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Intro: Detecting and responding to acute public health threats is one of the World Health Organization's (WHO) most important activities. Therefore, WHO established a unique approach for the global detection and verification of events of potential international public health concern and adopted an all-hazards approach as part of the International Health Regulations (2005), moving beyond a focus on infectious diseases only. Here, we analysed 20-year trends of acute public health events globally. Methods: We extracted data on acute public health events reported between 2002 and 2021 from the Event Management System (EMS). EMS is an internal WHO web-based platform used for tracking health threats globally. We examined the designation, source and hazard of events by WHO Region and over time by calculating descriptive statistics and trends using R. Findings: Between 2002 and 2021, 7572 events were recorded globally in EMS, ranging from 231 to 576 per year. Of these, 5466 (76%) were designated as substantiated, deemed true acute public health events, and only a small proportion (379, 5%) were unverifiable or had no designation. During the 20-year period, substantiated events were greatest in the WHO African Region (1684 events, 31%) and the WHO Region of the Americas (1312 events, 24%) and, similarly, by year, the burden was highest in those WHO regions. Globally, over time, two-thirds (3536, 65%) of substantiated events were initially reported by WHO and infectious diseases (4298, 79%) were the predominant cause of public health events. However, other causes, including animal origin or zoonoses were also important and disaster related events were on the rise in recent years, particularly in some WHO Regions. Conclusion: WHO has a robust system for global disease detection but health threats are continuously evolving. The impact of climate change and zoonoses is becoming more pronounced, emphasizing the importance of a One Health approach for disease detection.

Introduction: Acute necrotizing encephalopathy (ANE) of childhood is a rare inflammatory syndrome, classically associated with preceding febrile illness and followed by fulminant neurological deterioration including encephalopathy, seizures, and focal neurological deficits with multifocal lesions of the thalami, rostral brainstem, and cerebral and cerebellar gray and white matter. ANE is distinctly associated with significant rates of neurological sequelae and death. Multiple infectious and parainfectious etiologies have been associated with ANE, notably influenza A. Case Report: We report two cases of ANE associated with parainfluenza infection. Both children were treated with high-dose methylprednisolone and intravenous immunoglobulin, and one treated with tocilizumab. However, both patients suffered rapid neurological deterioration and death despite aggressive intervention. Conclusion: We present two cases of ANE with rapid neurological deterioration and death despite aggressive medical therapy. Rapid treatment with immunomodulatory treatments can lead to symptomatic recovery of variable degree in some patients. While high-dose steroids, intravenous immunoglobulin, and plasma exchange are common therapies for ANE, some case reports have suggested interleukin-6 (IL-6) blockade with tocilizumab can be beneficial. We report the nineteenth documented child in pediatric literature treated for ANE with tocilizumab, who did not respond to treatment, suggesting the response is heterogeneous and warrants additional investigation.

Introduction: Participation in early-phase HIV cure studies includes clinical risks with little to no likelihood of clinical benefit. Examining the willingness of people living with HIV to participate is important to guide study design and informed consent. Our study examined the overall willingness of people living with HIV to participate in HIV cure research in the US, focusing on perceived risks and benefits of participation. Methods: We undertook an online survey of adults living with HIV in the US. Survey questions were developed based on previous research and a scoping review of the literature. We quantitatively assessed individuals’ perceived risks and benefits of HIV cure-related research and respondents’ willingness to participate in different modalities of HIV cure studies. Results: We recruited 409 study participants of whom 400 were eligible for the study and were included in the analysis (nine were not eligible due to self-declared HIV-negative status). We found >50% willingness to participate in 14 different types of HIV cure studies. Perceived clinical benefits and social benefits were important motivators, while personal clinical risks appeared to deter potential participation. Roughly two-thirds of survey respondents (68%) indicated that they were somewhat willing to stop treatment as part of HIV cure research. In the bivariate models, females, African Americans/blacks, Hispanics, individuals in the lowest income bracket, people living with HIV for longer periods of their lives, and people who were self-perceived ‘very healthy’ were less willing to participate in certain types of HIV cure studies than others. Multivariate results showed the perceived benefits (adjusted odds ratios >1) and perceived risks (adjusted odds ratios

