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As dozens of new National Immunization Technical Advisory Groups (NITAGs) were established worldwide in the past decade, and as existing NITAGs continued to play an important role in vaccine policy, global NITAG partners recognized a need for a standardized assessment tool to evaluate and strengthen their functions. This article describes the development of the NITAG Maturity Assessment Tool (NMAT), a stepwise evaluation tool that assesses NITAGs on seven key indicators of structure and process. A draft tool was developed through an iterative, consensus-based process with an expert working group before it was piloted with an economically and geographically diverse convenience sample of NITAGs. The final NMAT is a flexible tool that can be used by in-country or external evaluators to understand NITAG maturity, identify priorities for optimization, and measure the impact of strengthening efforts., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Knowledge of the composition of proteins that interact with plasma DNA will provide a better understanding of the homeostasis of circulating nucleic acids and the various modes of interaction with target cells, which may be useful in the development of gene targeted therapy approaches. The goal of the present study is to shed light on the composition and architecture of histone-containing nucleoprotein complexes (NPCs) from the blood plasma of healthy females (HFs) and breast cancer patients (BCPs) and to explore the relationship of proteins with crucial steps of tumor progression: epithelial-mesenchymal transition (EMT), cell proliferation, invasion, cell migration, stimulation of angiogenesis, and immune response. MALDI-TOF mass spectrometric analysis of NPCs isolated from blood samples using affine chromatography was performed. Bioinformatics analysis showed that the shares of DNA-binding proteins in the compositions of NPCs in normal and cancer patients are comparable and amount to 40% and 33%, respectively; in total, we identified 38 types of DNA-binding motifs. Functional enrichment analysis using FunRich 3.13 showed that, in BCP blood, the share of DNA-binding proteins involved in nucleic acid metabolism increased, while the proportion of proteins involved in intercellular communication and signal transduction decreased. The representation of NPC passenger proteins in breast cancer also changes: the proportion of proteins involved in transport increases and the share of proteins involved in energy biological pathways decreases. Moreover, in the HF blood, proteins involved in the processes of apoptosis were more represented in the composition of NPCs and in the BCP blood-in the processes of active secretion. For the first time, bioinformatics approaches were used to visualize the architecture of circulating NPCs in the blood and to show that breast cancer has an increased representation of passenger proteins involved in EMT, cell proliferation, invasion, cell migration, and immune response. Using breast cancer protein data from the Human Protein Atlas (HPA) and DEPC, we found that 86% of NPC proteins in the blood of BCPs were not previously annotated in these databases. The obtained data may indirectly indicate directed protein sorting in NPCs, which, along with extracellular vesicles, can not only be diagnostically significant molecules for liquid biopsy, but can also carry out the directed transfer of genetic material from donor cells to recipient cells.

National Immunization Technical Advisory Groups (NITAGs) are independent bodies that help improve national immunization programmes in decision making on immunization policy. The new NITAG Maturity Assessment Tool (NMAT) provided an opportunity to conduct a region-wide assessment to improve NITAG capacity and foster institutional growth. We share experience of the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) in using NMAT and the use of findings to develop improvement plans. NITAG chairs and secretariats from 22 EMR countries attended a virtual NMAT training in 2023. They self-assessed their NITAGs using the tool and developed improvement plans. An algorithm used the data to determine maturity levels for seven indicators. We consolidated results for the region by income groups. Of 22 countries (or NITAGs), 20 (91%) submitted NITAG assessment findings and 19 an improvement plan. The proportion of criteria met per indicator varied from 36% for independence and non-bias to 74% for establishment and composition. Maturity level varied by indicator. Of 20 NITAGs, less than half had an intermediate or higher-level maturity for the indicators of independence and non-bias 1 (5%), operations 3 (15%), making recommendations 4 (20%), stakeholder recognition 6 (30%), and resources and secretariat support 7 (35%). Meanwhile 11 (55%) NITAGs had an intermediate or higher maturity level for the indicators of establishment and composition and for integration into policy making process. Participants described NMAT as a concise, useful, user-friendly tool. NMAT is a practical tool that can be used by NITAGs to provide insights and strategic direction for individual countries and regionally. Prevention and management of conflict of interest is the domain that requires the most improvement in EMR. Planned activities should be implemented, monitored and a follow up assessment conducted in 2025., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Relevance: Insulinoma is the most common hormonally active neuroendocrine tumor (NET) of the pancreas. In recent years, there has been a trend towards an increase in the incidence of NET especially insulinoma., Aim: Summarizing and analyzing current data on various approaches to the treatment of insulinoma. Our review includes a comprehensive assessment of the advantages and disadvantages of currently available insulinoma treatment methods in comparison with past experience, as well as a review of promising methods that are not currently widely used., Materials and Methods: Analysis of literature from such databases as scientific electronic library elibrary.ru, Pubmed, Google Scholar, MedLine, Scopus and Web of Science., Results: The most common treatment for insulinoma is surgery. For patients with high operative risk, alternative methods such as alcohol ablation, radiofrequency ablation, and tumor embolization may be used. Medications include the use of somatostatin analogues, diazoxide. The literature describes the potential benefit of the use of beta-blockers, phenytoin, glucagon, however, in clinical trials, these drugs have not demonstrated a significant effect. For the treatment of malignant and metastatically advanced insulinoma, targeted therapy (primarily Everolimus), chemotherapy, as well as embolization (including chemoembolization, radioembolization), radiofrequency ablation (RFA), microwave ablation and cryoablation, ultrasound ablation (HIFU), laser ablation, brachytherapy, irreversible electroporation are used., Conclusion: The study of new drugs is an important task for scientists, among medications the most promising are new generations of somatostatin analogues, targeted drugs and chemotherapy drugs. The rare frequency of insulinoma makes it difficult to conduct randomized controlled trials and prospective studies. That is why physicians and scientists need to maintain close contacts with each other and take into account the experience of treating each patient with such disease, which will help develop effective treatment algorithms in the future.

