utrecht, the Netherlands: meeting report.

In the last decade, work on neglected tropical diseases (NTDs) has gained momentum. This was accelerated by the London Declaration on NTDs in January 2012. Work on NTDs has expanded worldwide and many countries have set up NTD control and elimination programs. However, the work has focussed disproportionately on preventive treatment. There is an urgent need for more attention and resources to work with people with NTD-related morbidity and disability. A lot can be gained in the fight against NTDs by combining knowledge and experience from cross-cutting fields. For this reason a workshop was organized bringing together scientists, experts and practitioners from different NTD backgrounds to explore options for cross-cutting strategies, interventions and research in the field of NTDs, particularly focusing on issues related to morbidity management and disability, in the broadest sense. The workshop produced an inventory of cross-cutting issues, an overview of knowledge gaps and research questions, proposals for pilot (research) projects and a list of recommendations. One of the main recommendations is based on the need for baseline data: to review existing indicators used for monitoring and surveillance of NTD-related morbidity and disability in order to identify common indicators that can be shared across NTDs.

CDK6-a review of the past and a glimpse into the future: from cell-cycle control to transcriptional regulation.

The G1 cell-cycle kinase CDK6 has long been thought of as a redundant homolog of CDK4. Although the two kinases have very similar roles in cell-cycle progression, it has recently become apparent that they differ in tissue-specific functions and contribute differently to tumor development. CDK6 is directly involved in transcription in tumor cells and in hematopoietic stem cells. These functions point to a role of CDK6 in tissue homeostasis and differentiation that is partially independent of CDK6's kinase activity and is not shared with CDK4. We review the literature on the contribution of CDK6 to transcription in an attempt to link the new findings on CDK6's transcriptional activity to cell-cycle progression. Finally, we note that anticancer therapies based on the inhibition of CDK6 kinase activity fail to take into account its kinase-independent role in tumor development.

MicroResearch: finding sustainable local health solutions in East Africa through small local research studies.

BACKGROUND: Sub-Saharan African countries have urged grassroots input to improve research capacity. In East Africa, MicroResearch is fostering local ability to find sustainable solutions for community health problems. At 5years, the following reports its progress. METHODS: The MicroResearch program had three integrated components: (1) 2-week training workshops; (2) small proposal development with international peer review followed by project funding, implementation, knowledge translation; (3) coaching from experienced researchers. Evaluation included standardized questions after completion of the workshops, 2013 online survey of recent workshop participants and discussions at two East Africa MicroResearch Forums in 2013. RESULTS: Between 2008 and 2013, 15 workshops were conducted at 5 East Africa sites with 391 participants. Of the 29 projects funded by MicroResearch, 7 have been completed; of which 6 led to changes in local health policy/practice. MicroResearch training stimulated 13 other funded research projects; of which 8 were external to MicroResearch. Over 90% of participants rated the workshops as excellent with 20% spontaneously noting that MicroResearch changed how they worked. The survey highlighted three local research needs: mentors, skills and funding - each addressed by MicroResearch. On-line MicroResearch and alumni networks, two knowledge translation partnerships and an East Africa Leaders Consortium arose from the MicroResearch Forums. CONCLUSION: MicroResearch helped build local capacity for community-directed interdisciplinary health research.

Diabetes and Diabetic Retinopathy Management in East Africa: Knowledge, Attitudes, and Practices of Hospital Staff in Kenya.

