Response to Mass-Casualty Incidents and Outbreaks: A Prehospital Disaster Training Package Developed for the National Emergency Medical Service in Sierra Leone

Sierra Leone is a country highly prone to disasters, still recovering from the catastrophic 2014 Ebola epidemic. In 2018, the country launched its first National Emergency Medical Service (NEMS) aiming to strengthen the provision of essential health services to the population with the long-term goal of creating a resilient health system able to effectively respond to and recover from emergencies. The Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), together with the Italian NGO Doctors with Africa (CUAMM), under the direct supervision of the Ministry of Health and Sanitation (MoHS), developed a prehospital Disaster Training Package (DTP) to be delivered to all NEMS personnel to boost the prehospital management of mass-casualty incidents (MCIs) and outbreaks. The DTP included a first phase in which NEMS local trainers underwent a training-of-trainers (ToT) course, enabling them to deliver cascade trainings to 16 district ambulance supervisors, 441 paramedics, 441 ambulance drivers, and 36 operators working in the NEMS operation center. This on-going training package represents the first Disaster Medicine training course for prehospital health professionals in Sierra Leone

Re: Shantha et al.: Ophthalmic manifestations and causes of vision impairment in Ebola virus disease survivors in Monrovia, Liberia (Ophthalmology. 2017;124:170-177).

No abstract available

Characterizing HIV-1 genetic subtypes and drug resistance mutations among children, adolescents and pregnant women in Sierra Leone

Human immunodeficiency virus (HIV) drug resistance (HIVDR) is widespread in sub-Saharan Africa. Children and pregnant women are particularly vulnerable, and laboratory testing capacity remains limited. We, therefore, used a cross-sectional design and convenience sampling to characterize HIV subtypes and resistance-associated mutations (RAMs) in these groups in Sierra Leone. In total, 96 children (age 2–9 years, 100% ART-experienced), 47 adolescents (age 10–18 years, 100% ART-experienced), and 54 pregnant women (>18 years, 72% ART-experienced) were enrolled. Median treatment durations were 36, 84, and 3 months, respectively, while the sequencing success rates were 45%, 70%, and 59%, respectively, among children, adolescents, and pregnant women. Overall, the predominant HIV-1 subtype was CRF02_AG (87.9%, 95/108), with minority variants constituting 12%. Among children and adolescents, the most common RAMs were M184V (76.6%, n = 49/64), K103N (45.3%, n = 29/64), Y181C/V/I (28.1%, n = 18/64), T215F/Y (25.0%, n = 16/64), and V108I (18.8%, n = 12/64). Among pregnant women, the most frequent RAMs were K103N (20.6%, n = 7/34), M184V (11.8%, n = 4/34), Y181C/V/I (5.9%, n = 2/34), P225H (8.8%, n = 3/34), and K219N/E/Q/R (5.9%, n = 2/34). Protease and integrase inhibitor-RAMs were relatively few or absent. Based on the genotype susceptibility score distributions, 73%, 88%, and 14% of children, adolescents, and pregnant women, respectively, were not susceptible to all three drug components of the WHO preferred first-line regimens per 2018 guidelines. These findings suggest that routine HIVDR surveillance and access to better ART choices may improve treatment outcomes in Sierra Leone.This research was funded by the Roe Green Travel Medicine and Global Health Award 2019 (Award Number J0628), University Hospitals Cleveland Medical Center (G.A.Y.), Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional-FEDER, Red Española de Investigación en SIDA (RD16/0025/0026) (E.P.), Xunta Galicia-Fondo Social Europeo (IN606A-2016/023) (E.P.) and Fundación Biomédica Galicia Sur (E.P.)

Use of an amplatzer vascular plug in embolization of a pulmonary artery aneurysm in a case of hughes-stovin syndrome: a case report

<p>Abstract</p> <p>Introduction</p> <p>Hughes-Stovin syndrome is a rare condition characterized by peripheral deep venous thrombosis accompanied by single or multiple pulmonary arterial aneurysms. The limited number of cases has precluded controlled studies of the management of pulmonary artery aneurysms, which usually cause massive hemoptysis leading to death. This is the first report of a new endovascular treatment of a single large pulmonary arterial aneurysm.</p> <p>Case presentation</p> <p>An 18-year-old Caucasian man was referred to our department with recurrent severe hemoptysis. His medical history included Hughes-Stovin syndrome diagnosed during a recent hospital admission. The patient was initially treated with corticosteroids. Because of his recurrent hemoptysis, we decided to embolize a 3.5 cm pulmonary arterial aneurysm using an Amplatzer Vascular Plug. The procedure was not complicated, and the patient's post-intervention course was uneventful. The patient has remained free from any complications of the embolization 36 months after the procedure.</p> <p>Conclusion</p> <p>Percutaneous embolization of a single large pulmonary artery aneurysm with an Amplatzer Vascular Plug in a patient with Hughes-Stovin syndrome is a less invasive procedure that represents the best multidisciplinary approach in treating these patients.</p