Circulating DNA (cirDNA) is a promising tool in translational medicine. However, studies of cirDNA have neglected its association with proteins, despite ample evidence that this interaction may affect the fate of DNA in the bloodstream and its molecular functions. The goal of the current study is to shed light on the differences between the proteomic cargos of histone-containing nucleoprotein complexes (NPCs) from healthy female (HFs) and breast cancer patients (BCPs), and to reveal the proteins involved in carcinogenesis. NPCs were isolated from the blood samples of HFs and BCPs using affinity chromatography. A total of 177 and 169 proteins were identified in NPCs from HFs and BCPs using MALDI-TOF mass spectrometry. A bioinformatics analysis revealed that catalytically active proteins, as well as proteins that bind nucleic acids and regulate the activity of receptors, are the most represented among the unique proteins of blood NPCs from HFs and BCPs. In addition, the proportion of proteins participating in ion channels and proteins binding proteins increases in the NPCs from BCP blood. However, the involvement in transport and signal transduction was greater in BCP NPCs compared to those from HFs. Gene ontology term (GO) analysis revealed that the NPC protein cargo from HF blood was enriched with proteins involved in the negative regulation of cell proliferation, and in BCP blood, proteins involved in EMT, invasion, and cell migration were observed. The combination of SPG7, ADRB1, SMCO4, PHF1, and PSMG1 NPC proteins differentiates BCPs from HFs with a sensitivity of 100% and a specificity of 80%. The obtained results indirectly indicate that, in tandem with proteins, blood cirDNA is an important part of intercellular communication, playing a regulatory and integrating role in the physiology of the body.

Cell-free DNA (cfDNA) circulates in the bloodstream packed in membrane-coated structures (such as apoptotic bodies) or bound to proteins. To identify proteins involved in the formation of deoxyribonucleoprotein complexes circulating in the blood, native complexes were isolated using affinity chromatography with immobilized polyclonal anti-histone antibodies from plasma of healthy females (HFs) and breast cancer patients (BCPs). It was found that the nucleoprotein complexes (NPCs) from HF plasma samples contained shorter DNA fragments (~180 bp) than BCP NPCs. However, the share of DNA in the NPCs from cfDNA in blood plasma in HFs and BCPs did not differ significantly, as well as the share of NPC protein from blood plasma total protein. Proteins were separated by SDS-PAGE and identified by MALDI-TOF mass spectrometry. Bioinformatic analysis showed that in the presence of a malignant tumor, the proportion of proteins involved in ion channels, protein binding, transport, and signal transduction increased in the composition of blood-circulating NPCs. Moreover, 58 (35%) proteins are differentially expressed in a number of malignant neoplasms in the NPCs of BCPs. Identified NPC proteins from BCP blood can be recommended for further testing as breast cancer diagnostic/prognostic biomarkers or as being useful in developing gene-targeted therapy approaches.

Ovarian cancer (OC) is one of the most common and fatal types of gynecological cancer. In the early phase of OC detection, the current treatment and diagnostic methods are not efficient and sensitive enough. Therefore, it is crucial to explore the mechanisms of OC metastasis and discover valuable factors for early diagnosis of female cancers and novel therapeutic strategies for metastasis. Exosomes are known to be involved in the development, migration, and invasion of cancer cells, and their cargo could be useful for the non-invasive biopsy development. CD151- and Tspan8-positive exosomes are known to support the degradation of the extracellular matrix, and are involved in stroma remodeling, angiogenesis and cell motility, as well as the association of miR-24 and miR-101 with these processes. The objective of this study was to explore the relationship of these components of exosomal cargo, in patients with OC, to clarify the clinical significance of these markers in liquid biopsies. The levels of tetraspanins Tspan8+ and CD151+ exosomes were significantly higher in plasma exosomes of OC patients compared with healthy females (HFs). The relative levels of miR-24 and miR-101 in plasma exosomes of HFs were significantly higher than in plasma exosomes of OC patients, while the levels of these microRNAs in exosomes from plasma and ascites of ill females showed no difference. Our study revealed a strong direct correlation between the change in the ascites exosomes CD151+Tspan8+ subpopulation level and the expression levels of the ascites (R = 0.81, p < 0.05) and plasma exosomal miR-24 (R = 0.74, p < 0.05) in OC patients, which confirms the assumption that exosomal cargo act synergistically to increase cellular motility, affecting cellular processes and signaling. Bioinformatics analysis confirmed the involvement of CD151 and Tspan8 tetraspanins and genes controlled by miR-24-3p and miR-101 in signaling pathways, which are crucial for carcinogenesis, demonstrating that these tetraspanins and microRNAs are potential biomarkers for OC screening, and predictors of poor clinicopathological behavior in tumors.

In women, breast cancer (BC) is the most commonly diagnosed cancer (24.5%) and the leading cause of cancer death (15.5%). Understanding how this heterogeneous disease develops and the confirm mechanisms behind tumor progression is of utmost importance. Exosomes are long-range message vesicles that mediate communication between cells in physiological conditions but also in pathology, such as breast cancer. In recent years, there has been an exponential rise in the scientific studies reporting the change in morphology and cargo of tumor-derived exosomes. Due to the transfer of biologically active molecules, such as RNA (microRNA, long non-coding RNA, mRNA, etc.) and proteins (transcription factors, enzymes, etc.) into recipient cells, these lipid bilayer 30-150 nm vesicles activate numerous signaling pathways that promote tumor development. In this review, we attempt to shed light on exosomes' involvement in breast cancer pathogenesis (including epithelial-to-mesenchymal transition (EMT), tumor cell proliferation and motility, metastatic processes, angiogenesis stimulation, and immune system repression). Moreover, the potential use of exosomes as promising diagnostic biomarkers for liquid biopsy of breast cancer is also discussed.

