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Most metastatic recurrences of triple negative breast cancer (TNBC) occur within five years of diagnosis, yet late relapses of TNBC (lrTNBC) do occur. Our objective was to develop a risk prediction model of lrTNBC using readily available clinicopathologic and sociodemographic features. We included patients diagnosed with stage I–III TNBC between 1998 and 2012 at ten academic cancer centers. lrTNBC was defined as relapse or mortality greater than 5 years from diagnosis. Features associated with lrTNBC were included in a multivariable logistic model using backward elimination with a p < 0.10 criterion, with a final multivariable model applied to training (70%) and independent validation (30%) cohorts. A total 2210 TNBC patients with at least five years follow-up and no relapse before 5 years were included. In final multivariable model, lrTNBC was significantly associated with higher stage at diagnosis (adjusted Odds Ratio [aOR] for stage III vs I, 10.9; 95% Confidence Interval [CI], 7.5–15.9; p < 0.0001) and BMI (aOR for obese vs normal weight, 1.4; 95% CI, 1.0–1.8; p = 0.03). Final model performance was consistent between training (70%) and validation (30%) cohorts. A risk prediction model incorporating stage, BMI, and age at diagnosis offers potential utility for identification of patients at risk of development of lrTNBC and warrants further investigation. • Triple negative breast cancer (TNBC) late relapse may occur >5 years post-diagnosis. • Stage and body mass index were associated late relapse in a multivariable model. • We developed a risk prediction model for patients at risk of late relapse. • This work supports further investigation factors associated with late relapse TNBC. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to develop a neural network to characterize the effect of aging on the ECG in healthy volunteers. Moreover, the impact of the various ECG features on aging was evaluated.Methods& Results: A total of 6228 healthy subjects without structural heart disease were included in this study. A neural network regression model was created to predict age of the subjects based on their ECG; 577 parameters derived from a 12‑lead ECG of each subject were used to develop and validate the neural network; A tenfold cross-validation was performed, using 118 subjects for validation each fold. Using SHapley Additive exPlanations values the impact of the individual features on the prediction of age was determined. Of 6228 subjects tested, 1808 (29%) were females and mean age was 34 years, range 18-75 years. Physiologic age was estimated as a continuous variable with an average error of 6.9 ± 5.6 years (R2 = 0.72 ± 0.04). The correlation was slightly stronger for men (R2 = 0.74) than for women (R2 = 0.66). The most important features on the prediction of physiologic age were T wave morphology indices in leads V4 and V5, and P wave amplitude in leads AVR and II.Conclusion: The application of machine learning to the ECG using a neural network regression model, allows accurate estimation of physiologic cardiac age. This technique could be used to pick up subtle age-related cardiac changes, but also estimate the reversing of these age-associated effects by administered treatments. [ABSTRACT FROM AUTHOR]

The Academic Pediatrics Association has taken multiple steps over the last 2 years to incorporate the lenses of anti-racism and social justice into our mission and work. In this commentary, we discuss the creation and work of the Anti-Racism and Diversity Task Force, which was charged by the Academic Pediatrics Association's Board of Directors with identifying strategies to promote anti-racism and advance the diversity, equity and inclusion agenda. [ABSTRACT FROM AUTHOR]

Interns play a key role in medical student education, often observing behaviors that others do not. Their role in assessment, however, is less clear. Despite accreditation standards pertaining to residents' assessment skills, they receive little guidance or formal training in it. In order to better prepare residents for their role in medical student assessment, we need to understand their current experience. We aimed to describe the first-year resident experience assessing students' performance and providing input to faculty for student clinical performance assessments and grades in the inpatient setting. Pediatric interns at Children's National Hospital (CN) from February 2018 to February 2019 were invited to participate in semistructured interviews about their experience assessing students. Constant comparative methodology was used to develop themes. Ten interviews were conducted, at which point thematic saturation was reached. We identified 4 major themes: 1) Interns feel as though they assess students in meaningful, unique ways. 2) Interns encounter multiple barriers and facilitators to assessing students. 3) Interns voice varying levels of comfort and motivation assessing different areas of student work. 4) Interns see their role in assessment limited to formative rather than summative assessment. These findings depict the intern experience with assessment of medical students at a large pediatric residency program and can help inform ways to develop and utilize the assessment skills of interns. [ABSTRACT FROM AUTHOR]