Background: Monkeypox virus clade I is endemic in several central African countries and characterised by an increase in disease severity and mortality. Since October, 2023, a large-scale mpox outbreak has emerged in DR Congo, and in March, 2024, the first individuals with mpox were reported outside the endemic areas in Republic of the Congo. We aimed to provide insight into the epidemic by sequencing samples obtained from individuals with mpox in Republic of the Congo., Methods: In this cross-sectional, descriptive study, samples were collected from individuals with suspected mpox between Jan 15 and April 8, 2024, in Brazzaville, Pointe-Noire, Likouala, Cuvette-Centrale, and Plateaux (Republic of the Congo). Blood samples, skin or oropharyngeal swabs, or skin crusts were obtained for molecular diagnosis via real-time PCR. Monkeypox virus sequences were obtained and analysed using newly established nanopore sequencing methodology and bioinformatic pipeline. The sequences obtained were aligned and used to construct a maximum likelihood phylogenetic tree using IG-TREE., Findings: 61 samples were collected from individuals with suspected mpox, 31 of which were positive for monkeypox virus and were included in our analysis (four positive samples were excluded due to unavailability of epidemiological data or insufficient biological material). Individuals who tested positive for monkeypox virus were from Cuvette-Centrale (19 [61%] of 31), Likouala (eight [26%]), and Pointe-Noire (four [13%]). 20 (65%) were male and 11 (35%) were female. Phylogenetic analysis of sequences showed two major clusters within clade Ia. One cluster was made up of four sequences from this study clustering with two monkeypox virus sequences from the current DR Congo outbreak, three older sequences from Central African Republic sequenced between 2017 and 2018, and seven sequences from DR Congo sequenced in 2006-07 and 2022. The second cluster was made up of 16 sequences from this study clustering with sequences from the current DR Congo outbreak. In addition, sequences from Republic of the Congo show multiple phylogenetic positioning suggesting the occurrence of multiple co-circulating strains in the human population., Interpretation: Our findings suggest that multiple monkeypox virus strains are co-circulating in the human population, highlighting the need for implementation of expanded mpox surveillance, especially in countries bordering DR Congo and Republic of the Congo, in combination with control measures focused on containing the current outbreaks in these countries to prevent escalation into a larger-scale epidemic., Funding: Intramural Research Program of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 Published by Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: The medial arm flap (MAF) has been used as a pedicle flap and free flap to reconstruct various deformities, including those of the head and neck, axilla, elbow, chest, and hand. This study reviews the anatomy of the flap, the technique of flap harvest, its clinical applications, and a systematic review of the current published literature., Methods: An online systematic review of MEDLINE, EMBASE, PubMed, and The Cochrane Library from inception to September 30, 2023, was completed. Studies that investigate the anatomy, technique or clinical outcomes of medial arm flaps were included. Clinical data extracted includes patient, defect, flap characteristics, complications, and take-back procedures. Anatomic data extracted includes anatomical variations, and vascular characteristics and patterns., Results: Between 1980 and 2023, 50 papers were published outlining the medial arm flap. Anatomic studies detail the anatomy of 384 medial arms, and outcomes are reported for 283 MAFs (75 free flaps and 208 pedicle flaps). The superior ulnar collateral artery is most commonly cited as the dominant arterial supply to the middle third of the medial arm. The majority of patients required reconstruction post-burn (39.2%), trauma (17.7%), and tumor excision (12.4%). MAFs were mostly used to reconstruct defects of the head and neck (41.7%), the hand and wrist (21.9%), and the elbow (16.3%). Eleven flaps (4.1%) suffered partial flap failure, and two flaps (0.7%) suffered total flap failure., Conclusion: This manuscript demonstrates that the MAF is a reliable and underutilized flap option with a well-hidden donor scar and a low complication rate., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest to disclose, (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection of the splenic vessels via the Warshaw Technique (WT) or via preservation of the splenic vessels (SVP). Our study aims to compare outcomes for the two methods of LSPDP., Methods: We performed a retrospective chart review with intent-to-treat analysis of adults undergoing LSPDP at a single institution from 2009 to 2021. We compared demographic characteristics, operative parameters, oncologic pathology review, and postoperative outcomes., Results: There were 102 consecutive cases of LSPDP (59 WT, 43 SVP) over 12 years. The rate of successful spleen preservation was not significantly different between the two groups (76.3%WT, 65.1%VSP,p = 0.27). Rates of conversion to laparotomy, postoperative complications including pancreatic fistulas and splenic infarcts and amount of intraoperative blood loss were similar between the groups. Median operative time was significantly shorter with the WT (141 vs. 177 min, p < 0.05). The median length of stay in hospital was not significantly different among the groups., Conclusion: Both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique may be more efficient with respect to the use of limited operative resources., (Copyright © 2022 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Since the introduction of laparoscopic cholecystectomy over 30 years ago, rates of bile duct injury have remained elevated compared to the era of open cholecystectomy. We propose an anatomical landmark, the Inferior Boundary of Dissection, to help prevent dangerous dissection in the porta hepatis and provide clues as to when a critical view of safety may not be immediately achieved., Methods: This landmarking approach is based on fundamentals of biliary anatomy and surface landmarks of the liver., Results: The 'Boundary' extends from Rouviere's sulcus to the junction of the peritoneum and fat overlying the cystic and hilar plates, near the base of segment 4. This anatomic landmark represents the lower boundary for safe dissection, by outlining the location of the biliary pedicles., Conclusion: The two points of reference are reliable surface landmarks with predictable and consistent relationships to the biliary pedicles. It also serves as a line above which the gallbladder can be opened or mobilized in a 'top-around' approach, facilitating subtotal cholecystectomy when the hepatocystic triangle appears hostile due to inflammation. The landmark has been well-received in our region as a facile instrument for safe cholecystectomy and we advocate for its broader use., (Copyright © 2021 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: The Surgical Exploration and Discovery (SEAD) program was established to facilitate career decision-making by providing preclerkship students with comprehensive exposure to surgical specialties. Our short-term findings demonstrated that, compared to a control group, SEAD participants showed significantly greater career-related learning. The purpose of this study was to understand the long-term impact of the SEAD program., Design: This was a prospective cohort study. One group of students participated in a 2-week surgical curriculum (SEAD group) while another group read only the program manual (Manual group). Students were surveyed following their residency selection 3 years later. The outcome measures were final specialty preference (medical or surgical), program utility, and program satisfaction., Setting: Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada., Participants: A total of 18 medical students in the SEAD group, and 18 in the Manual group., Results: Survey response rate was 100%. There was no significant difference in the number of students who pursued surgical careers in the SEAD and Manual groups. All students who pursued a surgical residency were 'very interested' in surgery prior to SEAD-initial interest in surgery had a significant influence on final residency preference. Ninety-four percent (n = 17) of SEAD participants described the SEAD program as valuable to facilitating their career decision-making., Conclusions: Although SEAD does not generate sustained new interest in surgical disciplines, graduating students believe the program is valuable in facilitating career decision-making and perceive the program as a worthwhile time investment. These findings were true for students who selected both surgical and medical specialties, suggesting that early, multifaceted, exposure to surgery is a valuable addition to career exploration even for students who ultimately don't pursue surgical specialties. Going forward, integrating a longitudinal mentorship program may further improve the value of SEAD., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to explore psychological distress and examine the relationship between this distress and individual, family, and school factors among adolescents in four low- and middle-income countries (LAMICs) in Asia (i.e., Laos, Mongolia, Nepal, and Sri Lanka)., Methods: A total of 4,098 adolescents attending public schools in the four LAMICs were surveyed as part of the Healthy School Development Project, which aimed to develop school capacity for improving (1) health among all school members and (2) the school environment through tailored school health programs. Psychological distress, family factors (i.e., parental understanding and monitoring, and parental tobacco and alcohol use), and school factors (i.e., having close friends, not bullied, school attendance, and health education) were assessed using self-report questionnaires. Data were collected from September to November in 2012 and 2013. Data analysis comprised descriptive statistics, Chi-squared testing, and logistic regression., Results: Over half of the participants were women (53.2%-64.1%), and 33.7% (in Sri Lanka) to 53.8% (in Laos) were aged older than 15 years. Approximately 32.9% reported the presence of psychological distress; moreover, 7.9%-13.2% reported suicidal ideation. Parental monitoring and being bullied were associated with psychological distress in all four countries., Conclusion: One-third of adolescents experience psychological distress across these four LAMICs, which poses a substantial public health issue. Adolescents can benefit from family and school-based approaches for screening, ameliorating, and preventing psychological distress., (Copyright © 2019. Published by Elsevier B.V.)