Lay Abstract: Peer interaction can be challenging in autism spectrum disorder, but naturalistic peer-observation scales for preschoolers are limited. This study examined the newly developed Autism Peer Interaction Observation Scale, with 17 subcategories, which evaluate naturalistic peer interaction processes in preschoolers with autism spectrum disorder and typical development. We tested the Autism Peer Interaction Observation Scale to (a) characterize peer interactions of preschoolers with autism spectrum disorder who were cognitively able versus typical age-mates, (b) explore each group's hierarchical pattern of peer interaction behaviors, and (c) identify Autism Peer Interaction Observation Scale's links with standard reports for assessing social-communication functioning (Vineland Behavior Scales, 2nd ed.), social impairment (Social Responsiveness Scale, 2nd ed.), autism severity (Autism Diagnostic Observation Schedule, 2nd ed.), and intelligence quotient (Mullen) in the cognitively able preschoolers with autism spectrum disorder group. Participants comprised 85 preschoolers (50 cognitively able preschoolers with autism spectrum disorder, intelligence quotient > 75; 35 typical). Groups were matched according to age, intelligence quotient, and maternal education. Significant group differences emerged on all Autism Peer Interaction Observation Scale categories, with the typical group showing better social-communication functioning as compared to the cognitively able preschoolers with autism spectrum disorder group. Also, in cognitively able preschoolers with autism spectrum disorder that observed as demonstrating more typical peer relations on the Autism Peer Interaction Observation Scale showed better adaptive and socialization skills on the Vineland (Vineland Behavior Scales, 2nd ed.) and fewer social atypicalities on the Social Responsiveness Scale, 2nd ed. Higher intelligence quotient scores were linked with better observed social-communication functioning (on Autism Peer Interaction Observation Scale). Few Autism Peer Interaction Observation Scale social-communicative categories significantly correlated with the Autism Diagnostic Observation Schedule, 2nd ed. Findings highlight the Autism Peer Interaction Observation Scale as differentiating the two preschooler groups and providing additional knowledge about socially communicative peer interaction in natural settings. This new tool can help personalize social-communication programs and evaluations of early intervention outcomes, thereby leading to a fuller picture of these young children's functioning.

A National Immunization Technical Advisory Group (NITAG) is a multi-disciplinary body of national experts that provides evidence-based recommendations to policy-makers, assisting them in making sound immunization policy and programme decisions. The World Health Organization (WHO) Regional Office for Europe is working to strengthen the capacity of newly-established NITAGs and has targeted efforts on low- and middle-income countries. The Regional Office, in collaboration with WHO Headquarters and USA Centers for Disease Control and Prevention (CDC), developed a new training strategy and held training workshops to improve NITAGs' functioning and ability to make evidence-based recommendations. Feedback from countries that participated in trainings indicated that the updated training materials and interactive approach with follow-up technical support enabled them to align their NITAG charters and processes with WHO recommendations. To ensure continued progress, global and regional partners such as WHO and CDC should continue providing technical support to recently established NITAGs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

School-based vaccination (SBV) and checking students' vaccination records at school have the potential to optimize vaccination coverage among school-aged children. The primary aim of this paper is to describe adoption of SBV by countries from 2008 to 2017, including target age groups and vaccines delivered in 2017, as reported annually through the World Health Organization (WHO)-United Nations Children's fund (UNICEF) Joint Reporting Form (JRF). Expanding upon previous analyses, country-specific rates of primary school enrollment and home-based record (HBR) ownership were linked to the WHO-UNICEF JRF data, to identify countries with high potential to implement vaccination record checks at school. The proportion of countries reporting delivery of at least one routinely recommended vaccine dose in school settings increased from 95 (of 163 reporting; 58%) in 2008 to 108 (of 181 reporting; 60%) in 2017. The 13 additional countries that reported using SBV in 2017 were among 31 countries for which SBV data from the JRF were unavailable in 2017. The most common antigens delivered through SBV in 2017 were tetanus (94 countries), diphtheria (89 countries), and human papillomavirus (52 countries). Among 93 countries with data available for net primary school enrollment and HBR ownership, 52 (56%) countries had both ≥80% net primary school enrollment and ≥80% of children aged 12-23 months ever owning an HBR; 33 (63%) of these used SBV. If not already doing so, these 33 countries represent an opportunity to introduce routine checking of vaccination status at entry to, or during primary school. With the growing number of new vaccines and booster doses of childhood vaccines targeting school-age children, implementation of SBV and checking of student vaccination records at school may help improve vaccination coverage; however, additional data are needed to assess global prevalence of checking vaccination status at school and to identify factors facilitating optimal implementation of this strategy., (Published by Elsevier Ltd.)