The need for data to study the relationship between fatigued healthcare professionals and performance outcomes is evident, however, it is unclear which methodology is most appropriate to provide these insights. To address this issue, we performed a systematic review of relevant articles by searching the MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL databases. The literature search identified 2960 unique references, of which 82 were identified eligible. The impact on performance was studied on clinical outcomes, medical simulation, neurocognitive performance, sleep quantification and subjective assessment. In general results on performance are conflicting; impairment, no effect, and improvement were found. This review outlines the various methods currently available for assessing fatigue-impaired performance. The contrasting outcomes can be attributed to three main factors: differences in the operationalisation of fatigue, incomplete control data, and the wide variety in the methods used. We recommend the implementation of a clinically applicable tool that can provide uniform data. Until these data become available, caution should be used when developing regulations that can have implications for physicians, education, manpower planning, and ‒ ultimately ‒ patient care. [ABSTRACT FROM AUTHOR]

Travel behavior is undergoing a period of significant change in the United States. In 2016, public transit ridership fell in almost all major U.S. metropolitan regions. While Americans are still heavily dependent on the personal automobile for mobility, technological and societal changes are transforming how mobility is accomplished. This paper reviews the convergence of five trends leading to fundamental changes in public transportation: (1) changing generational behavior toward suburbanization and automobility; (2) new attitudes toward information communications technology; (3) shifting attitudes toward sharing and mobility on demand; (4) innovative alternatives to work and non-work travel; and (5) an increasing number of on-demand flexible route transportation options. The paper concludes with recommendations and guiding principles for public agencies to consider in responding to these trends. [ABSTRACT FROM AUTHOR]

Summary Background There are limited data on the epidemiology of respiratory syncytial virus (RSV) illness in HIV-infected adults or the elderly in Africa. We studied the epidemiology of RSV-associated severe acute respiratory illness (SARI) hospitalizations in adults in South Africa from 2009 through 2013. Methods Individuals admitted to sentinel surveillance hospitals were investigated by respiratory tract swabs for RSV, using a multiplex real-time polymerase chain reaction assay. The incidence of RSV-associated SARI was calculated for the one site with population denominators. Results Of 7796 participants investigated, 329 (4%) tested positive for RSV. On multivariable analysis, HIV-infected individuals with RSV-associated SARI had greater odds of being in the age groups 18–44 and 45–64 years (odd ratios (OR) 26.3; 95% confidence interval (CI) 6.2–112.1 and OR 11.4; 95% CI 2.6–50.0) compared with those ≥65 years and being female (OR 2.7; 95% CI 1.4–5.4). The relative risk of hospitalization with RSV-associated SARI was 12–18 times higher in HIV infected individual compared to that of HIV-uninfected. Conclusion The incidence of RSV-associated SARI was higher in HIV-infected individuals and those aged 65 years and older. Further studies are warranted to describe the disease association of RSV detected in adults with SARI. [ABSTRACT FROM AUTHOR]

Several papers have reported that artificial surveillance cues, such as images of watching eyes, cause anonymous participants to behave as if they are actually under surveillance, thus increasing moral behavior. In a series of four experiments, we found no evidence that artificial surveillance cues impact reported moral judgment, self-rated possession of positive traits, or religiosity. Two small meta-analyses, both comprising six experiments investigating the effect of artificial surveillance cues on moral judgment, provided mixed conclusions. One meta-analysis produced a mean effect size not significantly different from zero and the other produced a mean effect size on the edge of significance. On the whole, artificial surveillance cues have inconsistent effects, or possibly no effect, on moral outcomes. [ABSTRACT FROM AUTHOR]