PURPOSE: Good diabetes mellitus (DM) and diabetic retinopathy (DR) management depends largely on involved medical staff, prompting us to investigate knowledge, attitudes, and practices about DM and DR at a tertiary referral center in Kenya. DESIGN: The design for this study is exploratory qualitative using semistructured interviews. METHODS: Data from eye and diabetes clinic staff were collected until thematic saturation was reached, transcribed, and iteratively analyzed for relevant themes based on the constant comparative method. RESULTS: Among 46 participants (mean age, 38 years; 54% females), most were physicians (n = 25, 54%), followed by nurses (n = 14, 30%) and clinical officers (n = 6, 13%). Diabetes mellitus and DR were seen as urgent health problems (n = 42, 91%), and regular ophthalmic screening of diabetic patients was universally recommended. Two thirds (n = 32, 70%) were unaware of DM and DR management guidelines at the hospital. Participants identified training of staff in diagnosing (n = 30, 65%), efficient detection and referral of diabetic patients (n = 24, 52%), and improved outreach services (n = 14, 30%) as most pressing areas of need. Communication among hospital departments was found to be suboptimal. Reported barriers to good DR management were lack of retinal laser treatment and costs. CONCLUSIONS: Management outcomes for DM and DR may be improved by implementing integrated service provision, direct ophthalmological involvement in diabetic clinics, endorsement and effective distribution of guidelines, an increase in screening capacity, and the introduction of ongoing medical education covering DM and DR.

Somatic CALR mutations in myeloproliferative neoplasms with nonmutated JAK2.

BACKGROUND: Somatic mutations in the Janus kinase 2 gene (JAK2) occur in many myeloproliferative neoplasms, but the molecular pathogenesis of myeloproliferative neoplasms with nonmutated JAK2 is obscure, and the diagnosis of these neoplasms remains a challenge. METHODS: We performed exome sequencing of samples obtained from 151 patients with myeloproliferative neoplasms. The mutation status of the gene encoding calreticulin (CALR) was assessed in an additional 1345 hematologic cancers, 1517 other cancers, and 550 controls. We established phylogenetic trees using hematopoietic colonies. We assessed calreticulin subcellular localization using immunofluorescence and flow cytometry. RESULTS: Exome sequencing identified 1498 mutations in 151 patients, with medians of 6.5, 6.5, and 13.0 mutations per patient in samples of polycythemia vera, essential thrombocythemia, and myelofibrosis, respectively. Somatic CALR mutations were found in 70 to 84% of samples of myeloproliferative neoplasms with nonmutated JAK2, in 8% of myelodysplasia samples, in occasional samples of other myeloid cancers, and in none of the other cancers. A total of 148 CALR mutations were identified with 19 distinct variants. Mutations were located in exon 9 and generated a +1 base-pair frameshift, which would result in a mutant protein with a novel C-terminal. Mutant calreticulin was observed in the endoplasmic reticulum without increased cell-surface or Golgi accumulation. Patients with myeloproliferative neoplasms carrying CALR mutations presented with higher platelet counts and lower hemoglobin levels than patients with mutated JAK2. Mutation of CALR was detected in hematopoietic stem and progenitor cells. Clonal analyses showed CALR mutations in the earliest phylogenetic node, a finding consistent with its role as an initiating mutation in some patients. CONCLUSIONS: Somatic mutations in the endoplasmic reticulum chaperone CALR were found in a majority of patients with myeloproliferative neoplasms with nonmutated JAK2. (Funded by the Kay Kendall Leukaemia Fund and others.).

Lysosomal dysfunction causes neurodegeneration in mucolipidosis II 'knock-in' mice.

