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Dengue virus has four distinct serotypes and the genetic diversity within each of the four serotypes contribute to its complexity. An important aspect of dengue molecular evolutionary studies has been the dissection of the extent and structure of genetic variation among major genotypes within each serotype. It is important to understand the role of dengue genetic variability and its potential role and impact in the effectiveness of the dengue vaccine. Demographic data and blood were collected from patients seen at a tertiary hospital in the Philippines and clinically diagnosed with dengue from 2014-2019. Dengue virus (DENV) RT-PCR was used to confirm infection and positive samples underwent whole genome sequencing. Phylogenetic analysis was performed on 127 samples (25 DENV-1, 19 DENV-2, 70 DENV-3, and 13 DENV-4). We observed a serotype shift in 2014 and 2022. We detected the following genotypes per serotype for the wild-type (WT) DENV sequences: genotype IV (DENV-1), cosmopolitan (DENV-2), genotype I (DENV-3) and genotype IIa (DENV-4). WT DENV belonged to different genotypes versus the QDENGA strains and except for DENV-4, belonged to different genotypes versus the Dengvaxia strains. Comparing Dengvaxia vaccine sequences with WT DENV, we observed 23, 24, 34, and 9 positions with amino acid changes in the entire envelope protein, with 1, 5, 1, and 2 positions with amino acid changes identified among the important human monoclonal antibodies (mAbs) targeted epitope positions. We detected 24, 25, 36 and 12 positions with amino acid changes in the E protein with 0, 5, 1, and 2 positions with amino acid changes among the important mAbs targeted epitope positions for DENV-1, DENV-2, DENV-3, and DENV-4, respectively when comparing QDENGA vaccine sequences with the WT DENV. We showed low genotype complexity, genetically distinct clades and local evolution for DENV circulating in the Philippines., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work. (Sim Healthcare 19(5):319-325, 2024)., (Copyright © 2024 The Joint Commission, Society for Simulation in Healthcare. Published by Elsevier Inc. All rights reserved.)

Summary Statement: Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work., Competing Interests: J.F.C. receives an honorarium for serving as an associate editor of Simulation in Healthcare; J.F.C., S.F., and R.H.S. received travel support from the American Society of Anesthesiologists; D.P.S. is an advisor and receives payment or stock options as compensation for the following companies: Provation, SenSIght.AI, Kela Health, and Vox Telehealth. He is a senior partner for healthcare at A.I. MIR. The other authors declare no conflict of interest., (Copyright © 2024 Society for Simulation in Healthcare.)

Aims: To describe the development process of a device from the conception of the idea to the first contact with the commercial environment, and to demonstrate its practical application through an interdisciplinary collaboration between nursing and engineering for the design of a protective device for peripheral venous catheters., Background: Nurses are key agents for identifying unresolved needs or problems related to nursing care. To address these needs, creative ideation processes are often triggered among nurses to seek technological answers to these challenges., Results: The ten steps to develop a device are presented: (1) detecting an unsatisfied clinical need; (2) searching for preexisting marketed products; (3) searching for patents; (4) maintaining confidentiality throughout the process; (5) obtaining institutional support; (6) forming a multidisciplinary team; (7) developing the idea; (8) applying for a patent; (9) building the prototype; (10) marketing the device. This methodology was applied to design a protective device for peripheral venous catheters in hospitalized patients., Conclusions: Nurses can play a key role in the promotion of healthcare innovation in their field to improve procedures, thanks to their direct contact with patients, and by providing their insight on devices that can enhance patient care. The successful interdisciplinary collaboration between nurses and engineers can provide a response to relevant clinical problems such as the manipulation or removal of peripheral venous catheters., Implications for Nursing And/or Health Policy: A hospital policy is required to encourage the participation of nurses in innovative actions. Furthermore, it is important to support nurse leaders who can play a pivotal role in incorporating creativity into work environments and empowering other nurses to innovatively address clinical issues., No Patient or Public Contribution: This article describes the process for developing a health device., (© 2024 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses.)

Introduction: In recent years, euthanasia has been decriminalized or legalized in several countries. The debate on whether to legalize such a practice is open in many places and is a topic that arouses great controversy. Euthanasia has been presented as a response to situations of advanced, incurable, or irreversible disease, or situations that cause intolerable suffering to the person. However, in recent years, the claim has been asserted that this practice does not have to be associated with such situations. It may happen that a person wants to die and asks for help to do so, even if they are not in a specific clinical situation (pathology or condition) but are experiencing advanced age or present 'vital fatigue'., Aim: The objective of this article is to critically analyse the concept 'vital fatigue': define its meaning, its characteristics, its causes, and its consequences in the debate around euthanasia. To do this, a critical review of the main discussions and arguments present in the literature is made., Conclusions: It is concluded that vital fatigue can be understood as a product or manifestation of an individualistic and productivistic vision of the human being, in which its relational nature and intrinsic value remain in the background. The loss of the meaning of life also influences him. Therefore, in the face of this phenomenon, the most guaranteeing and ethical option is -we believe-accompaniment and holistic care of the person that allows the causal factors to be modulated, without the need to resort to euthanasia., Competing Interests: DISCLOSURES The authors declare no conflict of interest. The paper is solely the work of the listed authors; neither ChatGPT nor any similar artificial intelligence program was used to assist in writing any part of the paper., (Copyright © 2024 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

(1) Background: Artificial intelligence using machine learning techniques may help us to predict and prevent obesity. The aim was to design an interpretable prediction algorithm for overweight/obesity risk based on a combination of different machine learning techniques. (2) Methods: 38 variables related to sociodemographic, lifestyle, and health aspects from 1179 residents in Madrid were collected and used to train predictive models. Accuracy, precision, and recall metrics were tested and compared between nine classical machine learning techniques and the predictive model based on a combination of those classical machine learning techniques. Statistical validation was performed. The shapely additive explanation technique was used to identify the variables with the greatest impact on weight gain. (3) Results: Cascade classifier model combining gradient boosting, random forest, and logistic regression models showed the best predictive results for overweight/obesity compared to all machine learning techniques tested, reaching an accuracy of 79%, precision of 84%, and recall of 89% for predictions for weight gain. Age, sex, academic level, profession, smoking habits, wine consumption, and Mediterranean diet adherence had the highest impact on predicting obesity. (4) Conclusions: A combination of machine learning techniques showed a significant improvement in accuracy to predict risk of overweight/obesity than machine learning techniques separately.