Objectives A decrease in Ki67 during neoadjuvant therapy predicts response to tamoxifen. Previous trials have shown a decreased Ki67 in breast tumors with as little as two or more weeks of preoperative tamoxifen. Shortening the preoperative treatment time in window of opportunity clinical trials makes these trials more attractive to women. POWERPIINC examined the effect of 7 days of preoperative tamoxifen on breast tumor proliferation and patient symptoms. Methods Women with untreated stage I/II, ER-positive, invasive breast cancer with no contraindications to tamoxifen were enrolled. Women received 20 mg of tamoxifen for 7 days up to the day of surgery. Proliferation was assessed by Ki67 immunohistochemistry before and after 7 days of tamoxifen. Symptoms and QOL were assessed by the FACT-ES and MENQOL. Adherence was measured by pill counts. Results 52 women were enrolled, and 44 were evaluable for Ki67. The median age was 58.5 years, and the median tumor diameter was 1.2 cm. Most women (73%) were post-menopausal. Most tumors were PR positive (88%) and HER2-negative (92%). The Ki67 decreased by a geometric mean of 40% (95% CI 29%–63%), and 73% (95% CI 57%–85%) of women had tumors with decreased proliferation (p = 0.0001 by paired t -test). Adherence to taking tamoxifen during the preoperative period was 100%. Women reported minimal bother from psychosocial or physical symptoms at baseline or on the day of surgery. Conclusion Seven days of tamoxifen showed a similar relative decrease in Ki67 as that reported for longer courses, was acceptable to women, and could be considered for window of opportunity studies. [ABSTRACT FROM AUTHOR]

Many studies have seemingly demonstrated that anonymous individuals who are shown artificial cues of being watched behave as if they are being watched by real people. However, several studies have failed to replicate this surveillance cue effect. In light of these mixed results, we conducted two meta-analyses investigating the effect of artificial observation cues on generosity. Overall, our meta-analyses found no evidence to support the claim that artificial surveillance cues increase generosity, either by increasing how generous individuals are, or by increasing the probability that individuals will show any generosity at all. Therefore, surveillance cue effects should be interpreted cautiously. [ABSTRACT FROM AUTHOR]

As the field of sport management has grown, so has a plethora of teaching efforts and classroom methodologies. One such effort has entailed introducing the topic of sport-for-development, the utilization of sport to yield positive outcomes in society, to students. While academics within the field of sport-for-development have made great strides in recent years attempting to determine the impact of practitioners utilizing sport for social change, the majority of these efforts have targeted key stakeholders such as participants, staff, volunteers, leadership members and donors. Considering the paucity of literature on the influence of sport-for-development education on sport management students, the purpose of this research was to examine the impact of a sport-for-development class with a student population that had never taken a course of that nature. The authors utilized reflective journaling to fully delve into the thoughts of the 19 study participants in an effort to investigate the perception of the class and the lessons taught. The findings revealed that a sport-for-development classroom setting enhanced knowledge of the field and increased desire to become involved in some capacity. In addition, there was a noticeable gain in awareness of marginalized populations and out-groups through the lens of sport. [ABSTRACT FROM AUTHOR]

Objectives: The household is important in influenza transmission due to intensity of contact. Previous studies reported secondary attack rates (SAR) of 4-10% for laboratory-confirmed influenza in the household. Few have been conducted in middle-income countries.Methods: We performed a case-ascertained household transmission study during May-October 2013. Index cases were patients with influenza-like-illness (cough and self-reported or measured fever (≥38 °C)) with onset in the last 3 days and no sick household contacts, at clinics in South Africa. Household contacts of index cases with laboratory-confirmed influenza were followed for 12 days.Results: Thirty index cases in 30 households and 107/110 (97%) eligible household contacts were enrolled. Assuming those not enrolled were influenza negative, 21/110 household contacts had laboratory-confirmed influenza (SAR 19%); the mean serial interval was 2.1 days (SD = 0.35, range 2-3 days). Most (62/82; 76%) household contacts who completed the risk factor questionnaire never avoided contact and 43/82 (52%) continued to share a bed with the index case after illness onset.Conclusion: SAR for laboratory-confirmed influenza in South Africa was higher than previously reported SARs. Household contacts did not report changing behaviors to prevent transmission. These results can be used to understand and predict influenza transmission in similar middle-income settings. [ABSTRACT FROM AUTHOR]