Annual accumulation for Greenland updated using ice core data developed during 2000-2006 and analysis of daily coastal meteorological data

An updated accumulation map for Greenland is presented on the basis of 39 new ice core estimates of accumulation, 256 ice sheet estimates from ice cores and snow pits used in previous maps, and reanalysis of time series data from 20 coastal weather stations. The period 1950-2000 is better represented by the data than are earlier periods. Ice-sheetwide accumulation was estimated based on kriging. The average accumulation (95 confidence interval, or ±2 times standard error) over the Greenland ice sheet is 30.0 ± 2.4 g cm -2 a-1, with the average accumulation above 2000-m elevation being essentially the same, 29.9 ± 2.2 g cm-2 a -1. At higher elevations the new accumulation map maintains the main features shown in previous maps. However, there are five coastal areas with obvious differences: southwest, northwest, and eastern regions, where the accumulation values are 20-50 lower than previously estimated, and southeast and northeast regions, where the accumulation values are 20-50 higher than previously estimated. These differences are almost entirely due to new coastal data. The much lower accumulation in the southwest and the much higher accumulation in the southeast indicated by the current map mean that long-term mass balance in both catchments is closer to steady state than previously estimated. However, uncertainty in these areas remains high owing to strong gradients in precipitation from the coast inland. A significant and sustained precipitation measurement program will be needed to resolve this uncertainty. Copyright 2009 by the American Geophysical Union

Melting and differentiation of early-formed asteroids: The perspective from high precision oxygen isotope studies

A number of distinct methodologies are available for determining the oxygen isotope composition of minerals and rocks, these include laser-assisted fluorination, secondary ion mass spectrometry (SIMS)and UV laser ablation. In this review we focus on laser-assisted fluorination, which currently achieves the highest levels of precision available for oxygen isotope analysis. In particular, we examine how results using this method have furthered our understanding of early-formed differentiated meteorites. Due to its rapid reaction times and low blank levels, laser-assisted fluorination has now largely superseded the conventional externally-heated Ni “bomb” technique for bulk analysis. Unlike UV laser ablation and SIMS analysis, laser-assisted fluorination is not capable of focused spot analysis. While laser fluorination is now a mature technology, further analytical improvements are possible via refinements to the construction of sample chambers, clean-up lines and the use of ultra-high resolution mass spectrometers. High-precision oxygen isotope analysis has proved to be a particularly powerful technique for investigating the formation and evolution of early-formed differentiated asteroids and has provided unique insights into the interrelationships between various groups of achondrites. A clear example of this is seenin samples that lie close to the terrestrial fractionation line (TFL). Based on the data from conventional oxygen isotope analysis, it was suggested that the main-group pallasites, the howardite eucrite diogenite suite (HEDs) and mesosiderites could all be derived from a single common parent body. However,high precision analysis demonstrates that main-group pallasites have a Δ17O composition that is fully resolvable from that of the HEDs and mesosiderites, indicating the involvement of at least two parent bodies. The range of Δ17O values exhibited by an achondrite group provides a useful means of assessing the extent to which their parent body underwent melting and isotopic homogenization. Oxygen isotope analysis can also highlight relationships between ungrouped achondrites and the more well-populated groups. A clear example of this is the proposed link between the evolved GRA 06128/9 meteorites and the brachinites. The evidence from oxygen isotopes, in conjunction with that from other techniques, indicates that we have samples from approximately 110 asteroidal parent bodies (∼60 irons, ∼35 achondrites and stony-iron, and ∼15 chondrites) in our global meteorite collection. However, compared to the likely size of the original protoplanetary asteroid population, this is an extremely low value. In addition, almost all of the differentiated samples (achondrites, stony-iron and irons) are derived from parent bodies that were highly disrupted early in their evolution. High-precision oxygen isotope analysis of achondrites provides some important insights into the origin of mass-independent variation in the early Solar System. In particular, the evidence from various primitive achondrite groups indicates that both the slope 1 (Y&R) and CCAM lines are of primordial significance. Δ17O differences between water ice and silicate-rich solids were probably the initial source of the slope 1 anomaly. These phases most likely acquired their isotopic composition as a result of UV photo-dissociation of CO that took place either in the early solar nebula or precursor giant molecular cloud. Such small-scale isotopic heterogeneities were propagated into larger-sized bodies, such as asteroids and planets, as a result of early Solar System processes, including dehydration, aqueous alteration,melting and collisional interactions

Implementation of the Ebola Virus Persistence in Ocular Tissues and Fluids (EVICT) study: Lessons learned for vision health systems strengthening in Sierra Leone.

