INTRODUCTION In August, 2011, the F. Edward Hebert School of Medicine extensively revised its four year curriculum, focusing on the theme of “Molecules to Military Medicine.” Since most civilian medical schools undergoing a major curricular reform typically allow three to seven years for full implementation, the fact that its revision was designed and implemented in two years, was itself a momentous achievement. As such, this report will describe some of the key innovations associated with the new curriculum, followed by a summary of some of the leadership lessons that may help guide other programs considering similar types of curricular revision.

While studying chronic verruga peruana infections in Peru from 2003, we isolated a novel Bartonella agent, which we propose be named Candidatus Bartonella ancashi. This case reveals the inherent weakness of relying solely on clinical syndromes for diagnosis and underscores the need for a new diagnostic paradigm in developing settings.

Bartonella bacilliformis has caused debilitating illness since pre-Incan times, but relatively little is known about its epidemiology. A population-based, prospective cohort investigation was conducted in a Peruvian community with endemic bartonellosis. By use of house-to-house and hospital surveillance methods, cohort participants were monitored for evidence of bartonellosis. Of 690 participants, 0.5% had asymptomatic bacteremia at study initiation. After 2 years of follow-up, the incidence of infection was 12.7/100 person-years. The highest rates were in children <5 years old, and there was a linear decrease in incidence with increasing age. Seventy percent of cases were clustered in 18% of households. Age and bartonellosis in a family member were the best predictors of B. bacilliformis infection. There were multiple clinical presentations and significant subclinical infection. A cost-effective control strategy should include vector control and surveillance efforts focused on children and clusters of households with highest endemicity.

The consequences of climate variability on human health, especially for poor and medically underserved populations, have received much attention in recent years. Some of the most severe health hazards induced by climate variability are epidemics of vector‐borne infectious diseases. Entomologic studies have shown that insect vectors that transmit diseases, such as malaria, yellow fever, dengue, etc., are sensitive to temperature, humidity wind, and rainfall patterns, and therefore, their abundance is potentially influenced by climate variability. Because of its geographical location, the climate of tropical South America is strongly influenced by El Niño. The episodic outbreaks of various diseases in this region have been linked to the El Niño cycles. Yet, according to a report of the World Health Organization [1999], early results from South American epidemiological studies, which were based on the aggregated national disease data irrespective of the regional meteorological impacts, found no consistent correlation between the El Niño effect with the epidemics of malaria and yellow fever.

Bartonellosis is a vector-borne, highly fatal, emerging infectious disease, which has been known in the Peruvian Andes since the early 1600s and has continued to be a problem in many mountain valleys in Peru and other Andean South American countries. The causative bacterium, Bartonella bacilliformis (Bb), is believed to be transmitted to humans by bites of the sand fly Lutzomyia verrucarum. According to available medical records, the transmission of infection often occurs in river valleys of the Andes Mountains at an altitude between 800 and 3500 meters above sea level. It shows a seasonal pattern, which usually begins to rise in December, peaks in February and March, and is at its lowest from July until November. The epidemics of bartonellosis also vary interannually, occurring every four to eight years, and appear to be associated with the El Nino cycle. In response to the National Oceanic and Atmospheric Administration (NOAA) announcement on climate variability and human health, which was constructed to stimulate integrated multidisciplinary research in the area of climate variability and health interactions, we have conducted a study to investigate the relationship between the El Nino induced regional climate variation and the outbreak of bartonellosis epidemics in Peru. Two test sites, Caraz and Cusco, were selected for this study. According to reports, Caraz has a long-standing history of endemic transmission and Cusco, which is located about five degrees poleward of Caraz, had no recorded epidemics until the most recent 1997/1998 El Nino event. The goal of this study is to clarify the relative importance of climatic risk factors for each area that could be predicted in advance, thus allowing implementation of cost-effective control measures, which would reduce disease morbidity and mortality.

As part of a larger on-going investigation to study the disease bartonellosis, remote sensing images are being used to map the study area and to help determine environmental factors that may influence the abundance of sand flies, the insect thought to be the vector of the disease. A plot of positive patient houses on a Landsat image shows that most of the cases occur in the agricultural areas and few cases occur in the town. The disease does not occur more frequently near the river. One of the classes produced from an unsupervised classification of a Landsat image occurs frequently with the positive houses and infrequently with the negative houses. Additional positive and negative houses are needed to confirm this result and future studies will attempt to determine what environmental factors are represented by the class and how these factors might relate to sand fly distribution.

