SummaryBackgroundSurgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.MethodsThis international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.FindingsBetween Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).InterpretationCountries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

Needle-free liquid jet injectors were invented >50 years ago for the delivery of proteins and vaccines. Despite their long history, needle-free liquid jet injectors are not commonly used as a result of frequent pain and bruising. We hypothesized that pain and bruising originate from the deep penetration of the jets and can potentially be addressed by minimizing the penetration depth of jets into the skin. However, current jet injectors are not designed to maintain shallow dermal penetration depths. Using a new strategy of jet injection, pulsed microjets, we report on delivery of protein drugs into the skin without deep penetration. The high velocity (v >100 m/s) of microjets allows their entry into the skin, whereas the small jet diameters (50 -100 m) and extremely small volumes (2-15 nanoliters) limit the penetration depth (Ϸ200 m).In vitro experiments confirmed quantitative delivery of molecules into human skin and in vivo experiments with rats confirmed the ability of pulsed microjets to deliver therapeutic doses of insulin across the skin. Pulsed microjet injectors could be used to deliver drugs for local as well as systemic applications without using needles.MEMS ͉ nanotechnology ͉ noninvasive ͉ piezoelectric ͉ transdermal

As infectious disease surveillance systems expand to include digital, crowd-sourced, and social network data, public health agencies are gaining unprecedented access to high-resolution data and have an opportunity to selectively monitor informative individuals. Contact networks, which are the webs of interaction through which diseases spread, determine whether and when individuals become infected, and thus who might serve as early and accurate surveillance sensors. Here, we evaluate three strategies for selecting sensors—sampling the most connected, random, and friends of random individuals—in three complex social networks—a simple scale-free network, an empirical Venezuelan college student network, and an empirical Montreal wireless hotspot usage network. Across five different surveillance goals—early and accurate detection of epidemic emergence and peak, and general situational awareness—we find that the optimal choice of sensors depends on the public health goal, the underlying network and the reproduction number of the disease (R0). For diseases with a low R0, the most connected individuals provide the earliest and most accurate information about both the onset and peak of an outbreak. However, identifying network hubs is often impractical, and they can be misleading if monitored for general situational awareness, if the underlying network has significant community structure, or if R0 is high or unknown. Taking a theoretical approach, we also derive the optimal surveillance system for early outbreak detection but find that real-world identification of such sensors would be nearly impossible. By contrast, the friends-of-random strategy offers a more practical and robust alternative. It can be readily implemented without prior knowledge of the network, and by identifying sensors with higher than average, but not the highest, epidemiological risk, it provides reasonably early and accurate information.

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We study shock statistics in the scalar conservation law ∂tu+∂xf (u) = 0, x ∈ R, t > 0, with a convex flux f and spatially random initial data. We show that the Markov property (in x) is preserved for a large class of random initial data (Markov processes with downward jumps and derivatives of Lévy processes with downward jumps). The kinetics of shock clustering is then described completely by an evolution equation for the generator of the Markov process u(x, t), x ∈ R. We present four distinct derivations for this evolution equation, and show that it takes the form of a Lax pair. The Lax equation admits a spectral parameter as in [35], and has remarkable exact solutions for Burgers equation (f (u) = u 2 /2). This suggests the kinetic equations of shock clustering are completely integrable.MSC classification: 60J75, 35R60, 35L67, 82C99

Partially-averaged Navier-Stokes (PANS) approach has been recently developed as a possible bridging model between Reynolds-averaged Navier-Stokes (RANS) method and large-eddy simulations (LES). The resolution control parameters in PANS are the fractions of unresolved kinetic energy (fk) and unresolved dissipation (fε). We investigate the fixed-point behavior of PANS and present some preliminary results obtained using this model. By comparing the fixed-point behavior of PANS and URANS (unsteady Reynolds-averaged Navier-Stokes) methods, the possible advantage of the former over the latter is explained. Initial results from two-dimensional simulations of flow past square results are also presented.

Nuclear Overhauser effect (NOE) enhancements and relaxation times of 31P metabolites in human calf were measured in 12 volunteers (4 men and 8 women) at 1.5 T using a dual tuned four-ring birdcage. The NOE enhancements of inorganic phosphate (Pi), phosphocreatine (PCr), gamma-, alpha-, and beta-nucleoside triphosphate (NTP) from 19 measurements were 0.51 +/- 0.10, 0.64 +/- 0.03, 0.53 +/- 0.03, 0.56 +/- 0.08, and 0.47 +/- 0.05, respectively. The relaxation times were independent of proton irradiation and from 23 measurements were 3.49 +/- 0.35, 4.97 +/- 0.58, 4.07 +/- 0.36, 2.90 +/- 0.25, and 3.61 +/- 0.25 s for Pi, PCr, gamma-, alpha-, and beta-NTP, respectively. No significant differences between gender and age were observed for either NOE enhancements or relaxation times. Also, among nine volunteers, we observed no significant differences in T1 between the coupled and decoupled cases.

Proton-decoupled, 31P three-dimensional (3-D) chemical shift imaging (CSI) spectra have been acquired from the entire human brain using a new dual tuned resonator. The resonator operates in quadrature mode to provide improved sensitivity, excellent B1 homogeneity and reduced power deposition at both frequencies. Proton-decoupled and fully NOE enhanced, 31P spectra were acquired from normal volunteers using Waltz-4 proton decoupling with continuous wave bi-level excitation applied through a second radio frequency channel. Well resolved peaks in the phosphomonoester (PME) and phosphodiester regions were obtained from nonlocalized FIDs and spectra localized with 3-D CSI without processing for resolution enhancement. pH measurements made over large regions of the brain using the P(i) resonance show no significant variations (6.9 +/- 0.02) for a single individual. The improved spectral resolution and sensitivity of the PME resonances results in more well defined metabolite images of the PME peak region.