Mucolipidosis II is a neurometabolic lysosomal trafficking disorder of infancy caused by loss of mannose 6-phosphate targeting signals on lysosomal proteins, leading to lysosomal dysfunction and accumulation of non-degraded material. However, the identity of storage material and mechanisms of neurodegeneration in mucolipidosis II are unknown. We have generated 'knock-in' mice with a common mucolipidosis II patient mutation that show growth retardation, progressive brain atrophy, skeletal abnormalities, elevated lysosomal enzyme activities in serum, lysosomal storage in fibroblasts and brain and premature death, closely mimicking the mucolipidosis II disease in humans. The examination of affected mouse brains at different ages by immunohistochemistry, ultrastructural analysis, immunoblotting and mass spectrometric analyses of glycans and anionic lipids revealed that the expression and proteolytic processing of distinct lysosomal proteins such as α-l-fucosidase, ß-hexosaminidase, α-mannosidase or Niemann-Pick C2 protein are more significantly impacted by the loss of mannose 6-phosphate residues than enzymes reaching lysosomes independently of this targeting mechanism. As a consequence, fucosylated N-glycans, GM2 and GM3 gangliosides, cholesterol and bis(monoacylglycero)phosphate accumulate progressively in the brain of mucolipidosis II mice. Prominent astrogliosis and the accumulation of organelles and storage material in focally swollen axons were observed in the cerebellum and were accompanied by a loss of Purkinje cells. Moreover, an increased neuronal level of the microtubule-associated protein 1 light chain 3 and the formation of p62-positive neuronal aggregates indicate an impairment of constitutive autophagy in the mucolipidosis II brain. Our findings demonstrate the essential role of mannose 6-phosphate for selected lysosomal proteins to maintain the capability for degradation of sequestered components in lysosomes and autophagolysosomes and prevent neurodegeneration. These lysosomal proteins might be a potential target for a valid therapeutic approach for mucolipidosis II disease.

Assessment of diabetic retinopathy in newly diagnosed black Kenyan type 2 diabetics.

OBJECTIVE: To determine the prevalence and pattern of diabetic retinopathy in newly diagnosed black African patients with type 2 diabetes mellitus and the associated risk factors. DESIGN: Cross-sectional hospital-based study. SETTING: Eye clinic of Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS: Africans aged 20 years and above with newly diagnosed type 2 diabetes mellitus of up to 12 months duration. RESULTS: One hundred and forty one eyes of 71 patients were included in this study, while slides of 92 eyes of 65 patients were of good enough quality for evaluation. The mean duration of diabetes was 11.7 weeks (SD 16.6) and 11.3 (SD 10.1) in men and women respectively. Overall, the prevalence of diabetic retinopathy and clinically significant macula oedema was 30.4% and 8.7% respectively. There was a positive association between diabetic retinopathy and systolic blood pressure. CONCLUSION: The prevalence of diabetic retinopathy in newly diagnosed Africans with type 2 diabetes in Kenya is very high. This suggests longstanding undiagnosed diabetes.

The Sandwich fellowship: a subspecialty training model for the developing world.

Health care systems in many developing countries are rapidly evolving to respond to urbanization and shifting epidemiological profiles, creating an environment favorable for subspecialty development. The struggle for developing nations to train and retain highly skilled clinicians within academic institutions has highlighted the need for creative approaches to subspecialty education in these regions. The "Sandwich fellowship" is an educational model in which a fellow completes rotations at an academic institution in the developed world as well as in his or her home environment. An important component of the model is the expansion of institutional capacity at the fellow's home institution to create an enabling environment to practice newly acquired skills. The fellowship provides experience in diverse geographic and cultural contexts under the guidance of a preceptor from an institution in the developed world who teaches in both settings. Preceptors are given opportunities to continue professional growth and gain from exposure to pathology not commonly seen at home. Successful pilots of a Sandwich fellowship took place in ophthalmology and orthopedic surgery at the University of Ottawa in 2007-2008 and required funding from multiple sources with bilateral institutional support. Emphasis was also placed on teaching, leadership, management, and research so the fellows could return home and lead the development of their subspecialty areas. Early contact between administrations enables the model to serve as a gateway to a long-term partnership between developed world academic establishments and developing world institutions. Such a relationship yields a mutually beneficial exchange of knowledge and skills. Beneficiaries include the hospitals, their staff, and patients at both institutions.

Microbial contamination of multi-use ophthalmic solutions in Kenya.