Background: In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP) that set a target to eliminate measles and rubella in five of the six World Health Organization (WHO) regions by 2020. Significant progress has been made toward achieving this goal through intensive efforts by countries and Measles & Rubella Initiative (M&RI) partners. Accelerating progress will require evidence-based approaches to improve implementation of the core strategies in the Global Measles and Rubella Strategic Plan. The M&RI Research and Innovation Working Group (R&IWG) conducted a web-based survey as part of a process to identify measles and rubella research priorities. Survey findings were used to inform discussions during a meeting of experts convened by the M&RI at the Pan American Health Organization in November 2016., Methods: The cross-sectional web-based survey of scientific and programmatic experts included questions in four main topic areas: (1) epidemiology and economics (epidemiology); (2) new tools for surveillance, vaccine delivery, and laboratory testing (new tools); (3) immunization strategies and outbreak response (strategies); and (4) vaccine demand and communications (demand). Analyses were stratified by the six WHO regions and by global, regional, or national/sub-national level of respondents., Results: The six highest priority research questions selected by survey respondents from the four topic areas were the following: (1) What are the causes of outbreaks in settings with high reported vaccination coverage? (epidemiology); (2) Can affordable diagnostic tests be developed to confirm measles and rubella cases rapidly and accurately at the point of care? (new tools); (3) What are effective strategies for increasing coverage of the routine first dose of measles vaccine administered at 9 or 12 months? (strategies); (4) What are effective strategies for increasing coverage of the second dose given after the first year of life? (strategies); (5) How can communities best be engaged in planning, implementing and monitoring health services including vaccinations? (demand); (6) What capacity building is needed for health workers to be able to identify and work more effectively with community leaders? (demand). Research priorities varied by region and by global/regional/national levels for all topic areas., Conclusions: Research and innovation will be critical to make further progress toward achieving the GVAP measles and rubella elimination goals. The results of this survey can be used to inform decision-making for investments in research activities at the global, regional, and national levels., (Copyright © 2019. Published by Elsevier Ltd.)

The Measles & Rubella Initiative (M&RI) identified five key strategies to achieve measles and rubella elimination, including research and innovation to support cost-effective operations and improve vaccination and diagnostic tools. In 2016, the M&RI Research and Innovation Working Group (R&IWG) completed a research prioritization process to identify key research questions and update the global research agenda. The R&IWG reviewed meeting reports and strategic planning documents and solicited programmatic inputs from vaccination experts at the program operational level through a web survey, to identify previous research priorities and new research questions. The R&IWG then convened a meeting of experts to prioritize the identified research questions in four strategic areas: (1) epidemiology and economics, (2) surveillance and laboratory, (3) immunization strategies, and (4) demand creation and communications. The experts identified 19 priority research questions in the four strategic areas to address key areas of work necessary to further progress toward elimination. Future commitments from partners will be needed to develop a platform for improved coordination with adequate and predictable resources for research implementation and innovation to address these identified priorities., (Copyright © 2019. Published by Elsevier Ltd.)

National Immunization Technical Advisory Groups (NITAGs) are multidisciplinary national experts who provide independent, evidence-informed vaccine policy recommendations to national health authorities. An essential NITAG function is to ensure that these decisions are grounded in the best available evidence generated through a systematic, transparent process. However, in many low- and middle-income countries (LMICs), experience with this decision making method is limited. The Task Force for Global Health manages the Partnership for Influenza Vaccine Introduction (PIVI) program in collaboration with the Centers for Disease Control and Prevention, Ministries of Health, corporate partners and others. During 2017, PIVI worked with its country partners and the World Health Organization regional and local offices to assess NITAG strengthening needs and to provide technical assistance in 7 LMIC countries (Laos Peoples Democratic Republic, Mongolia, Vietnam, Armenia, Côte d'Ivoire; Moldova and the Republic of Georgia). Our workshops supported general NITAG capacity building and the evidence-based review process using vaccines of interest to the country. For NITAGs reviewing evidence on seasonal influenza, we developed an influenza resource package to support their review and provide country-relevant information in an easy to use format. Of the seven NITAGs trained, six have applied some of the concepts learnt: revision or development of formal transparent, systematic procedures for their operations; preparation of recommendations on seasonal influenza vaccination using quality-assessed data from systematic searches and local data; and have applied the principles learned for making other new vaccine recommendations. Our experience confirms that LMIC NITAGs are considerably under-resourced without adequate technical support or access to global peer-reviewed literature. Ongoing support from NITAG partners must be secured and creative approaches might be needed to help countries achieve the GVAP 2020 target and support development of sustainable vaccine policies and programs., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: To examine the association between routine blood tests during pregnancy and future risk of cardiovascular morbidity., Methods: The present case-control study was conducted among women who delivered at a teaching hospital in Israel between January 1, 2000, and December 31, 2012. The cohort comprised women who were subsequently hospitalized owing to cardiovascular morbidity (case group) and age-matched non-hospitalized women (control group). Blood levels of creatinine, glucose, potassium, urea, and uric acid were measured during pregnancy. Only women with at least one test result available for all five measurements were included. The relationship between upper quartile blood test values and cardiovascular hospitalization was assessed., Results: The study included 4115 women (212 in the case group and 3903 in the control group). Three measures were associated with a future risk of cardiovascular morbidity requiring hospitalization: creatinine (hazard ratio [HR] 1.86, 95% confidence interval [CI] 1.37-2.53; P<0.001); potassium (HR 1.48, 95% CI 1.09-2.01; P=0.013), and urea (HR 1.60, 95% CI 1.17-2.19; P=0.003). The number of blood test results in the upper quartile also increased such risk. The HRs for two tests and at least three tests were 1.65 (95% CI 1.06-2.56; P=0.026) and 3.32 (95% CI 2.19-5.04; P<0.001), respectively., Conclusions: Future cardiovascular morbidity was predicted by routine blood tests during pregnancy., (© 2018 International Federation of Gynecology and Obstetrics.)

All six World Health Organization (WHO) regions have now set goals for measles elimination by or before 2020. To prioritize measles elimination efforts and use available resources efficiently, there is a need to identify at-risk areas that are offtrack from meeting performance targets and require strengthening of programmatic efforts. This article describes the development of a WHO measles programmatic risk assessment tool to be used for monitoring, guiding, and sustaining measles elimination efforts at the subnational level. We outline the tool development process; the tool specifications and requirements for data inputs; the framework of risk categories, indicators, and scoring; and the risk category assignment. Overall risk was assessed as a function of indicator scores that fall into four main categories: population immunity, surveillance quality, program performance, and threat assessment. On the basis of the overall score, the tool assigns each district a risk of either low, medium, high, or very high. The cut-off criteria for the risk assignment categories were based on the distribution of scores from all possible combinations of individual indicator cutoffs. The results may be used for advocacy to communicate risk to policymakers, mobilize resources for corrective actions, manage population immunity, and prioritize programmatic activities. Ongoing evaluation of indicators will be needed to evaluate programmatic performance and plan risk mitigation activities effectively. The availability of a comprehensive tool that can identify at-risk districts will enhance efforts to prioritize resources and implement strategies for achieving the Global Vaccine Action Plan goals for measles elimination., (© 2015 Society for Risk Analysis.)