Alzheimer's disease (AD) is the leading cause of dementia globally, having a pathophysiology that is complex and multifactorial. Recent findings highlight the significant role of non-coding RNAs (ncRNAs), specifically microRNAs (miRNAs), long non-coding RNAs (lncRNAs), circular RNAs (circRNAs), and piwi-interacting RNAs (piRNAs) in the molecular mechanisms underlying AD. These ncRNAs are involved in critical biological processes such as cell proliferation, apoptosis, oxidative stress, amyloid-beta aggregation, tau phosphorylation, neuroinflammation, and autophagy, which are pivotal in AD development and progression. This systematic review aims to consolidate current scientific knowledge on the role of ncRNAs in AD, making it the first to encompass the four types of ncRNAs associated with the disease. Our comprehensive search and analysis reveal that ncRNAs not only play crucial roles in the pathogenesis of AD but also hold potential as biomarkers for its early detection and as novel therapeutic targets. Specifically, the findings underscore the significance of miRNAs in regulating genes involved in key AD pathways such as activin receptor signaling pathway, actomyosin contractile ring organization, and advanced glycation endproducts-receptor advanced glycation endproducts (AGE-RAGE) signaling pathway. This review also highlights the potential of ncRNAs in unveiling novel diagnostic and therapeutic strategies, emphasizing the need for further research to validate their clinical utility. Our systematic exploration provides a foundation for future bioinformatic analyses and the development of ncRNA-based precision medicine approaches for AD, offering new insights into the disease's molecular pathology and paving the way for innovative treatment strategies., Systematic Review Registration: PROSPERO, https://www.crd.york.ac.uk/prospero/, CRD42022355307., Competing Interests: RC, JSy, and AG were employed by SciLore LLC. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Canoy, Sy, Deguit, Castro, Dimaapi, Panlaqui, Perian, Yu, Velasco, Sevilleja and Gibson.)

Effective blood glucose management is crucial for people with diabetes to avoid acute complications. Predicting extreme values accurately and in a timely manner is of vital importance to them. People with diabetes are particularly concerned about suffering a hypoglycemia (low value) event and, moreover, that the event will be prolonged in time. It is crucial to predict hyperglycemia (high value) and hypoglycemia events that may cause health damages in the short term and potential permanent damages in the long term. This paper describes our research on predicting hypoglycemia events at 30, 60, 90, and 120 minutes using machine learning methods. We propose using structured Grammatical Evolution and dynamic structured Grammatical Evolution to produce interpretable mathematical expressions that predict a hypoglycemia event. Our proposal generates white-box models induced by a grammar based on if-then-else conditions using blood glucose, heart rate, number of steps, and burned calories as the inputs for the machine learning technique. We apply these techniques to create three types of models: individualized, cluster, and population-based. They all are then compared with the predictions of eleven machine learning techniques. We apply these techniques to a dataset of 24 real patients of the Hospital Universitario Principe de Asturias, Madrid, Spain. The resulting models, presented as if-then-else statements that incorporate numeric, relational, and logical operations between variables and constants, are inherently interpretable. The True Positive Rate and True Negative Rate metrics are above 0.90 for 30-minute predictions, 0.80 for 60 min, and 0.70 for 90 min and 120 min for the three types of models. Individualized models exhibit the best metrics, while cluster and population-based models perform similarly. Structured and dynamic structured grammatical evolution techniques perform similarly for all forecasting horizons. Regarding the comparison of different machine learning techniques, on the shorter forecasting horizons, our proposals have a high probability of winning, a probability that diminishes on the longer time horizons. Structured grammatical evolution provides advanced forecasting models that facilitate model explanation, modification, and retesting, offering flexibility for refining solutions post-creation and a deeper understanding of blood glucose behavior. These models have been integrated into the glUCModel application, designed to serve people with diabetes., (© 2024. The Author(s).)

This dataset provides a collection of Continuous Glucose Monitoring (CGM) data, insulin dose administration, meal ingestion counted in carbohydrate grams, steps, calories burned, heart rate, and sleep quality and quantity assessment ac- quired from 25 people with type 1 diabetes mellitus (T1DM). CGM data was acquired by FreeStyle Libre 2 CGMs, and Fitbit Ionic smartwatches were used to obtain steps, calories, heart rate, and sleep data for at least 14 days. This dataset could be utilized to obtain glucose prediction models, hypoglycemia and hyperglycemia prediction models, and research on the relationships among sleep, CGM values, and the rest of the mentioned variables. This dataset could be used directly from the preprocessed version or customized from raw data. The data set has been used previously with different machine learning algorithms to predict glucose values, hypo, and hyperglycemia and to analyze influences among the features and the quality and quantity of sleep in people with T1DM., (© 2024 The Authors.)

In the last week of September 2023, a surge of influenza-like illness was observed among students of the Armed Forces of the Philippines (AFP) Health Service Education and Training Center, where 48 (27 males and 21 females; age in years: mean 33, range 27-41) of 247 military students at the Center presented with respiratory symptoms. Between September 25 and October 10, 2023, all 48 symptomatic students were evaluated with real-time reverse transcription polymerase chain reaction and sequencing for both influenza and SARS-CoV-2. Thirteen (27%) students were found positive for influenza A/H3 only, 6 (13%) for SARS-CoV-2 only, and 4 (8%) were co-infected with influenza A/H3 and SARS-CoV-2. Seventeen influenza A/ H3N2 viruses belonged to the same clade, 3C.2a1b.2a.2a.3a, and 4 SARSCoV-2 sequences belonged to the JE1.1 lineage, indicating a common source outbreak for both. The influenza A/H3N2 circulating virus belonged to a different clade than the vaccine strain for 2023 (3C.2a1b.2a.2a). Only 4 students had received the influenza vaccine for 2023. In response, the AFP Surgeon General issued a memorandum to all military health institutions on October 19, 2023 that mandated influenza vaccination as a prerequisite for enrollment of students at all education and training centers, along with implementation of non-pharmaceutical interventions and early notification and testing of students exhibiting influenza-like-illness.

People with diabetes must carefully monitor their blood glucose levels, especially after eating. Blood glucose management requires a proper combination of food intake and insulin boluses. Glucose prediction is vital to avoid dangerous post-meal complications in treating individuals with diabetes. Although traditional methods, and also artificial neural networks, have shown high accuracy rates, sometimes they are not suitable for developing personalised treatments by physicians due to their lack of interpretability. This study proposes a novel glucose prediction method emphasising interpretability: Interpretable Sparse Identification by Grammatical Evolution. Combined with a previous clustering stage, our approach provides finite difference equations to predict postprandial glucose levels up to two hours after meals. We divide the dataset into four-hour segments and perform clustering based on blood glucose values for the two-hour window before the meal. Prediction models are trained for each cluster for the two-hour windows after meals, allowing predictions in 15-minute steps, yielding up to eight predictions at different time horizons. Prediction safety was evaluated based on Parkes Error Grid regions. Our technique produces safe predictions through explainable expressions, avoiding zones D (0.2% average) and E (0%) and reducing predictions on zone C (6.2%). In addition, our proposal has slightly better accuracy than other techniques, including sparse identification of non-linear dynamics and artificial neural networks. The results demonstrate that our proposal provides interpretable solutions without sacrificing prediction accuracy, offering a promising approach to glucose prediction in diabetes management that balances accuracy, interpretability, and computational efficiency.