Background: The declining popularity of surgical specialties among North American medical students has been attributed partially to limited early exposure and minimal involvement of surgeons in preclerkship education; in response, the Surgical Exploration and Discovery (SEAD) program was developed at the University of Toronto in 2012. SEAD is a 2-week curriculum that provides first-year medical students comprehensive exposure to surgical specialties through operating room observerships, simulation workshops, and career discussions. This study is the first to examine implementation of the SEAD program at another site., Methods: This prospective cohort study evaluated the effectiveness of the SEAD program in improving surgical knowledge and facilitating career decision making when compared with a control group. In all, 18 students participated in the SEAD program, and 18 students from the same class read only the program's instructional manual; both the groups completed multiple-choice tests and questionnaires at baseline and at completion to assess knowledge acquisition and career-related learning., Results: Both the groups significantly improved their surgical knowledge, but there was no difference between groups. SEAD participants made significantly greater progress in refining their career decisions when compared with the control group; all but one SEAD participant either gained interest in or ruled out a surgical specialty as a potential career choice compared with only 10 of the participants reading the manual only., Conclusions: The SEAD program provides a meaningful opportunity for medical students to explore surgical careers during preclerkship and to make better-informed career decisions. This expansion demonstrates that the program can be successfully reproduced at another institution., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

•First case report of successfully treating severe paclitaxel and docetaxel hypersensitivity reaction with nab-paclitaxel•We demonstrated that nab-paclitaxel is a safe taxane chemotherapy treatment option for patients who could not tolerate paclitaxel or docetaxel.