Purpose: Physician Quality Reporting System (PQRS) measure 10 assesses the percentage of radiology reports for possible stroke that document the presence or absence of hemorrhage, mass, and acute infarction. Although it is an important report quality metric, determining adherence to this measure is often laborious, limiting its practical use. The aim of this study was to assess adherence to PQRS measure 10 using an automated approach to facilitate continuous measurement. A secondary goal was to identify explanatory variables that may affect adherence. Methods: To determine measure adherence, a computerized algorithm was built, validated, and executed on 4,045 reports from CT and MRI examinations performed between January 2008 and October 2010 in patients with suspected stroke. Radiologist adherence was measured, accounting for differences in imaging modality, the presence of abnormalities, and trainee participation in report creation. Results: Of 4,045 reports, 58.1% met the PQRS requirement, documenting all 3 components. Although the presence of infarct increased the chance of PQRS adherence (P < .001), the existence of hemorrhage had the opposite effect (P < .001). Reports that had trainee participation were more likely to be in accordance with PQRS standards (62% vs 47%, P < .001). After controlling for pertinent variables, more than 2-fold variation in individual PQRS adherence (27%-68%) remained (P < .001). Conclusions: A considerable portion of eligible radiology reports do not include all components proposed by PQRS measure 10. An important contributor to performance gaps resides in individual physician variability. By automating measurement and monitoring of radiologist PQRS performance, informatics tools may enable targeted interventions to improve report quality. [ABSTRACT FROM AUTHOR]

We investigated a cluster of Burkholderia cepacia complex colonization in ventilated pediatric patients. Isolates from 15 patients, 2 sink drains, and several ventilator components were found to belong to a single B cenocepacia clone. Hospital tap water used during oral and tracheostomy care was identified as the most likely mechanism for transmission. [Copyright &y& Elsevier]

Summary: Metallic and magnetic nanostructures set electromagnetic boundary conditions which can lead to highly contorted fields in their immediate vicinity. While much attention has been devoted to enhancements in electric field strength, we argue that equally interesting phenomena arise from enhancements in magnetic and electric field gradients. Nonuniform fields near nanostructures can induce molecular transitions that are forbidden by electric dipole selection rules. We illustrate this claim with two examples. “Superhelical” electromagnetic fields are predicted to show enhanced asymmetry in their interaction with chiral molecules, far greater than that due to circularly polarized light. Such fields could be used to induce chiral photochemistry with large enantiomeric excess. Steeply varying DC magnetic fields are predicted to enhance the rate of intersystem crossing in molecular bi-radicals. Such fields could provide a route to new nanomagnetic catalysts and to magnetic control of chemical reactions. [Copyright &y& Elsevier]

Abstract: We argue that a central function of religious attendance in the contemporary United States is to support a high-fertility, monogamous mating strategy. Although religious attendance is correlated with many demographic, personality, moral, and behavioral variables, we propose that sexual and family variables are at the core of many of these relationships. Numerous researchers have assumed that religious socialization causes people to feel moral reactions and engage in behaviors promoted by religious groups. On our view, mating preferences are centrally involved in individual differences in attraction to religious groups. In a sample of 21,131 individuals who participated in the US General Social Survey, sexual behaviors were the relatively strongest predictors of religious attendance, even after controlling for age and gender. Effects of age and gender on religious attendance were weaker and substantially reduced when controlling for sexual and family patterns. A sample of 902 college students provided more detailed information on religious, moral, and sexual variables. Results suggest that (1) moral views about sexual behavior are more strongly linked to religious attendance than other moral issues, and (2) mating strategy is more powerful than standard personality variables in predicting religious attendance. These findings suggest that reproductive strategies are at the heart of variations in religious attendance. [Copyright &y& Elsevier]