Objective: Our objective was to evaluate the outcome of a training program on long-term confidence of interns and attending physicians., Design: In this prospective cohort study, general surgery interns underwent a training program on informed consent that involved didactics, standardized patient encounters, and supplemental procedure specific guides at the start of the academic year. At the end of the academic year, we surveyed interns from the classes of 2020 (trained) and 2019 (untrained) about their experience and confidence in obtaining an informed consent. Further, we queried attending physicians on their experience and confidence in the interns at the end of each academic year., Setting: Single academic general surgery residency program based at 2 urban tertiary hospitals., Participants: General surgery interns including unmatched preliminary residents and categorical interns from general surgery, interventional radiology, and urology., Results: Twenty-four incoming interns participated in the training program. Intern confidence discussing operation benefits improved from a median score of 4 to 5 (p = 0.03), and total confidence improved from a median score of 15 to 17.5 (p = 0.08). There was no difference in median total confidence scores (15 vs. 17.5; p = 0.21) between classes. Attending physicians had similar median total confidence scores following intervention (10 vs. 11; p = 0.87). Intern satisfaction was 80% with the didactic session, and 90% with standardized patient encounters. Twenty percent of learners used the supplemental procedure specific guides., Conclusions: Implementation of an intern targeted program on informed consent that incorporated didactics and standardized patient encounters was viewed as useful and may contribute to long-term improvements in confidence., (Copyright © 2023. Published by Elsevier Inc.)

Background: To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources., Methods: An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher's exact test assessed differences in prescribing practices between specialties., Results: Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient's history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills ( P < .001)., Discussion: The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.

Background: Sleep quality disturbances are frequent in adults with type 1 diabetes. However, the possible influence of sleep problems on glycemic variability has yet to be studied in depth. This study aims to assess the influence of sleep quality on glycemic control., Materials and Methods: An observational study of 25 adults with type 1 diabetes, with simultaneous recording, for 14 days, of continuous glucose monitoring (Abbott FreeStyle Libre system) and a sleep study by wrist actigraphy (Fitbit Ionic device). The study analyzes, using artificial intelligence techniques, the relationship between the quality and structure of sleep with time in normo-, hypo-, and hyperglycemia ranges and with glycemic variability. The patients were also studied as a group, comparing patients with good and poor sleep quality., Results: A total of 243 days/nights were analyzed, of which 77% ( n = 189) were categorized as poor quality and 33% ( n = 54) as good quality. Linear regression methods were used to find a correlation ( r =0.8) between the variability of sleep efficiency and the variability of mean blood glucose. With clustering techniques, patients were grouped according to their sleep structure (characterizing this structure by the number of transitions between the different sleep phases). These clusters showed a relationship between time in range and sleep structure., Conclusions: This study suggests that poor sleep quality is associated with lower time in range and greater glycemic variability, so improving sleep quality in patients with type 1 diabetes could improve their glycemic control., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Botella-Serrano, Velasco, Sánchez-Sánchez, Garnica and Hidalgo.)

We clinically characterized PCR detected breakthrough infections among partially/fully vaccinated cases with majority given an inactivated vaccine, CoronaVac. From 1 March to 15 July 2021, we detected 182 SARS-CoV-2 infections among vaccinated cases with 129 classified as breakthrough infections. Majority were male, 30-39 y.o., and were asymptomatic or mildly symptomatic with few severe cases. Alpha, Beta and Delta VOCs were detected from sequenced breakthrough infections. Healthcare workers had significantly lower Ct values(higher viral loads) versus non-HCWs. Our results underscore the importance of regular PCR screening for HCWs due to the risk of SARS-CoV-2 transmission from asymptomatic breakthrough infections and provide evidence supporting administration of a booster dose especially to HCWs., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: It is important to evaluate the performance of existing rapid influenza diagnostic tests (RIDTs) and the factors that can affect performance especially when the circulation dynamics of influenza strains change such as the displacement and replacement of the circulating seasonal influenza strains., Materials and Methods: Nasal swabs were collected from patients presenting at V Luna Medical Center, Armed Forces of the Philippines Health Service Command, with influenza-like illness (ILI) with one swab tested using Quickvue (QV) influenza A+B RIDT (Quidel) and the other swab tested using the ABI 7500 (Applied Biosystems) real-time reverse transcriptase-polymerase chain reaction. Sensitivity, specificity, positive predictive value, and negative predictive value were estimated. We identified clinical symptoms predictive of influenza subtype and evaluated the independence of QV sensitivity on (1) Cycle threshold (Ct) value, controlling for timing of collection; (2) timing of collection, controlling for Ct value; and (3) Ct value and timing of collection taken together., Results: Between August 2011 and October 2016, patients presenting with ILI (n = 2333) underwent testing. Quickvue sensitivity across all subtypes was significantly correlated with lower Ct values (higher virus titers) (P <.001) and, except for flu A/H3 (P = .974), was also significantly associated with timing of specimen collection (P <.05). No statistically significant difference was noted in QV sensitivity for Flu A/H3 (P = .130), pandemic H1/N1 (P = .207), Flu A/H3 + pandemic H1/N1 (P = .341), and Flu B (P = .103) across different age groups but sensitivity of QV significantly differed (P <.001) across the different influenza subtypes., Conclusion: Overall specificity of QV was high across all flu subtypes, but overall sensitivity was low (Flu A/pdm H1) to moderate (Flu A/H3 and Flu B). The findings highlight the need to develop more sensitive influenza RDTs to detect circulating influenza strains and the use of the quadrivalent flu vaccine during the annual influenza vaccination., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: The aim of this study was to investigate the effectiveness of devices manufactured with 3D printing for performing transanal endoscopic procedures without pneumorectum., Methods: Functional devices were designed in the Polytechnic School of Engineering of Gijón from 2016 to 2018 using three-dimensional (3D) solid modelling software (Solid-Works®), that allows customization of the device (diameter and length). The devices were made in acrylonitrile butadiene styrene (ABS) by additive manufacturing using an HP Designjet 3D Printer, with fused deposition modelling (FDM) technology. Tests were carried out on mixed simulators (with viscera) and cadavers with a prototype in the form of an open cylindrical base ellipsoid spindle with two bars. In this paper, we present the information of the first series of patients in which this device has been used to perform a full-thikness endoscopic resection of the rectal wall without pneumorectum. The characteristics of the patients, size, and location of the lesion, the type of anesthesia used, the duration of the procedure, hospital stay, complications, and pathology were analyzed. An endoscopic follow-up was also carried out for at least 2 years., Results: Seven interventions were carried out in six patients. The lesions were located at a mean distance of 5 cm from the anal verge and an average area of 11.8 cm 2 . Four of the procedures were performed with general anesthesia and 3 with spinal anesthesia. Histopathology examination identified 3 adenomas, 3 pT1 and 1 pT2 adenocarcinomas. All excisions were full thickness. En bloc excision was possible in all cases. In only one case of a benign polyp there was a positive lateral margin. As regards complications, there was one case of postoperative rectal bleeding without the need for transfusions. There were no readmissions and no postoperative mortality., Conclusions: An innovative device made with a 3D printer can be used successfully in transanal endoscopic resections of the rectal wall, with spinal anaesthesia and avoiding the need for pneumorectum., (© 2021. Springer Nature Switzerland AG.)