BACKGROUND: Following the West African Ebola virus disease (EVD) outbreak of 2013-2016 and more recent EVD outbreaks in the Democratic Republic of Congo, thousands of EVD survivors are at-risk for sequelae including uveitis, which can lead to unremitting inflammation and vision loss from cataract. Because of the known risk of Ebola virus persistence in ocular fluid and the need to provide vision-restorative, safe cataract surgery, the Ebola Virus Persistence in Ocular Tissues and Fluids (EVICT) Study was implemented in Sierra Leone. During implementation of this multi-national study, challenges included regulatory approvals, mobilization, community engagement, infection prevention and control, and collaboration between multiple disciplines. In this report, we address the multifacted approach to address these challenges and the impact of implementation science research to address an urgent clinical subspecialty need in an outbreak setting. METHODOLOGY/PRINCIPAL FINDINGS: Given the patient care need to develop a protocol to evaluate ocular fluid for Ebola virus RNA persistence prior to cataract surgery, as well as protocols to provide reassurance to ophthalmologists caring for EVD survivors with cataracts, the EVICT study was designed and implemented through the work of the Ministry of Health, Sierra Leone National Eye Programme, and international partnerships. The EVICT study showed that all 50 patients who underwent ocular fluid sampling at 19 and 34 months, respectively, tested negative for Ebola virus RNA. Thirty-four patients underwent successful cataract surgery with visual acuity improvement. Here we describe the methodology for study implementation, challenges encountered, and key issues that impacted EVD vision care in the immediate aftermath of the EVD outbreak. Key aspects of the EVICT study included defining the pertinent questions and clinical need, partnership alignment with key stakeholders, community engagement with EVD survivor associations, in-country and international regulatory approvals, study site design for infection prevention and control, and thorough plans for EVD survivor follow-up care and monitoring. Challenges encountered included patient mobilization owing to transportation routes and distance of patients in rural districts. Strong in-country partnerships and multiple international organizations overcame these challenges so that lessons learned could be applied for future EVD outbreaks in West and Central Africa including EVD outbreaks that are ongoing in Guinea and Democratic Republic of Congo. CONCLUSIONS/SIGNIFICANCE: The EVICT Study showed that cataract surgery with a protocol-driven approach was safe and vision-restorative for EVD survivors, which provided guidance for EVD ophthalmic surgical care. Ophthalmologic care remains a key aspect of the public health response for EVD outbreaks but requires a meticulous, yet partnered approach with international and local in-country partners. Future efforts may build on this framework for clinical care and to improve our understanding of ophthalmic sequelae, develop treatment paradigms for EVD survivors, and strengthen vision health systems in resource-limited settings

Mustelus canis,the smooth dogfish shark as a model for immunoprivileged sites in yolk sac placentation and sperm storage

Placental viviparity and sperm storage make their first appearance in the vertebrate line in Chondrichthyes, the oldest extant jawed vertebrates. Although viviparity is advantageous for nourishment and growth of the offspring, it involves an immunological risk for sperm containing paternal antigens and the placenta containing fetal antigens. The placental smoothhound shark, Mustelus canis, has yolk sac placentation and stores sperm throughout the year in sperm storage tubules (SST) of the terminal zone (TZ) in the oviducal gland (OG) in the female. This animal has been used as a model to examine the uteroplacental complex and SST. Techniques used were transmission electron microscopy and immunohistochemistry to investigate the tissue expression of the cytokines interlukin 1 (IL-1) α, IL-1 β, its specific membrane receptor, IL-1 receptor type I (IL-1R tI) and macrophage migration inhibitory factor (MIF). In addition the uteroplacental complex has been profiled as to the diversity of its glycosylation, which was found to be as complex as that found in both reptilian and mammalian placenta. Immunostaining of the uteroplacental complex for IL-1 α, IL-1 β, IL-R tI revealed by binding leucocytes of both the mother and fetus. Yolk sac endoderm was also positive for all the epitopes studied while ectoderm was positive only for IL-1 α. Immunoreactivity in the uterine endometrium was obtained for IL-1 α and its receptor while the egg envelope was always negative. Placenta and SST were positive for MIF and IL-1 receptor. The present findings on the expression of the interleukin system and MIF in the uteroplacental complex and SST suggest that these cytokines are involved in evolutionarily conserved immunological mechanisms that anticipate the presence of paternal and fetal antigens in maternal tissues