All countries in the World Health Organization European Region committed to eliminating endemic transmission of measles and rubella by 2015, and disease incidence has decreased dramatically. However, there was little progress between 2012 and 2013, and the goal will likely not be achieved on time. Genuine political commitment, increased technical capacity, and greater public awareness are urgently needed, especially in Western Europe., (Project HOPE—The People-to-People Health Foundation, Inc.)

The long-standing and widespread use of vaccines against measles has resulted in a dramatic decline in cases and measles mortality worldwide compared with the pre-vaccination era.All regions of the World Health Organization (WHO) have measles elimination goals and the WHO regions of the Americas, Europe and Western Pacific also have rubella elimination goals. This article aims to report on progress toward elimination of measles and rubella in the WHO European Region based on the latest available data. We also discuss current challenges and actions needed to reach this goal in the Region. Despite substantial progress made towards controlling measles and rubella, the countries of the WHO European Region continue to face challenges in interrupting endemic transmission of these diseases. Widespread outbreaks and endemic transmission of measles and rubella persisted in some countries of the Region in 2014 and have continued in 2015. Interrupting endemic transmission in each and every country is necessary to declare elimination for the entire Region. High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. In the absence of sustained political commitment and implementation of the required strategies by all countries, the goal of eliminating these diseases in the WHO European Region is at stake.

Context: Immunizations are the most effective way to reduce incidence of vaccine-preventable diseases. Immunization information systems (IISs) are confidential, population-based, computerized databases that record all vaccination doses administered by participating providers to people residing within a given geopolitical area. They facilitate consolidation of vaccination histories for use by health care providers in determining appropriate client vaccinations. Immunization information systems also provide aggregate data on immunizations for use in monitoring coverage and program operations and to guide public health action., Evidence Acquisition: Methods for conducting systematic reviews for the Guide to Community Preventive Services were used to assess the effectiveness of IISs. Reviewed evidence examined changes in vaccination rates in client populations or described expanded IIS capabilities related to improving vaccinations. The literature search identified 108 published articles and 132 conference abstracts describing or evaluating the use of IISs in different assessment categories., Evidence Synthesis: Studies described or evaluated IIS capabilities to (1) create or support effective interventions to increase vaccination rates, such as client reminder and recall, provider assessment and feedback, and provider reminders; (2) determine client vaccination status to inform decisions by clinicians, health care systems, and schools; (3) guide public health responses to outbreaks of vaccine-preventable disease; (4) inform assessments of vaccination coverage, missed vaccination opportunities, invalid dose administration, and disparities; and (5) facilitate vaccine management and accountability., Conclusions: Findings from 240 articles and abstracts demonstrate IIS capabilities and actions in increasing vaccination rates with the goal of reducing vaccine-preventable disease.

Background: Vaccine-preventable diseases (VPD) are still a major cause of morbidity and mortality worldwide. In high and middle-income settings, immunization coverage is relatively high. However, in many countries coverage rates of routinely recommended vaccines are still below the targets established by international and national advisory committees. Progress in the field of communication technology might provide useful tools to enhance immunization strategies., Objective: To systematically collect and summarize the available evidence on the effectiveness of interventions that apply new media to promote vaccination uptake and increase vaccination coverage., Design: We conducted a systematic literature review. Studies published from January 1999 to September 2013 were identified by searching electronic resources (Pubmed, Embase), manual searches of references and expert consultation. Study setting We focused on interventions that targeted recommended vaccinations for children, adolescents and adults and: (1) aimed at increasing community demand for immunizations, or (2) were provider-based interventions. We limited the study setting to countries that are members of the Organisation for Economic Co-operation and Development (OECD)., Main Outcome Measures: The primary outcome was a measure of vaccination (vaccine uptake or vaccine coverage). Considered secondary outcomes included willingness to receive immunization, attitudes and perceptions toward vaccination, and perceived helpfulness of the intervention., Results: Nineteen studies were included in the systematic review. The majority of the studies were conducted in the US (74%, n = 14); 68% (n = 13) of the studies were experimental, the rest having an observational study design. Eleven (58%) reported results on the primary outcome. Retrieved studies explored the role of: text messaging (n.7, 37%), smartphone applications (n.1, 5%), Youtube videos (n.1, 5%), Facebook (n.1, 5%), targeted websites and portals (n.4, 21%), software for physicians and health professionals (n.4, 21%), and email communication (n.1, 5%). There is some evidence that text messaging, accessing immunization campaign websites, using patient-held web-based portals and computerized reminders increase immunization coverage rates. Insufficient evidence is available on the use of social networks, email communication and smartphone applications., Conclusion: Although there is great potential for improving vaccine uptake and vaccine coverage by implementing programs and interventions that apply new media, scant data are available and further rigorous research - including cost-effectiveness assessments - is needed.