Here, we report the complete genome sequences of 11 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants from the Philippines. Lineage analysis showed 3 B.1.1.7 and 8 B.1.351 sequences. One B.1.1.7 sequence contained two additional mutations, F318N and V320F, with V320F located in the receptor binding domain of the S1 subunit.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) belonging to the family Coronaviridae and genus Betacoronavirus is the causative agent of COVID-19 disease and was first identified in Wuhan, China. SARS-CoV-2 spread globally with >28 million cases and 911,000 deaths recorded worldwide as of September 12, 2020. The Philippines reported the first case of community transmission on March 5, 2020, and despite the government imposing one of the longest and strictest lockdowns in Southeast Asia, the number of confirmed COVID-19 cases still surged with >250,000 cases and 4,000 deaths reported as of September 12, 2020. It is important to estimate the burden and impact of SARS-CoV-2 on the military population since this can affect the military readiness., Materials and Methods: Nasopharyngeal and oropharyngeal swabs were collected and SARS-CoV-2 real-time RT-PCR testing was performed on the samples. Phylogenetic analysis was performed using sequences from 23 SARS-CoV-2-positive specimens from this study and sequences retrieved from GenBank and GISAID databases., Results: From April 14 to August 15, 2020, a total of 12,432 specimens were tested with 763 (6%) unique individuals testing positive for SARS-CoV-2 by rRT-PCR. In the military population, majority of the patients who were tested (80%) and those who tested positive for SARS-CoV-2 (86%) were male. Military and civilian status was available for 7,672 patients with 515/5,042 (10%) positive among military patients and 248/2,630 (9%) positive among civilian patients. Both military and civilian populations had the highest case counts of SARS-CoV-2-positive cases in the 21- to 30- and 31- to 40-year-old age groups, while the 71- to 80-year-old age group had the highest proportion (18%) of SARS-CoV-2-positive cases. Sequencing analysis showed 19 different variants in the 23 genomes. Twenty of the 23 genomes were classified under clade GR/B1.1, 2 genomes were classified under clade GR/B1.1.28, and 1 genome was classified under Clade O/B.6. Twenty-two of the 23 sequences collected after June 25, 2020, contained the D614G mutation., Conclusion: We describe here the results of SARS-CoV-2 testing for military and civilian patients and personnel. The 21- to 30- and 31- to 40-year-old age groups had the highest case counts of SARS-CoV-2-positive cases. Sequencing results showed the presence of the D614G mutation in the spike protein in a majority of specimens collected from the end of June to July 2020., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: It is critical to rapidly detect novel and non-seasonal influenza strains. Currently available assays have limited sensitivity in detecting novel influenza subtypes. We performed a multi-country field validation of the FluChip-8G Insight, an assay able to detect and characterize influenza A/B viruses and non-seasonal influenza viruses., Materials and Methods: We evaluated the performance of the FluChip-8G Insight on nasal and throat swab clinical samples from Thailand, Philippines and Nepal. Influenza PCR positive and negative samples tested using the US CDC Human Influenza Dx Panel reference standard were selected for testing using the FluChip-8G Influenza Insight., Results: A total of 909 specimens were included in the analysis. The overall sensitivity and specificity of the FluChip-8G Insight to detect combined influenza A+B was 86 % and 100%, respectively. PPV and NPV were estimated at 100 % (95 % CI 99-100) and 73 % (95 % CI 68-78), respectively. Sensitivity across all influenza subtypes was 100% for specimens with <20 and 20-25 Ct values, respectively, but as Ct values increased, sensitivity across all influenza subtypes decreased significantly (p < 0.001) for specimens with Ct values ≥32., Conclusion: The FluChip-8G Insight showed good precision and reproducibility among all 3 sites with robust identification of both influenza A and B targets with Ct values <32 and in the absence of co-infection. Positioning this platform in countries considered as hotspots for the emergence of novel/zoonotic influenza strains can increase the lead time in detecting and containing novel influenza strains with pandemic potential., (Published by Elsevier B.V.)

This paper attempts to find the factors that affect the number of cases and deaths of coronavirus disease 2019 (COVID-19) patients a year after the first outbreak in Wuhan, China. There were 141 countries affected with COVID-19 involved in the study. Countries were grouped based on population. Using ordinary least squares regression, it was found that the total number of cases and deaths were significantly related with the levels of population of the different countries. On the overall, median age of the country, and average temperature are positively related with the number of deaths from the virus. On the other hand, population density is positively related with the deaths due to COVID for low populated countries. The result of this preliminary study can be used as a benchmark for authorities in the formulation of policies with regards to treating COVID-19 related issues.

Here, we report the coding-complete genome sequences of 23 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) samples from the Philippines. Sequences were obtained from nasopharyngeal and oropharyngeal swabs from coronavirus disease 2019 (COVID-19)-positive patients. Mutation analysis showed the presence of the D614G mutation in the spike protein in 22 of 23 genomes.