Between 1985 and 1987, examinations for human immune deficiency virus (HIV) antibody were done on 25,392 prostitutes working in 64 cities throughout the Philippines. The country-wide seropositivity rate among prostitutes based on this sample was 0.8/1,000. Of the HIV cases, 85% were working in just two cities whose prostitute populations comprised 50% of the total sample. The average incidence rate for the same two cities after 1 year was 2.3/1,000. HIV antibody-positive women were enrolled in a case-control study to determine demographic and epidemiologic risk factors. This study involving 34 HIV-positive prostitutes and 61 randomly selected negative control prostitutes did not reveal any risk factors related to sexual or other types of behavior. A history of genital warts, a history of abnormal vaginal discharge, and cytomegalovirus antibody were significantly more frequent in the HIV-positive cases than in the controls; however, by logistic regression analysis, only an abnormal vaginal discharge was independently associated with HIV infection. Absence of any evidence of transmission by blood transfusion or i.v. drug abuse suggests that HIV was introduced by the heterosexual route.

A fatal case of tuberculous meningitis caused by a multiply-resistant tubercle bacillus is described, the first such case from Southeast Asia. Increased efforts to isolate Mycobacterium tuberculosis from the cerebrospinal fluid and determine the extent and pattern of drug resistance are necessary if the high mortality from this disease is to be reduced.

Journal Article The Rapid Diagnosis of Leptospirosis: A Prospective Comparison of the Dot Enzyme-Linked Immunosorbent Assay and the Genus-Specific Microscopic Agglutination Test at Different Stages of Illness Get access George Watt, George Watt U. S. Naval Medical Research Unit Number 2, Manila, Philippines Please address requests for reprints to the Publications Office, U. S. Naval Medical Research Unit Number 2, APO San Francisco, California 95628. Search for other works by this author on: Oxford Academic PubMed Google Scholar Lily M. Alquiza, Lily M. Alquiza U. S. Naval Medical Research Unit Number 2, Manila, Philippines Search for other works by this author on: Oxford Academic PubMed Google Scholar Laurena P. Padre, Laurena P. Padre U. S. Naval Medical Research Unit Number 2, Manila, Philippines Search for other works by this author on: Oxford Academic PubMed Google Scholar Maria Linda Tuazon, Maria Linda Tuazon U. S. Naval Medical Research Unit Number 2, Manila, Philippines Search for other works by this author on: Oxford Academic PubMed Google Scholar Larry W. Laughlin Larry W. Laughlin U. S. Naval Medical Research Unit Number 2, Manila, Philippines Search for other works by this author on: Oxford Academic PubMed Google Scholar The Journal of Infectious Diseases, Volume 157, Issue 4, April 1988, Pages 840–842, https://doi.org/10.1093/infdis/157.4.840 Published: 01 April 1988 Article history Received: 30 June 1987 Revision received: 02 November 1987 Published: 01 April 1988

Rapid diagnostic tests for tuberculous meningitis are urgently needed because delayed treatment increases the already high mortality rate of this disease. Direct acid-fast staining of cerebrospinal fluid is the only quick method generally available, but it lacks sensitivity. Therefore, we evaluated the use of an enzyme-linked immunosorbent assay (ELISA) to mycobacterial antigen and antibody in the cerebrospinal fluid of 29 patients with proven tuberculous meningitis, 83 patients with nontuberculous central nervous system infections, and 15 normal controls. The specificity of the test was 96%; the four false-positive results all occurred in patients with bacterial meningitis. Fifteen (52%) of 29 patients with tuberculous meningitis had either a positive antigen or antibody ELISA test, which was significantly more than the number of patients testing positive by direct staining (two of 29 positive; P less than .01). We therefore recommend using an ELISA to detect antigen and antibody but caution that because of limited sensitivity a negative test result does not exclude the diagnosis of tuberculous meningitis.

Punjabi, Narain H. M.D.; Hoffman, Stephen L. M.D.; Edman, David C. Ph.D.; Sukri, Nono M.D.; Laughlin, Larry W. M.D., Ph.D.; Pulungsih, Sri Pandam M.D.; Rivai, Atti Rifajati M.D.; Sutoto, M.D.; Moechtar, Asril M.D.; Woodward, Theodore E. M.D.; Baltimore, MD Author Information

Although human cases of leptospirosis have been reported from the Philippines, there is a lack of data on its prevalence. We therefore surveyed three rice-farming villages for the presence of leptospiral antibody. Out of 155 sera tested, 63 (43.6%) tested positive using the standard microagglutination test. Antibodies were more frequent in men than women (48 vs. 31%, respectively, p less than 0.01), and less common in the elderly. Exposure to leptospires occurs frequently in rice farmers, and leptospirosis is likely to be an underdiagnosed cause of both mild and severe febrile illness in the Philippines.