Objective: To describe the national scope and magnitude of outpatient adverse drug events (ADEs) that lead to emergency department (ED) visits in children and adolescents. Study design: To conduct an active surveillance of patients 18 years of age or younger who came to EDs with ADEs from Jan 1, 2004, to Dec 31, 2005, through a nationally representative, stratified probability sample of 63 US hospitals with EDs. The main outcome measures were national estimates of the number, type, patient demographics, and clinical characteristics of ADEs. Results: Annually, an estimated 158,520 patients ≤18 years old (95% CI, 117,745-199,295; 2 per 1000 persons) were treated in EDs for ADEs. Almost half (49.4%) of these visits occurred in patients between 1 and 4 years of age. Unintentional overdoses were the most common type of ADE (44.9%), followed by allergic reactions (35%), and adverse effects (12.6%). Antimicrobial agents, analgesic medications, and respiratory medications accounted for almost half of ADEs (25.2%, 13.7%, and 10.6%, respectively). Fewer than 1 in 10 patients (9.5%) required hospitalization or extended observation. Conclusions: Interventions targeting unintentional overdoses of medications commonly given to preschool-aged children would likely have the highest impact in reducing ED visits from outpatient ADEs. [Copyright &y& Elsevier]

Background and Purpose: Accurate subtyping of ischemic stroke in the acute setting is a potentially important but very difficult task. Microvascular disease is a systemic disorder, and we hypothesized that impaired renal function, which is most commonly a result of microvascular disease, would correlate with the subtype of small-artery occlusion (SAO) in patients with acute ischemic stroke. Methods: This was a retrospective cohort study of consecutive patients with ischemic stroke. Clinical and laboratory data at admission were analyzed and compared with the final determination of stroke subtype. We determined whether serum creatinine level at admission was independently associated with final determination of the SAO stroke subtype. Results: There was no correlation between elevated baseline creatinine (≥1.5 mg/dL) and SAO (odds ratio = 0.38, 95% confidence interval 0.01-2.98, P = .38). The most helpful predictor of a final SAO subtype was lacunar syndrome on initial examination, but only in patients with diabetes (positive predictive value = 67%, 95% confidence interval 30%-93%). Conclusions: Laboratory evidence of impaired renal function does not aid the early identification of the SAO stroke subtype in patients with acute stroke. In addition, an initial lacunar syndrome only effectively identifies SAO among patients with diabetes, not the general stroke population. [Copyright &y& Elsevier]

Objectives: To determine whether infants of parents whose primary language is not English are less likely to receive recommended preventive care than infants of parents whose primary language is English. Study design: We conducted a retrospective cohort study of all 38,793 1-year-old Medicaid-enrolled infants born in Washington state between January 1, 1999 and September 30, 2000. The main exposure was self-reported primary language of parents. Using multivariate regression, we estimated the relative risk of receiving appropriate and timely receipt of preventive care visits in the first year as recommended by the American Academy of Pediatrics and Washington state Medicaid. Results: Fewer than 1 in 6 (15.4%) infants received all 6 recommended preventive care visits in their first year of life. Infants of parents whose primary language was not English were half as likely to receive all recommended preventive care visits compared with infants of parents whose primary language was English (adjusted relative risk = 0.53; 95% confidence interval = 0.49 to 0.58). This disparity was seen in white, Hispanic, and African-American infants, but not in Asian-American infants. Conclusions: Disparities based on primary language exist in receipt of recommended pediatric preventive care in white, Hispanic, and African-American infants enrolled in Medicaid. [Copyright &y& Elsevier]