Large-scale conformational transitions are involved in the life-cycle of many types of virus. The dsDNA phages, herpesviruses, and adenoviruses must undergo a maturation transition in the course of DNA packaging to convert a scaffolding-containing precursor capsid to the DNA-containing mature virion. This conformational transition converts the procapsid, which is smaller, rounder, and displays a distinctive skewing of the hexameric capsomeres, to the mature virion, which is larger and more angular, with regular hexons. We have used electron cryomicroscopy and image reconstruction to obtain 15 A structures of both bacteriophage P22 procapsids and mature phage. The maturation transition from the procapsid to the phage results in several changes in both the conformations of the individual coat protein subunits and the interactions between neighboring subunits. The most extensive conformational transformation among these is the outward movement of the trimer clusters present at all strict and local 3-fold axes on the procapsid inner surface. As the trimer tips are the sites of scaffolding binding, this helps to explain the role of scaffolding protein in regulating assembly and maturation. We also observe DNA within the capsid packed in a manner consistent with the spool model. These structures allow us to suggest how the binding interactions of scaffolding and DNA with the coat shell may act to control the packaging of the DNA into the expanding procapsids., (Copyright 2000 Academic Press.)

The procapsids of bacterial viruses are the products of the polymerization of coat and scaffolding subunits, as well as the precursors in DNA packaging. Electron cryo-microscopy has been used to study the three-dimensional structures of bacteriophage P22 procapsids containing wild-type and mutant scaffolding proteins. The scaffolding mutant structure has been resolved to 19 A resolution and agrees with the 22 A resolution wild-type procapsid reconstruction. Both procapsid reconstructions contain an outer icosahedral coat protein shell and an inner scaffolding protein core. The outer core protein forms a T = 7 icosahedral lattice with distinctive channels present at the centers of the pentons and hexons. In addition, the hexons display a prominent skew. Computational isolation of the skewed hexon shows the presence of a local 2-fold axis that reduces the number of unique conformations in the asymmetric unit to four at this resolution. We have classified the four unique subunits into three distinct classes, based upon the shape of the upper domain and the presence of a channel leading to the inner coat protein surface. In addition, at the inner surface of the coat protein, finger-like regions that extend towards the scaffolding protein core are present in two of the subunits. The finger-like regions suggest the presence of an ordered interaction between the inner coat protein and the scaffolding protein. However, an icosahedral scaffolding protein shell is not formed, and the innermost scaffolding protein core does not pack with icosahedral symmetry.

Purpose: To describe adolescents' utilization of ambulatory health services and its association with sociodemographic and health status characteristics., Methods: Adolescents (N = 199) were selected from a larger group of urban middle and high school students who had previously participated in a health risk survey. Subjects were surveyed about their health status and use of ambulatory medical services. Subjects' parents/guardians were also surveyed about sociodemographic information. Bivariate and multivariate analyses using Chisquare statistics and logistic regression techniques assessed the contribution of hypothesized variables to use of routine medical, illness-related medical, and dental services., Results: Most adolescents reported having seen a physician (70%) or a dentist (79%) within the past year. Subjects reported using a wide variety of practitioners and settings, with family/general practitioners (29%), and the private office setting (23%) most commonly reported. Subjects having a regular source of care and those perceiving their health as "excellent" or "very good" were 2.4 and 3.4 times more likely to have used routine medical services than those without a regular source of care and those reporting their health as "fair" or "poor." In contrast, the strongest predictors of having received illness-related care in the past year were the presence of a current medical problem and an age by gender interaction factor. Those reporting a current medical problem were twice as likely as those not reporting a problem and older females were 6.6 times as likely as younger males to have received illness-related care within the past year. The only significant predictor of recent dental care was having private insurance., Conclusion: For adolescents enabling variables, such as having a regular source of care and health insurance, are stronger predictors of routine use of medical and dental care, whereas medical need and sociodemographic factors, such as age and gender, are more important in predicting use of illness-related care. These results support, in part, models that have been previously developed to explain use of ambulatory health services.