Background: The European region, certified as polio free in 2002, had recent wild poliovirus (WPV) introductions, resulting in a major outbreak in Central Asian countries and Russia in 2010 and in current widespread WPV type 1 circulation in Israel, which endangered the polio-free status of the region., Methods: We assessed the data on the major determinants of poliovirus transmission risk (population immunity, surveillance, and outbreak preparedness) and reviewed current threats and measures implemented in response to recent WPV introductions., Results: Despite high regional vaccination coverage and functioning surveillance, several countries in the region are at high or intermediate risk of poliovirus transmission. Coverage remains suboptimal in some countries, subnational geographic areas, and population groups, and surveillance (acute flaccid paralysis, enterovirus, and environmental) needs further strengthening. Supplementary immunization activities, which were instrumental in the rapid interruption of WPV1 circulation in 2010, should be implemented in high-risk countries to close population immunity gaps. National polio outbreak preparedness plans need strengthening. Immunization efforts to interrupt WPV transmission in Israel should continue., Conclusions: The European region has successfully maintained its polio-free status since 2002, but numerous challenges remain. Staying polio free will require continued coordinated efforts, political commitment and financial support from all countries., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Function of the microcirculation after primary percutaneous coronary intervention (PCI) is dynamic and contributes to unpredictability of recovery of left ventricular (LV) systolic function., Aim: This study was conducted to evaluate sequential Doppler velocity parameters of the left anterior descending coronary artery (LAD) in predicting recovery of global and regional LV systolic function., Methods: Thirty-five consecutive patients, 24 males, age 59 ± 12 years, with acute anterior ST-elevation myocardial infarction (STEMI) who had primary PCI were studied. Thrombolysis in myocardial infarction (TIMI) and myocardial blush grades were evaluated. Transthoracic echocardiographic (TTE) studies, evaluation of left ventricular ejection fraction (LVEF), LAD territory wall-motion score index (WMSI), and sampling of LAD Doppler velocities up to 6 hours post-PCI, 48 hours postprocedure, and predischarge were performed., Results: Thrombolysis in myocardial infarction grade before PCI averaged 0.86 ± 1.19 and post-PCI 2.89 ± 0.32, P < 0.05. Myocardial blush grade before PCI was 0.41 ± 0.98 and after PCI 2.22 ± 0.93, P < 0.05. Diastolic velocity deceleration time (DDT) in the LAD early after PCI was less than 600 ms in 16 subjects. Immediately after PCI, in subjects with DDT > 600 ms, LVEF was 38.5 ± 6% and predischarge 49.2 ± 8.7%, P = 9.77 × 10−5 and LAD-WMSI decreased from 2 ± 0.38 to 1.4 ± 0.48, P = 0.000163. In subjects with DDT < 600 ms LAD-WMSI did not change significantly. Early and minimal LAD-DDT correlated with improvement in LV systolic function, r = 0.6, whereas post-PCI blush grade had lower correlation with LVEF, r = 0.39., Conclusions: Global and regional LV systolic function after PCI in acute anterior MI can be predicted by LAD-DDT better than by post-PCI myocardial blush.

Measles and rubella persist in the World Health Organization European Region despite long-standing and widespread use of vaccines against them. Our aim was to review the epidemiology of measles and rubella in relation to the goal of eliminating these diseases from the Region by 2015. We report on the number of measles and rubella cases by country in 2012 and present an analysis of preliminary measles and rubella surveillance data for 2013. We analysed data of these diseases for 2013 by age group, diagnosis confirmation (clinical, laboratory-confirmed and epidemiologically linked), and vaccination, hospitalization and importation status. We also report on measles-related deaths. For 2012, there were 26,785 [corrected] measles cases and 29,601 rubella cases reported in the Region. For 2013, these figures were 31,520 and 39,367 respectively. Most measles cases in 2013 (96%; n = 30,178) were reported by nine countries: Georgia (7830), Germany (1773), Italy (2216), the Netherlands (2499), Romania (1074), the Russian Federation (2174), Turkey (7404), Ukraine (3308) and the United Kingdom (1900). In 2013, most measles cases were among unvaccinated persons and over one in three patients were aged 20 years and older. For 2013, almost all rubella cases were reported by Poland (n = 38,585; 98%). High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. Without sustained political commitment and accelerated action by Member States and partners, the elimination of measles and rubella in the WHO European Region may not be achieved., (© 2014 The Authors Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.)

Objectives: To evaluate the economic impact of the 2009 routine US childhood immunization schedule, including diphtheria and tetanus toxoids and acellular pertussis, Haemophilus influenzae type b conjugate, inactivated poliovirus, measles/mumps/rubella, hepatitis B, varicella, 7-valent pneumococcal conjugate, hepatitis A, and rotavirus vaccines; influenza vaccine was not included., Methods: Decision analysis was conducted using population-based vaccination coverage, published vaccine efficacies, historical data on disease incidence before vaccination, and disease incidence reported during 2005 to 2009. Costs were estimated using the direct cost and societal (direct and indirect costs) perspectives. Program costs included vaccine, administration, vaccine-associated adverse events, and parent travel and work time lost. All costs were inflated to 2009 dollars, and all costs and benefits in the future were discounted at a 3% annual rate. A hypothetical 2009 US birth cohort of 4,261,494 infants over their lifetime was followed up from birth through death. Net present value (net savings) and benefit-cost ratios of routine childhood immunization were calculated., Results: Analyses showed that routine childhood immunization among members of the 2009 US birth cohort will prevent ∼42,000 early deaths and 20 million cases of disease, with net savings of $13.5 billion in direct costs and $68.8 billion in total societal costs, respectively. The direct and societal benefit-cost ratios for routine childhood vaccination with these 9 vaccines were 3.0 and 10.1., Conclusions: From both direct cost and societal perspectives, vaccinating children as recommended with these vaccines results in substantial cost savings.