Background: Hereditary angioedema (HAE) is a congenital disorder with recurrent attacks of localized swelling of submucosal tissue, subcutaneous tissue, or both caused by a deficiency of the plasma protein C1 inhibitor (C1 esterase inhibitor [C1INH]). Objective: We sought to evaluate the effects of recombinant human C1INH (rhC1INH) isolated from the milk of transgenic rabbits in 12 asymptomatic patients with HAE. Methods: rhC1INH was intravenously administered at doses of 6.25 to 100 U/kg on 2 occasions. Results: rhC1INH appeared safe and was well tolerated. The course of functional C1INH in plasma showed a full initial recovery (dose-normalized maximum concentration of about 0.02 U/mL/U/kg) and a dose-dependent clearance of rhC1INH. After infusion of rhC1INH at 100 U/kg, a clearance of approximately 13 mL/min, a half-life of approximately 3 hours, and a volume of distribution of approximately 3 L were observed. Infusion at this dose led to functional C1INH levels in plasma of at least twice the normal level for about 2 hours and greater than 0.4 U/mL for about 9 hours. rhC1INH displayed dose-dependent biologic activity by increasing the C4 level, which was about 2-fold at 12 hours after rhC1INH at 100 U/kg, and decreasing levels of cleaved C4. Conclusion: The observed safety profile and biologic activity of rhC1INH warrants further clinical studies to assess its efficacy in treating HAE attacks. [Copyright &y& Elsevier]

Background: The field of obstetrics and gynecology requires complex decision-making and skills because of unexpected high-risk situations. These skills are influenced by alertness, reaction time, and concentration. Night shifts result in sleep deprivation, which might impair these functions, although it is still unclear to what extent.Objective: This study aimed to investigate whether a night shift routinely impairs the obstetrics and gynecology consultants' and residents' fitness to perform and whether this reaches a critical limit compared with relevant frames of reference.Study Design: Residents (n=33) and consultants (n=46) in obstetrics and gynecology conducted multiple measurements (n=415) at precall, postcall, and noncall moments with the fitness to perform self-test. The self-test consists of an adaptive pursuit tracking task that is able to objectively measure alertness, reaction time, concentration, and hand-eye coordination and Visual Analog Scale tests to subjectively score alertness. The test is validated with a sociolegal reference of a 0.06% ethanol blood concentration (the peak level after 2 units of alcohol, the legal driving limit). This equals -1.37% on the objective score and -8.17 points on subjective alertness. Linear mixed models were used to analyze the difference within subjects over a night shift, integrating repeated measures over time.Results: The overnight objective difference between postcall and precall measurements was -0.62 (P<.05) for residents and 0.28 (P=NS) for consultants, both not exceeding the sociolegal reference as a group. Objective impairment exceeded the reference for 31% of the residents and 28% of the consultants. Subjective alertness decreased in residents (-18.26; P<.001) and consultants (-10.85; P<.001), both exceeding the reference. No residents had to continue work postcall versus 7.8% of the consultants. None of the consultants that had to continue work were in an objective critically impaired state.Conclusion: This study provides insight and awareness of individual performance after night shifts with clear frames of reference. The performance of residents is negatively and significantly affected by night shifts; therefore, a scheduled day off after a night shift is justified. Consultants showed no overall impairment; however, a quarter did exceed the alcohol limit reference after their night shift. If not logistically feasible to schedule a protected day off after a night shift, our group recommends safe shift scheduling, including options to transfer care after a demanding night shift to prevent working in a compromised state. [ABSTRACT FROM AUTHOR]