BACKGROUND/AIMS: Contaminated ophthalmic solutions represent a potential cause of avoidable ocular infection. This study aimed to determine the magnitude and pattern of microbial contamination of multi-dose ocular solutions at the Department of Ophthalmology, University of Nairobi, at the Kenyatta National Hospital, Kenya. METHODS: 101 vials were obtained for microbial examination after an average use of 2 weeks. The dropper tip and the residual eye drop were examined for contamination. The specimens were cultured, the number of colonies counted, the organisms identified and susceptibility testing to selected antimicrobial agents was done. RESULTS: Six (6%) of the 101 analysed vials were contaminated: 4/77 vials (5%) from a multi-user setting and 2/24 vials (8%) from a single user setting. Three contaminations (3/38, 8%) occurred in vials from the eye ward, another three (3/59, 5%) in vials from the outpatient clinic. Most bacteria identified belonged to the normal commensal flora of the eye. Isolated contaminants were micrococci (n = 2), Staphylococcus epidermidis, Haemophilus sp, Bacillus sp and a Gram negative rod. The dropper tip was more often contaminated (n = 6) than the residual solution (n = 1), and only one vial showed a contamination of both the drop and the tip. CONCLUSION: Our data show a contamination rate of 6%, which is in the lower range of data published on the contamination of eye drops elsewhere (0.07% to 35.8%).

JunB is a gatekeeper for B-lymphoid leukemia.

Loss of JunB has been observed in human leukemia and lymphoma, but it remains unknown, whether this loss is relevant to disease progression. Here, we investigated the consequences of JunB deficiency using Abelson-induced B-lymphoid leukemia as a model system. Mice deficient in JunB expression succumbed to Abelson-induced leukemia with increased incidence and significantly reduced latency. Similarly, bcr/abl p185-transformed JunB-deficient (junB(Delta/Delta)) cells induced leukemia in RAG2(-/-) mice displaying a more malignant phenotype. These observations indicated that cell intrinsic effects within the junB(Delta/Delta) tumor cells accounted for the accelerated leukemia development. Indeed, explantated bcr/abl p185 transformed junB(Delta/Delta) cells proliferated faster than the control cells. The proliferative advantage emerged slowly after the initial transformation process and was associated with increased expression levels of the cell cycle kinase cdk6 and with decreased levels of the cell cycle inhibitor p16(INK4a). These alterations were due to irreversible reprogramming of the cell, because - once established - accelerated disease induced by junB(Delta/Delta) cells was not reverted by re-introducing JunB. Consistent with this observation, we found that the p16 promoter was methylated. Thus, JunB functions as a gatekeeper during tumor evolution. In its absence, transformed leukemic cells acquire an enhanced proliferative capacity, which presages a more malignant disease.

Hypertension and stroke--rationale behind the ACCESS trial. Acute Candesartan Cilexetil Evaluation in Stroke Survivors.

Antihypertensive treatment achieves its greatest benefit in the primary prevention of stroke. Primary prevention studies show 38% fewer strokes when systolic/diastolic values are reduced by 10-12/5-6 mmHg. Secondary stroke prevention has been less investigated, but restrokes seems to be reduced with antihypertensive treatment. Secondary prevention achieves 25-30% less strokes, if diastolic BP can be reduced by 3-4 mmHg. Today's guidelines for antihypertensive therapy in acute ischemic stroke suggest reducing BP values over 220 mmHg systolic (AHA) or 200/110 (German Hypertension Society). No data are available about antihypertensive treatment in acute stroke patients. No intervention trials have so far evaluated an immediate BP reduction on the clinical outcome of the patients neurological status (morbidity) or mortality rates in the acute stroke situation. However, some studies show an increase in mortality after a quick and rapid BP reduction in a short time interval. The ACCESS study was designed to evaluate the possible benefits of a careful and moderate, but immediate blood pressure reduction in patients with an acute stroke compared to a restrictive antihypertensive therapy. Candesartan cilexetil was selected as the antihypertensive drug for its slow onset of action and moderate BP reduction, as well as its very good tolerability. Experimental studies point at possible advantages in acute stroke. The study was designed as a prospective, randomized, double-blind, placebo-controlled, multicenter trial (500 patients). Inclusion criteria were an acute ischemic stroke with a motor paresis and severe hypertension. Primary endpoints were the patients morbidity (functional status measured with Rankin and Barthel index, degree of motor deficity by NIH scale) and mortality rates after three months. First results are presented.