Introduction: About one third of the world population is estimated to be infected with Mycobacterium tuberculosis (MTB), and this proportion is expected to be higher in countries with a high tuberculosis (TB) burden. The Philippines is both a high tuberculosis burden and a high multidrug resistant tuberculosis (MDR-TB) burden country. Though TB has been extensively described in the civilian population, there is limited data on TB in the military population. The objectives are: (1) To determine MTB/MDR-TB prevalence among military and civilian patients in the Philippines presenting with clinically suspected TB in a tertiary military hospital and (2) To determine performance of direct sputum smear microscopy (DSSM) using Ziehl-Neelsen (ZN) staining compared to Xpert MTB/RIF real-time reverse transcriptase polymerase chain reaction., Materials and Methods: Sputum samples were obtained from patients, clinically suspected with TB, and/or with TB associated signs/symptoms. Sputum specimens were tested using DSSM with ZN staining and Xpert MTB/RIF assay (Cepheid, Sunnyvale, California) and patient demographic and clinical data were collected., Results: From March 2015 to December 2018, a total of 795 (173 military personnel [164 active duty and 9 retired]; 618 civilians; and 4 with no data on military/civilian status) patients with TB associated symptoms or clinically suspected with TB were tested. Overall, MTB prevalence was 81/795 (10%). MTB prevalence among active duty and retired military personnel were 27/164 (16%) and 4/9 (44%), respectively while MTB prevalence for civilian patients was 50/618 (8%) (p value = 0.0003; OR = 2.48 [95% C.I. 1.5-4]). Among active and retired military personnel who tested positive for MTB, rifampin resistance was 4/27 (15%) and 1/4 (25%), respectively, while rifampin resistance for civilian patients was 9/50 (18%) (p value = 1; OR = 0.88 [95% C.I. 0.26-2.90]). For active duty military personnel, average MTB prevalence (based on Xpert MTB/RIF) covering years 2015-2018 was 21% and ranged from 13% to 35%, while average rifampin resistance among MTB positive active duty military personnel was 15% and ranged from 0% to 25%. Overall sensitivity and specificity of DSSM compared to Xpert MTB/RIF were 70% and 96%, respectively. Positive and negative predictive values of DSSM to accurately categorize MTB in symptomatic cases (with Xpert MTB/RIF as "true positive" reference) were 74% and 95%, respectively. Performance of DSSM varied according to MTB load detected by Xpert MTB/RIF with increasing DSSM sensitivity observed as the MTB load detected by Xpert MTB/RIF increased (p = 0.02)., Conclusion: This report describes high MTB and MDR-TB prevalence rates among symptomatic military patients with military personnel having higher odds of MTB infection compared to the civilian patients in the study. Since DSSM (ZN) sensitivity greatly varied depending on MTB load, the Xpert MTB/RIF should be used as a first-line diagnostic tool to identify MTB and detect rifampin resistance among presumptive TB cases instead of DSSM (ZN) microscopy., (© The Author 2020. Published by Oxford University Press Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Graduating surgery residents often feel unprepared to practice autonomously in the current era of surgical training. We implemented an integrated simulation curriculum to improve residents' autonomy and increase their confidence to practice independently. In this study, we chose a laparoscopic ventral hernia repair (LVHR) as our pilot operation to test proof of concept and on which we would construct our integrated curriculum., Study Design: The curriculum included a web-based cognitive component, inanimate model simulation session with follow-up at 2 weeks and 6 months, and self-confidence questionnaires. Faculty rated each resident's procedure-specific skill by using a modified Global Operative Assessment of Laparoscopic Skills (GOALS) criteria and a task-specific checklist., Results: Thirteen junior residents, 7 senior residents, and 7 faculty surgeons completed the curriculum. Four junior residents (31%) achieved proficiency at their first session, 10 (77%) after the second session (p = 0.031), and 6 (67%) at 6 months (p ≥ 0.99). Three residents regressed and did not maintain proficiency after the second assessment. Performance (GOALS) scores improved (p = 0.0313) at week 2 and were maintained at 6 months (p = 0.5625). Required faculty direction decreased (p = 0.004), and resident confidence in completing the procedure independently improved (p < 0.004) over the 6-month curriculum., Conclusions: Assessing procedure-specific and global laparoscopic skills through a simulation-based curriculum is feasible and can be used to augment resident training. Our curriculum demonstrated improvement in proficiency and self-confidence while performing an LVHR. Additional study is needed to examine the optimal way to integrate procedure-specific simulation models into training programs., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Bacterial wound infections are a danger to both military and civilian populations. The nature of injury and infection associated with combat related wounds are important in guiding antibiotic prophylaxis and empiric treatment guidelines., Materials and Methods: The isolates were screened for drug-resistance by the MicroScan Walkaway Plus System using either the Negative Breakpoint Combo Panel (NBCP) 30 or 34 or Positive Breakpoint Combo Panel (PBPC) 20 or 23. Isolates with a minimum inhibitory concentration (MIC) of ≥8 μg/mL to imipenem and/or meropenem were tested for both carbapenemase production using the CarbaNP test and real-time PCR to determine molecular resistance mechanisms. Plasmid conjugation analysis was performed to define potential for horizontal gene transfer., Results: We characterized 634 bacterial wound isolates collected from September 2013 to December 2017 from patients seen at a Philippine military tertiary hospital presenting with combat or non-combat injuries [354 (military) and 280 (civilians)]. Staphylococcus aureus was the most predominant bacterial species isolated from wounds in both populations (104/634, 16%). A variety of Gram-negative bacterial species comprised 442/634 (70%) of the isolates identified, with the most prevalent shown to be Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella pneumoniae, Escherichia coli, and Acinetobacter sp. Carbapenemase production was detected in 34/442 (8%) Gram-negative isolates. Testing for molecular resistance mechanisms showed 32/34 (17 military, 15 civilian) wound isolates were blaNDM positive and 2 were blaVIM positive, with the two blaVIM isolates found in the civilian population. Plasmid conjugation of 14 blaNDM and 2 blaVIM positive wound isolates representatives showed 2/16 (13%) produced E. coli J53 transconjugants (E. coli from a civilian; E. cloacae from a military)., Conclusion: We describe in this study the wound bacterial and antibiotic resistance profile in the military (combat vs non-combat associated) and civilian population. We observed that, with the exception of Acinetobacter sp., resistance of prevalent Gram-negative bacterial species to imipenem or meropenem were not significantly different between the military and civilian populations. We also presented data on the prevalent bacterial species isolated from both combat and non-combat wounds in a military tertiary care hospital setting as well as the carbapenemase-encoding gene primarily responsible for carbapenem resistance as well as evidence of horizontal transfer via mobile genetic elements. Clinicians may use this information to guide empiric antibiotic coverage for the predominant organisms if wound culture results are not readily available.A prospective, longitudinal evaluation of the wound bacterial profile documenting the changing bacterial flora using higher resolution molecular strategies can provide a more comprehensive understanding of the diversity, composition, and abundance of bacterial composition of the wound microbial community from the time of injury, during the course of evacuation from the field to higher level of care facilities, and up to wound resolution., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Emergency surgical airway is a low frequency, high risk clinical scenario. Implementing a simulation-based curriculum may bridge the gap in surgical training and address quality assurance/performance improvement (QAPI) needs., Methods: We designed and implemented an Advanced Surgical Airway Curriculum (ASAC) modeled after proficiency-based training. General Surgery residents and student nurse anesthetists were enrolled. Evaluation consisted of cognitive tests, procedure checklists and questionnaire., Results: In total, 78 participants successfully completed the ASAC. Trainees agreed that the curriculum provided the cognitive and psychomotor skills necessary to perform both an open and needle cricothyroidotomy., Conclusions: In the age of increased patient safety concerns, QAPI initiatives can serve as a driver for simulation-based training curricula, with particular focus on individualized, active learning. This may be particularly useful in high risk, low frequency scenarios in which the traditional method of "See one, Do one, Teach one," is not feasible., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Spiking neural networks (SNN) are the third generation of artificial neural networks. SNN are the closest approximation to biological neural networks. SNNs make use of temporal spike trains to command inputs and outputs, allowing a faster and more complex computation. As demonstrated by biological organisms, they are a potentially good approach to designing controllers for highly nonlinear dynamic systems in which the performance of controllers developed by conventional techniques is not satisfactory or difficult to implement. SNN-based controllers exploit their ability for online learning and self-adaptation to evolve when transferred from simulations to the real world. SNN's inherent binary and temporary way of information codification facilitates their hardware implementation compared to analog neurons. Biological neural networks often require a lower number of neurons compared to other controllers based on artificial neural networks. In this work, these neuronal systems are imitated to perform the control of non-linear dynamic systems. For this purpose, a control structure based on spiking neural networks has been designed. Particular attention has been paid to optimizing the structure and size of the neural network. The proposed structure is able to control dynamic systems with a reduced number of neurons and connections. A supervised learning process using evolutionary algorithms has been carried out to perform controller training. The efficiency of the proposed network has been verified in two examples of dynamic systems control. Simulations show that the proposed control based on SNN exhibits superior performance compared to other approaches based on Neural Networks and SNNs., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Industry 4.0 offers new development opportunities for surgeons. Computer-aided design and 3D printing allow for the creation of prototypes and functional end products. Until now, it was difficult for new devices to get to the manufacturing phase. Nowadays, the main limitations are our creativity, available spaces to test our creations and obtaining financing., (Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: A decade has passed since the first Spanish percutaneous pulmonary Melody valve implant (PPVI) in March 2007. Our objective was to analyze its results in terms of valvular function and possible mid-term follow-up complications., Methods: Spanish retrospective descriptive multicenter analysis of Melody PPVI in patients < 18 years from the first implant in March 2007 until January 1, 2016., Results: Nine centers were recruited with a total of 81 PPVI in 77 pediatric patients, whose median age and weight were 13.3 years (interquartile range [IQR], 9.9-15.4) and 46kg (IQR, 27-63). The predominant cardiac malformation was tetralogy of Fallot (n = 27). Most of the valves were implanted on conduits, especially bovine xenografts (n = 31). The incidence of intraprocedure and acute complications was 6% and 8%, respectively (there were no periprocedural deaths). The median follow-up time was 2.4 years (IQR, 1.1-4.9). Infective endocarditis (IE) was diagnosed in 4 patients (5.6%), of which 3 required surgical valve explant. During follow-up, the EI-related mortality rate was 1.3%. At 5 years of follow-up, 80% ± 6.9% and 83% ± 6.1% of the patients were free from reintervention and pulmonary valve replacement., Conclusions: Melody PPVI was safe and effective in pediatric patients with good short- and mid-term follow-up hemodynamic results. The incidence of IE during follow-up was relatively low but was still the main complication., (Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Knowledge of tire-road friction characteristics is essential for the proper performance of most relevant vehicle active safety systems. Therefore, its determination is necessary to improve the effectiveness of these systems and to avoid or reduce the consequences of traffic accidents. For this reason, there is a great deal of literature concerning methods and devices for measuring and modeling tire-road friction. Most of these methods have focused on determining the road friction resistance, taking only road composition and making measurements in wet conditions into account. However, friction forces are also dependent on the tire type, since the contact is established between the tire and the road in real driving conditions. Thus, the type and characteristics of the tire have to be considered in the study of the interaction between the vehicle and the road. The aim of this work is to unify the study of the friction coefficient, taking into consideration the two existing bodies involved in the contact, i.e., the tire and road and the main factors that influence the forces in the contact. To this end, a modification of the Pacejka Magic Formula is proposed to include the effects of the main parameters that influence the contact, such as road composition and its state, tire type, vehicle speed, and slip between the tire and the road. To do so, real tests have been conducted on several roads and with different operating conditions. As a result, a more accurate tire-road friction model has been obtained., Competing Interests: The authors declare no conflict of interest.