Objective: To examine preventive care visit patterns among commercially insured adolescents during 2003-2010. In 2005-2007, the Advisory Committee on Immunization Practices (ACIP) recommended 3 vaccines targeted at adolescents. We also investigate the relationship between preventive care visits and immunization., Study Design: Data were drawn from the MarketScan database. Adolescents aged 11-21 continuously enrolled in the same insurance plan during the calendar year were included. We calculated the annual proportion of adolescents with at least 1 preventive and 1 vaccination-related visit. Longitudinal analyses were conducted by following the 1992 birth cohort for 8 consecutive years., Results: The proportion of adolescents making at least 1 preventive visit increased from 24.6%-41.1% during 2003-2010. The rate of vaccination-related visits increased from 12.9%-26.3%. The magnitude of the increase in preventive and vaccination-related visits was greater during the years in which ACIP issued recommendations. The rates of preventive and vaccination-related visits were considerably higher among female and early adolescents and adolescents in managed care plans. Longitudinal analyses indicated that only 2.4% of adolescents had an annual preventive visit during the 8 years., Conclusions: Yearly improvements in preventive care visits by adolescents were substantial. ACIP recommendations may be associated with this improvement. However, ongoing efforts are needed to improve the use and delivery of preventive care services., (Copyright © 2014 Mosby, Inc. All rights reserved.)

The role of parapancreatitis in the intra-abdominal hypertension (IAH) progression in patients with severe acute pancreatitis with various forms of organs failure was studied. It was analyzed the treatment results of 63 patients with severe acute pancreatitis. The patients were divided into 4 groups: the first group (n=24) had not the signs of organs failure, the second group (n=15) - with symptoms of acute respiratory failure (ARF), the third group (n=11) - with a combination of ARF and acute cardiovascular failure (CVF) and the fourth group (n=13) - with a combination of ARF, CVF and acute renal failure. Intra-abdominal pressure (IAP) was measured at 1, 3, 5, 7- days from the beginning of the disease with calculation of the abdominal perfusion pressure and filtration gradient values. The prevalence evaluation of parapancreatitis was carried out on the basis of CT-data with bolus-dosing of the contrast agent, ultrasound, video laparoscopy as well as data obtained during operation and autopsy. It was defined that the intra-abdominal pressure (IAP) values was not significantly different and complied with intra-abdominal hypertension of the first grade in patients of the groups 1-3 at the first day. IAP was significantly higher and complied with intra-abdominal hypertension of the second grade in patients of the fourth group. IAP normalized to 5-7th days in patients of the first and the second groups. The patients of the third and the fourth groups had IAH of the second grade in the 7th day. There was reliable (p<0.01) average positive correlation (r=0.57) between the indications of IAH and the scale APACHE II. The patients with common parapancreatitis (n=39) had indications of IAP and APACHE II significantly higher than in patients with local forms of parapancreatitis (n=24; p<0.01). Common defeat of retroperitoneal fat determined persistent increase of IAP more than the presence of effusion in the abdominal cavity. In case of the first grade of IAH the mortality was 6.6%, the second grade - 37.5%, the third grade - 58.3% and the fourth grade - 80%. All died patients had a common parapancreatitis. The authors consider that the indications of IAP and APACHE II let to suppose an adverse outcome by the development of multiple organ failure in the early stages of the disease. Common parapancreatitis is the main feature of the persistent IAH (IAP increase during 5-7 days), which is an indication for early decompression operations on the abdominal wall.

Objectives: Nationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents., Design: Cross-sectional study with multilevel modeling., Setting and Participants: States in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare & Medicaid Service's Minimum Data Set for October 1, 2008, through March 31, 2009., Measurements: Residents' influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination)., Results: States with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage., Conclusion: Inequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination., (Published by Elsevier Inc.)

Background: A shortage of Haemophilus influenzae type b (Hib) vaccine that occurred in the United States during December 2007 to September 2009 resulted in an interim recommendation to defer the booster dose, but to continue to vaccinate as recommended with the primary series during the first year of life., Objectives: To quantify effects of the Hib shortage on vaccination coverage and to determine if any demographic subgroups were disproportionately affected., Methods: Data from the 2009 National Immunization Survey (NIS) were divided based on child's age at the onset of the shortage. Comparisons were made in primary series coverage by 9 months between children <7 months versus ≥7 months at the start of the shortage. Comparisons in primary series plus booster dose completion by 19 months were made between children who were <12 months versus ≥12 months at the start of the shortage., Results: Nationally, there was a difference in Hib primary series completion by 9 months among children age <7 months versus ≥7 months at the start of the shortage (73.9% versus 81.2%, P<0.001). There was a large difference in the percentage of children fully vaccinated with the primary series plus booster dose by 19 months among children age <12 months versus ≥12 months at the start of the shortage (39.5% versus 66.0%, P<0.001). There were differential effects of the shortage on primary series coverage among states and for some demographic characteristics., Conclusions: As expected booster dose coverage was reduced consistent with interim recommendations, but primary series coverage was also reduced by 7 percentage points nationally., (Published by Elsevier Ltd.)