A novel 3D composite cathode structure, comprised of MnCr 2 O 4 spinel-based nanowires, is hereby presented. The reagentless self-seeded spinel-based nanowires are synthesized using an extremely simple, one-step, growth process that is comprised of 5% hydrogen in nitrogen at atmospheric pressure, under 1100 °C , without any external catalyst or reagent. This simple one-step process allows the density-controlled growth of highly crystalline spinel nanowires directly from common stainless steel mesh substrates, which acts both as reagents source and as a current collector. Electrochemical measurements show that this cathode exhibits high capacity (>230 mA h/g), stable cyclability (>370 cycles), high coulombic efficiency (>99%) and high rate performance (>2C). The novel 3D composite cathode structure exhibits several major advantages over conventional 2D cathodes, both in terms of the synthesis process, cost-effectiveness and in terms of electrochemical performance enhancement possibilities. Image 1 • A novel 3D composite cathode structure, comprised of MnCr 2 O 4 spinel-based nanowires, is hereby presented. • The self-seeded spinel-based nanowires are grown by an extremely simple, one-step, growth process, without any external catalyst or reagent. • Cathodes exhibit high capacity (> 230 mAh/g), high cyclability (> 360 cycles), high coulombic efficiency (> 99%) and high rate performance (> 2C). • The 3D-cathode exhibits several major advantages over conventional 2D cathodes in terms of the synthesis, cost and electrochemical performance. [ABSTRACT FROM AUTHOR]

Objective: The effectiveness of Haemophilus influenzae type b (Hib) vaccine in preventing severe pneumonia in Asian children has been questioned, and many large Asian countries yet to introduce Hib conjugate vaccine in immunization programs. The primary objective of this study was to assess Hib conjugate vaccine effectiveness (VE) on radiologically-confirmed pneumonia in children born after introduction of Hib conjugate vaccine in Pakistan. Study design: A matched case-control study enrolled cases of radiologically-confirmed pneumonia in several hospitals serving low-income populations during 2009-2011. Cases were matched by age and season with 3 hospital and 5 neighborhood controls. Pneumonia was diagnosed using standardized World Health Organization criteria for chest radiograph interpretation. Matched OR were estimated for VE. Results: A total of 1027 children with radiologically-confirmed pneumonia were enrolled; 975 cases, 2925 hospital controls, and 4875 neighborhood controls were analyzed. The coverage for 3 doses of diphtheria-tetanus-pertussis-hepatitis B-Hib conjugate vaccine was 13.7%, 18%, and 22.7% in cases, hospital controls and neighborhood controls, respectively. Estimated Hib VE for radiologically-confirmed pneumonia was 62% with 3 doses of vaccine using hospital controls and 70% using neighborhood controls. Conclusions: Hib conjugate vaccine prevented a significant fraction of radiologically-confirmed pneumonia in children in Pakistan. Maximizing impact on child survival needs improved immunization coverage. [Copyright &y& Elsevier]

Objectives: Some Asian countries have been reluctant to adopt Haemophilus influenzae type b (Hib) conjugate vaccination because of uncertainty over disease burden. We assessed the impact of introduction of Hib conjugate vaccine into the Expanded Program on Immunization in Bangladesh on purulent and laboratory-confirmed H influenzae meningitis. Study design: Within a well-defined catchment area around 2 surveillance hospitals in Dhaka, Bangladesh, we compared the incidence of Hib meningitis confirmed by culture, latex agglutination, and polymerase chain reaction assay among infants 1 year before and 1 year after introduction of Hib conjugate vaccine. We adjusted the incidence rate for the proportion of children who sought care at the surveillance hospitals. Results: Among infants, the incidence of confirmed Hib meningitis decreased from 92-16 cases per 100 000 within 1 year of vaccine introduction (vaccine preventable incidence = 76; 95% CI 18, 135 per 100 000). The incidence of purulent meningitis decreased from 1659-1159 per 100 000 (vaccine preventable incidence = 500; 95% CI: 203, 799 per 100 000). During the same time period, there was no significant difference in the incidence of meningitis due to Streptococcus pneumoniae. Conclusions: Introduction of conjugate Hib conjugate vaccine into Bangladesh Expanded Program on Immunization markedly reduced the burden of Hib and purulent meningitis. [Copyright &y& Elsevier]