During 2013-2016, we isolated bla NDM - and bla VIM -harboring Enterobacteriaceae and nonfermentative bacteria from patients in the Philippines. Of 130 carbapenem-resistant isolates tested, 45 were Carba NP-positive; 43 harbored bla NDM , and 2 harbored bla VIM . Multidrug-resistant microbial pathogen surveillance and antimicrobial drug stewardship are needed to prevent further spread of New Delhi metallo-β-lactamase variants.

Carotid artery atherosclerosis is a risk factor to develop cerebrovascular disease. Atheroma plaque can become instable and provoke a cerebrovascular event or else remain stable as asymptomatic type. The exact mechanism involved in plaque destabilization is not known but includes among other events smooth muscle cell (SMC) differentiation. The goal of this study was to perform thorough analysis of gene expression differences in SMCs isolated from carotid symptomatic versus asymptomatic plaques. Comparative transcriptomics analysis of SMCs based on RNAseq technology identified 67 significant differentially expressed genes and 143 significant differentially expressed isoforms in symptomatic SMCs compared with asymptomatic. 37 of top-scoring genes were further validated by digital PCR. Enrichment and network analysis shows that the gene expression pattern of SMCs from stable asymptomatic plaques is suggestive for an osteogenic phenotype, while that of SMCs from unstable symptomatic plaque correlates with a senescence-like phenotype. Osteogenic-like phenotype SMCs may positively affect carotid atheroma plaque through participation in plaque stabilization via bone formation processes. On the other hand, plaques containing senescence-like phenotype SMCs may be more prone to rupture. Our results substantiate an important role of SMCs in carotid atheroma plaque disruption.

Background: Military personnel are vulnerable to diarrhea. Diarrheal disease is common when deployed for operations or exercise in developing countries. Although diarrheal disease is transient, cumulative time lost and medical asset can have a significant impact on military operations. Currently, diagnostics of diarrheal etiology typically relies on a mixture of conventional bacteriology, enzyme-linked immunosorbent assay, and polymerase chain reaction (PCR)-based methods including real-time PCR. These methods, however, can be time and labor intensive, although the identification of diarrheal etiology needs to be informative and rapid for treatment and prevention. Real-time PCR has been increasingly used to identify pathogens. Real-time PCR panels of common diarrheal pathogens have been developed, but several diarrheal pathogens are not included in the panel. An expanded and customizable panel to detect diarrhea etiology has been developed employing TaqMan Array Card (TAC) technology. TAC performs 384 real-time PCR reactions simultaneously. As currently configured for diarrheal disease by the University of Virginia, a maximum of 8 samples can be tested simultaneously with approximately 48 target pathogens per sample including bacteria, fungi, helminths, protozoan parasites, and viruses. TAC diarrheal disease panels have been successfully applied to detect pathogens in acute diarrheal stool samples from young children in several international multicenter diarrhea studies., Methods: In this study, TAC was applied to stool samples collected under an approved human use protocol from military personnel with acute diarrhea participating in the annual joint military exercise, Balikatan, between the Republic of the Philippines and the United States in 2014. Several established pathogen-specific real-time PCR detection assays were also performed in parallel for comparative purposes., Findings: TAC was applied to 7 stool samples. Campylobacter spp. was the most common diarrheal disease pathogen detected. Results from TAC matched 5 out of 6 pathogen specific real-time PCR assays. TAC required a total of 5-6 hours to complete all the procedures from nucleic acid extraction and data analysis, whereas a minimum of 18 hours and 4 hours are required for conventional bacteriology and enzyme-linked immunosorbent assay, respectively, per pathogen., Discussion: With TAC, pathogen load can be estimated from the amount of nucleic acid present for each pathogen, which can be analyzed further to better determine pathogen attribution and to compare pathogen load between case and control samples. Unfortunately, such correlative analysis was not possible because of the limited sample size available in this study. A larger sample size is needed for further evaluation of TAC on a specific population set, including military personnel. Regardless, TAC was found to be a useful and functional diagnostic platform that is less time-consuming, easy to use with high reproducibility, and costs less per sample compared to the current typically employed methods. The successful application of TAC in acute diarrhea stool samples from a US military population in the Philippines demonstrates its versatility as a potential candidate for a next-generation diagnostics platform., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Here, we present the complete genome sequences of two Zika virus (ZIKV) strains, Zika virus/Homo sapiens-tc/THA/2014/SV0127-14 and Zika virus/H. sapiens-tc/PHL/2012/CPC-0740, isolated from the blood of patients collected in Thailand, 2014, and the Philippines, 2012, respectively. Sequencing and phylogenetic analysis showed that both strains belong to the Asian lineage., (Copyright © 2016 Ellison et al.)