Praziquantel undergoes extensive first-pass hepatic biotransformation, but there is little information on its disposition or toxicity when administered to patients with liver disease. To define the influence of liver disease on the pharmacokinetics of praziquantel, we administered it orally to 30 patients with proven Schistosoma japonicum infection whose liver disease was carefully assessed as being severe, moderate, or absent. Both the peak plasma concentration of praziquantel and the bioavailability (measured as the area under the plasma concentration time curve) were significantly greater in the two groups of patients with liver disease (P less than .005), as were the concentrations of the two identified metabolites of praziquantel. Mild side effects were associated with high peak concentrations of praziquantel, but a syndrome of severe abdominal pain followed by bloody diarrhea was not. Our results indicate that the side effects and bioavailability of praziquantel are increased in the presence of liver disease.

The effect of a 7-day course of intravenous penicillin (6 million units/day) on severe, advanced leptospirosis was examined in a randomised, placebo-controlled, double-blind trial involving 42 patients. Every measurable aspect of the disease was favourably affected by penicillin. Fever lasted more than twice as long in the placebo group (11·6 [SD 8·34] days vs 4·7 [4·19] days, p<0·005), and by the fourth day after starting penicillin more than half the treatment group, but only 1 of 19 in the placebo group, were afebrile (p<0·005). Creatinine rises persisted more than thrice as long in the patients receiving only placebo (8·3 [8·46] days vs 2·7 [1·90] days; p<0·01). Penicillin also shortened the hospital stay and prevented leptospiruria. Intravenous penicillin should be given to patients with severe leptospirosis, even if therapy can be begun only late in the course of their disease.

The effects of tourniquet application were prospectively studied in 36 hospitalized patients who developed neurotoxic symptoms after bites by the Philippine cobra (Naja naja philippinensis). Tourniquets had been applied in 94% of cases and delayed the onset of symptoms. Four patients were asymptomatic prior to the release of their tourniquet and in 11 patients symptoms worsened precipitously. Most importantly, 4 patients developed complete respiratory paralysis requiring artificial ventilation on its removal. Medical personnel seeing patients after a possible cobra bite should remove any tourniquet very gradually with both specific therapy and ventilatory support at hand. We recommend tourniquet application in the Philippines only after the bite of a definitely identified cobra and when removal can take place under controlled hospital conditions.

Journal Article Fansidar resistance in the Philippines Get access George Watt, George Watt U.S. Naval Medical Research Unit No. 2, APO San Francisco, California 96528, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Laurena P. Padre, Laurena P. Padre U.S. Naval Medical Research Unit No. 2, APO San Francisco, California 96528, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Linda R. Tuazon, Linda R. Tuazon U.S. Naval Medical Research Unit No. 2, APO San Francisco, California 96528, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Larry W. Laughlin Larry W. Laughlin U.S. Naval Medical Research Unit No. 2, APO San Francisco, California 96528, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Transactions of The Royal Society of Tropical Medicine and Hygiene, Volume 81, Issue 3, May-June 1987, Page 521, https://doi.org/10.1016/0035-9203(87)90191-X Published: 01 June 1987 Article history Accepted: 23 December 1986 Published: 01 June 1987

Amodiaquine was compared to chloroquine in two groups of Filipino patients with uncomplicated falciparum malaria. Every patient received 25 mg/kg of base orally given over three days. In a hospital study, all eight patients receiving chloroquine cleared their parasitemia by day 6, but six of eight patients receiving amodiaquine failed to clear parasitemia and in four patients there was no response at all (RIII resistance); this difference was significant (P less than 0.01). In a village based study, there was initial clearing of parasitemia in each patient. However, recrudescent infection occurred in all five patients receiving amodiaquine (RI resistance). Five of six falciparum infections were sensitive to chloroquine, while parasitemia reappeared in one patient. In this village, resistance to amodiaquine was significantly more common than resistance to chloroquine (P less than 0.05). To our knowledge, this is the first report of amodiaquine being substantially worse than chloroquine in the treatment of Plasmodium falciparum infection.