Objective: Haemophilus influenzae type b (Hib) conjugate vaccine was included into the national vaccination schedule of Ukraine in 2006. The objective of this study was to demonstrate the effectiveness of Hib conjugate vaccine against radiologically-confirmed hospitalized pneumonia in children. Study design: Children <2 years old with radiologically confirmed pneumonia admitted to 11 participating hospitals in Kiev and Dnepropetrovsk between April 2007 and June 2009 were included in a case-control evaluation. Four controls were matched to each case by date of birth (within 14 days) and outpatient clinic. We estimated ORs for vaccination and vaccine effectiveness ((1 − OR)*100%) using conditional logistic regression, adjusting for comorbid conditions and contraindications for vaccination. Results: We enrolled 188 case-children and 735 controls. Median age was 16 months (range 4-24 months). Fifty-one percent of cases and 67% of controls received ≥1 doses of Hib conjugate vaccine; 26% of cases and 37% of controls received ≥3 doses. The effectiveness of ≥1 dose Hib conjugate vaccine was estimated at 45% (95% CI 18%-63%). Conclusions: Our study showed that Hib infections are important causes of hospitalized radiologically confirmed pneumonia in young children in Ukraine. [Copyright &y& Elsevier]

Objective: In 2005, 4 Clostridium sordellii-associated toxic shock fatalities were reported in young Californian women after medical abortions. The true incidence of this rare disease is unknown, and a population-based study has never been performed. Additional clostridia-associated deaths were sought to describe associated clinical characteristics. Study Design: Population-based death certificate review and a clinical case definition for clostridial-associated toxic shock identified women with likelihood of dying from a Clostridium infection. Formalin-fixed autopsy tissues underwent immunohistochemical and polymerase chain reaction assays. Results: Thirty-eight women were suspected of having C sordellii-associated death. Five tested positive for Clostridium species: 3 for Clostridium perfringens, 1 for C sordellii, and 1 for both. Deaths occurred after the medical procedures for cervical dysplasia (n = 2), surgical abortion (n = 1), stillborn delivery (n = 1), and term live birth (n = 1). None had a medical abortion. Conclusion: C sordellii and C perfringens are associated with undiagnosed catastrophic infectious gynecologic illnesses among women of childbearing age. [Copyright &y& Elsevier]

A letter to the editor is presented in response to an article on the treatment of agitation and psychosis in dementia that was published in one of the previous issues.

Study objective: We describe emergency department (ED) visits in which patients had blood cultured and examine changes in blood culture use. Methods: Data from the 2001 to 2004 National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to US hospital EDs, were analyzed. About 400 EDs reported data for approximately 37,000 visits each year. Trends in blood culture use were examined among persons 3 months of age and older. Visits by admitted/transferred patients were compared to those released. Results: About 3.1 million blood cultures were ordered annually in US EDs; blood cultures were ordered at 2.8% of all visits. From 2001 through 2004, the proportion of visits where a blood culture was ordered increased by 33%, particularly in adults. The proportion of visits with a pneumonia diagnosis where a blood culture was ordered rose by 23% during the study period; these visits accounted for 22% of the increase in blood culture use among admitted patients. Almost half of blood cultures were ordered at visits in which the patient was released from the ED. For visits by released patients 3 years of age and older who had blood cultured, 43% had neither fever nor antibiotic prescriptions. Conclusion: There is an increasing national trend in the use of blood cultures at adult patient ED visits; a large proportion of these cultures were for released patients without apparent indicators for bacteremia, such as fever or antibiotic prescriptions. Factors and impact associated with this dynamically changing practice need further evaluation. [Copyright &y& Elsevier]

Highlights: [•] We explore the uptake of public bikesharing systems in Europe and North America. [•] We apply diffusion theory to understand the spread of system adoptions. [•] Europe’s system uptake is more advanced and new systems continue to emerge. [•] Uptake of systems in North America is gaining momentum. [•] Notable systems act as sources of learning, inspiring the creation of new systems. [Copyright &y& Elsevier]