Proper understanding of the long-term epidemiology of chikungunya has been hampered by poor surveillance. Outbreak years are unpredictable and cases often misdiagnosed. Here we analyzed age-specific data from 2 serological studies (from 1973 and 2012) in Cebu, Philippines, to reconstruct both the annual probability of infection and population-level immunity over a 60-year period (1952-2012). We also explored whether seroconversions during 2012-2013 were spatially clustered. Our models identified 4 discrete outbreaks separated by an average delay of 17 years. On average, 23% (95% confidence interval [CI], 16%-37%) of the susceptible population was infected per outbreak, with >50% of the entire population remaining susceptible at any point. Participants who seroconverted during 2012-2013 were clustered at distances of <230 m, suggesting focal transmission. Large-scale outbreaks of chikungunya did not result in sustained multiyear transmission. Nevertheless, we estimate that >350 000 infections were missed by surveillance systems. Serological studies could supplement surveillance to provide important insights on pathogen circulation., (© The Author 2015. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: The mean age of dengue has been increasing in some but not all countries. We sought to determine the incidence of dengue virus (DENV) infection in adults and children in a prospective cohort study in the Philippines where dengue is hyperendemic., Methodology/principal Findings: A prospective cohort of subjects ≥6 months old in Cebu City, Philippines, underwent active community-based surveillance for acute febrile illnesses by weekly contact. Fever history within the prior seven days was evaluated with an acute illness visit followed by 2, 5, and 8-day, and 3-week convalescent visits. Blood was collected at the acute and 3-week visits. Scheduled visits took place at enrolment and 12 months that included blood collections. Acute samples were tested by DENV PCR and acute/convalescent samples by DENV IgM/IgG ELISA to identify symptomatic infections. Enrolment and 12-month samples were tested by DENV hemagglutination inhibition (HAI) assay to identify subclinical infections. Of 1,008 enrolled subjects, 854 completed all study activities at 12 months per-protocol undergoing 868 person-years of surveillance. The incidence of symptomatic and subclinical infections was 1.62 and 7.03 per 100 person-years, respectively. However, in subjects >15 years old, only one symptomatic infection occurred whereas 27 subclinical infections were identified. DENV HAI seroprevalence increased sharply with age with baseline multitypic HAIs associated with fewer symptomatic infections. Using a catalytic model, the historical infection rate among dengue naïve individuals was estimated to be high at 11-22%/year., Conclusions/significance: In this hyperendemic area with high seroprevalence of multitypic DENV HAIs in adults, symptomatic dengue rarely occurred in individuals older than 15 years. Our findings demonstrate that dengue is primarily a pediatric disease in areas with high force of infection. However, the average age of dengue could increase if force of infection decreases over time, as is occurring in some hyperendemic countries such as Thailand.

Chikungunya virus (CHIKV) often co-circulates with dengue virus (DENV). A cross-sectional surveillance study was conducted at a tertiary hospital in Manila, Philippines, to describe the prevalence and characteristics of DENV and CHIKV infections among patients seeking care for dengue-like illness. Acute blood samples from patients ≥ 6 months of age clinically diagnosed with dengue from November 2012 to December 2013 underwent reverse transcription polymerase chain reaction (RT-PCR) to detect DENV and CHIKV RNA. A total of 118 patients with clinically diagnosed dengue (age range = 1-89 years, mean = 22 years; male-to-female ratio = 1.51) were tested by DENV RT-PCR; 40 (34%) were DENV PCR-positive (age range = 1-45 years, mean = 17 years). All DENV serotypes were detected: 11 (28%) DENV-1, 6 (15%) DENV-2, 6 (15%) DENV-3, and 17 (42%) DENV-4. Of 112 patients clinically diagnosed with dengue and tested by CHIKV RT-PCR, 11 (10%) were CHIKV PCR-positive (age range = 2-47 years, mean = 20.3 years). No coinfections were detected. Presenting signs/symptoms did not differ between DENV- and CHIKV-positive cases. Sequencing of envelope 1 gene from two CHIKV PCR-positive samples showed Asian genotype. This study highlights the potential for misdiagnosis of medically attended CHIKV infections as DENV infection and the difficulty in clinically differentiating dengue and chikungunya based on presenting signs/symptoms alone. This underscores the necessity for diagnostic laboratory tests to distinguish CHIKV infections in the background of actively co-circulating DENV., (© The American Society of Tropical Medicine and Hygiene.)

Background: A comparative study was performed to evaluate the effectiveness and costs of a fibrin sealant (Tissucol Duo [known as Tisseel in the United States], Baxter International, Deerfield, Illinois) to improve postoperative outcomes in patients with spinal cord injury undergoing surgical treatment for pressure ulcers (PrUs)., Methods: Between January and June 2011, 27 patients underwent surgical treatment for PrUs with the direct application of Tissucol Duo sprayed before closure. The costs and outcomes obtained in this cohort were compared with those obtained in a previous retrospective study where 71 patients underwent conventional surgery., Results: Lower rates of hematoma-seroma were observed in the study group (3.7% vs 33.8%; P < .05). Drain removal occurred earlier (10 vs 15 days; P < .05), and the average drain volume was also lower (155 vs 360 mL; P < .05) for this group. The mean length of hospital stay was significantly lower in the study group and was the main contributing factor to the overall costs., Conclusions: The application of Tissucol Duo during surgical treatment of PrUs in patients with spinal cord injury has been shown to be effective in reducing postoperative complications and in shortening the duration of the hospital stay with a consequent savings in costs.

Dengue is a mosquito-transmitted virus infection that causes epidemics of febrile illness and hemorrhagic fever across the tropics and subtropics worldwide. Annual epidemics are commonly observed, but there is substantial spatiotemporal heterogeneity in intensity. A better understanding of this heterogeneity in dengue transmission could lead to improved epidemic prediction and disease control. Time series decomposition methods enable the isolation and study of temporal epidemic dynamics with a specific periodicity (e.g., annual cycles related to climatic drivers and multiannual cycles caused by dynamics in population immunity). We collected and analyzed up to 18 y of monthly dengue surveillance reports on a total of 3.5 million reported dengue cases from 273 provinces in eight countries in Southeast Asia, covering ∼ 10(7) km(2). We detected strong patterns of synchronous dengue transmission across the entire region, most markedly during a period of high incidence in 1997-1998, which was followed by a period of extremely low incidence in 2001-2002. This synchrony in dengue incidence coincided with elevated temperatures throughout the region in 1997-1998 and the strongest El Niño episode of the century. Multiannual dengue cycles (2-5 y) were highly coherent with the Oceanic Niño Index, and synchrony of these cycles increased with temperature. We also detected localized traveling waves of multiannual dengue epidemic cycles in Thailand, Laos, and the Philippines that were dependent on temperature. This study reveals forcing mechanisms that drive synchronization of dengue epidemics on a continental scale across Southeast Asia.

Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons. Despite its high incidence there remains a range of treatment of approaches. Current practices in biliary surgery vary as to timing, intraoperative utilization of biliary imaging, and management of bile duct stones despite growing evidence in the literature defining best practice. Management of patients with acute cholecystitis with early laparoscopic cholecystectomy (LC) results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy. Regardless of this data, many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis. The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy, minimizing the risk for inadvertent injury to surrounding structures, and lowering conversion rates, however it is rarely utilized. Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal. Yet, there is evidence that intraoperative laparoscopic stone extraction is safe, feasible and may have added advantages. This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.

Controlling the number of layers of graphene grown by chemical vapor deposition is crucial for large scale graphene application. We propose here an etching process of graphene which can be applied immediately after growth to control the number of layers. We use nickel (Ni) foil at high temperature (T = 900 °C) to produce multilayer-AB-stacked-graphene (MLG). The etching process is based on annealing the samples in a hydrogen/argon atmosphere at a relatively low temperature (T = 450 °C) inside the growth chamber. The extent of etching is mainly controlled by the annealing process duration. Using Raman spectroscopy we demonstrate that the number of layers was reduced, changing from MLG to few-layer-AB-stacked-graphene and in some cases to randomly oriented few layer graphene near the substrate. Furthermore, our method offers the significant advantage that it does not introduce defects in the samples, maintaining their original high quality. This fact and the low temperature our method uses make it a good candidate for controlling the layer number of already grown graphene in processes with a low thermal budget.

Although mortality is low after the modified Fontan procedure, there is a significant percentage of patients with prolonged postoperative recovery. The objective of this study is to evaluate the usefulness of postoperative administration of oral sildenafil and inhaled nitric oxide on early postoperative outcome. A prospective interventional and comparison study with a historical cohort was conducted. Between January, 2010 and March, 2013, 16 patients received oral sildenafil during immediate modified Fontan postoperative period. Inhaled nitric oxide was also administered if the patient was kept intubated 12 hours after surgery. Early postoperative outcome was compared with a historical cohort of 32 patients on whom the modified Fontan procedure was performed between March, 2000 and December, 2009. Postoperative administration of sildenafil and nitric oxide had no influence on early postoperative outcome after the modified Fontan procedure in terms of duration of pleural effusions, mechanical ventilation time, length of stay in the ICU, and length of hospital stay.

Diarrheal and respiratory illness surveillance was conducted during the 2014 Republic of the Philippines-U.S. Exercise Balikatan in the Philippines. Seven stool and three respiratory specimens that met the inclusion criteria were collected. Diarrhea stool specimens were tested with commercial enzyme-linked immunosorbent assay kits and real-time polymerase chain reaction (PCR) for 12 viral, bacterial, and protozoan pathogens. Campylobacter, enterotoxigenic Escherichia coli (ETEC), and enteropathogenic Escherichia coli (EPEC) were detected in four of seven (57%), two of seven (29%), and four of seven (57%) specimens, respectively. There were co-infections of EPEC and ETEC in two cases and EPEC and Campylobacter spp. in one case. Respiratory samples were tested using RT-PCR. One of three samples was positive for influenza B. Laboratory-based surveillance is important in determining causative agents for illnesses experienced by military personnel during deployment. Development of vaccines for enteric diseases should be expedited to mitigate their impact on operational readiness.

Background: Chikungunya virus (CHIKV) is a globally re-emerging arbovirus for which previous studies have indicated the majority of infections result in symptomatic febrile illness. We sought to characterize the proportion of subclinical and symptomatic CHIKV infections in a prospective cohort study in a country with known CHIKV circulation., Methods/findings: A prospective longitudinal cohort of subjects ≥6 months old underwent community-based active surveillance for acute febrile illness in Cebu City, Philippines from 2012-13. Subjects with fever history were clinically evaluated at acute, 2, 5, and 8 day visits, and at a 3-week convalescent visit. Blood was collected at the acute and 3-week convalescent visits. Symptomatic CHIKV infections were identified by positive CHIKV PCR in acute blood samples and/or CHIKV IgM/IgG ELISA seroconversion in paired acute/convalescent samples. Enrollment and 12-month blood samples underwent plaque reduction neutralization test (PRNT) using CHIKV attenuated strain 181/clone25. Subclinical CHIKV infections were identified by ≥8-fold rise from a baseline enrollment PRNT titer <10 without symptomatic infection detected during the intervening surveillance period. Selected CHIKV PCR-positive samples underwent viral isolation and envelope protein-1 gene sequencing. Of 853 subjects who completed all study procedures at 12 months, 19 symptomatic infections (2.19 per 100 person-years) and 87 subclinical infections (10.03 per 100 person-years) occurred. The ratio of subclinical-to-symptomatic infections was 4.6:1 varying with age from 2:1 in 6 month-5 year olds to 12:1 in those >50 years old. Baseline CHIKV PRNT titer ≥10 was associated with 100% (95%CI: 46.1, 100.0) protection from symptomatic CHIKV infection. Phylogenetic analysis demonstrated Asian genotype closely related to strains from Asia and the Caribbean., Conclusions: Subclinical infections accounted for a majority of total CHIKV infections. A positive baseline CHIKV PRNT titer was associated with protection from symptomatic CHIKV infection. These findings have implications for assessing disease burden, understanding virus transmission, and supporting vaccine development.