Background: Recommendations for annual seasonal influenza vaccination have expanded to now include >300 million children and adults each year. Community settings have become increasingly important venues for influenza vaccination. We sought to identify barriers to and solutions for expanding influenza vaccination in community settings., Methods: Semi-structured telephone interviews were conducted from 01/09 to 06/10 with a range of stakeholders involved in influenza vaccination, including health plans, medical services firms, retail based clinics, pharmacies, schools, and state and local public health immunization programs. Participants (n=65) were asked about barriers and feasible solutions to influenza vaccine delivery to children and adults in community settings. Key themes were identified through iterative coding using a grounded theory approach., Results: Stakeholders identified specific financial barriers to influenza vaccine delivery in 3 major areas: purchase and distribution, delivery, and reimbursement. Limited purchasing power, the uncertain nature of public demand, and unpredictable timing of influenza vaccine supply were important barriers to enhance delivery in community settings. Barriers to delivery included complexities in running off-site clinics, especially in school settings, the need to manage publicly vs. privately purchased vaccines separately, and state-to-state variability in requirements for credentialing, physician oversight, and reporting. Reimbursement barriers included a protracted credentialing process, the need to determine insurance eligibility at point-of-service, and lack of a billing infrastructure in off-site clinics. Opportunities to mitigate financial barriers to influenza vaccine delivery in community settings focused on coordination across providers and the role of public health as a "trusted broker" to overcome existing challenges., Conclusions: Financial and systems barriers hamper the optimal use of community settings to effectively deliver influenza vaccines. Public health partners at the federal, state, and local levels are well-positioned to facilitate the engagement of all stakeholders in this important and complex vaccine delivery system., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Oftentimes the etiological diagnostic differentiation between viral and bacterial infections is problematic, while clinical management decisions need to be made promptly upon admission. Thus, alternative rapid and sensitive diagnostic approaches need to be developed. Polymorphonuclear leukocytes (PMNs) or phagocytes act as major players in the defense response of the host during an episode of infection, and thereby undergo functional changes that differ according to the infections. PMNs functional activity can be characterized by quantification and localization of respiratory burst production and assessed by chemiluminescent (CL) byproduct reaction. We have assessed the functional states of PMNs of patients with acute infections in a luminol-amplified whole blood system using the component CL approach. In this study, blood was drawn from 69 patients with fever (>38 °C), and diagnosed as mainly viral or bacterial infections in origin. Data mining algorithms (C4.5, Support Vector Machines (SVM) and Naïve Bayes) were used to induce classification models to distinguish between clinical groups. The model with the best predictive accuracy was induced using C4.5 algorithm, resulting in 94.7% accuracy on the training set and 88.9% accuracy on the testing set. The method demonstrated a high predictive diagnostic value and may assist the clinician one day in the distinction between viral and bacterial infections and the choice of proper medication.

Objectives: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies., Design: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey., Setting: One thousand one hundred seventy-four participating nursing homes sampled systematically with probability proportional to bed size., Participants: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004., Measurements: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility-level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels., Results: Overall in the United States, vaccination coverage was higher for Caucasian and African-American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility-wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively)., Conclusion: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African-American residents, narrowing the national vaccination racial gap., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

Background: In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that long-term care (LTC) facilities certified by CMS offer each resident annual influenza vaccination. Subsequently, vaccination status was added to resident assessments collected beginning in the influenza season, 2005-2006. This is the first year immunization coverage can be reported based on a census of LTC residents., Objectives: Report influenza immunization coverage for LTC residents by state, resident, and facility characteristics. Identify uses of the data and areas in need of improvement., Methods: Analysis of CMS' Minimum Data Set of 1,851,676 residents in nursing homes from October 1 through December 31 but who could have been discharged between January 1 and March 31 merged with data for 14,493 non-hospital-based facilities from the Online Survey and Certification Assessment Reporting System., Results: Overall, 83% of residents were offered the vaccine and 72% had received the vaccine. Almost 10% refused to receive the vaccine, 14% were not offered the vaccine, 1% were ineligible, and 3% were missing vaccination status. Vaccination coverage varied significantly among states (range: 49% to 87%). Fewer African Americans and Hispanics than whites were offered the vaccine (79% and 79% versus 84%, respectively) and received it (65% and 66% versus 73%, respectively); more African Americans refused the vaccine (12%) than residents of other races and/or ethnicities. Residents of Medicaid-certified-only facilities had higher levels of vaccination than residents of other facilities (82% versus < or =73%)., Conclusion: MDS immunization data can be used as surveillance to work with states to improve coverage. Further research to examine racial disparities in vaccination among LTC residents is needed., (Published by Elsevier Inc.)

Objective: The goal was to explore the association of being underinsured and receiving doses at a health department clinic (HDC) with not receiving all recommended adolescent vaccine doses., Methods: A total of 5657 adolescents, 13 to 17 years of age, were sampled in the National Immunization Survey-Teen in 2006-2007., Results: A total of 63.9% of all adolescents were covered by private health insurance. Among privately insured adolescents, approximately 31.3% were underinsured. Compared with fully insured adolescents, underinsured adolescents were more likely to receive doses at an HDC for tetanus-diphtheria toxoids/tetanus toxoids-reduced diphtheria toxoids-acellular pertussis vaccine (25.1% vs 6.2%; P < .05), tetravalent meningococcal conjugate vaccine (11.5% vs 2.5%; P < .05), and quadrivalent human papillomavirus vaccine (16.2% vs 3.4%; P < .05). Also, compared with fully insured adolescents, underinsured adolescents who received doses at an HDC had lower estimated rates of vaccination coverage for tetanus-diphtheria toxoids/tetanus toxoids-reduced diphtheria toxoids-acellular pertussis vaccine (58.5% vs 70.9%; P < .05), tetravalent meningococcal conjugate vaccine (10.8% vs 25.8%; P < .05), and quadrivalent human papillomavirus vaccine (7.8% vs 14.3%; P < .05)., Conclusion: Underinsured adolescents who receive doses at an HDC have lower rates of vaccination coverage than do fully insured adolescents.

Objectives: To report awareness of human papillomavirus (HPV) and HPV vaccine among women aged 18-49 years and, for recommended women aged 18-26 years, estimate initiation of HPV vaccination and describe factors associated with vaccination initiation among a national sample., Methods: Data were analyzed from the National Immunization Survey-Adult, a nationally representative telephone survey conducted May-August 2007. Questions were asked about awareness of HPV and HPV vaccine and vaccine receipt., Results: A total of 1102 women aged 18-49 years were interviewed, 168 were aged 18-26 years. Overall, awareness of HPV (84.3%) and of HPV vaccine (78.9%) were high. Among women 18-26 years of age, vaccination initiation (> or =1 dose) was 10%. Factors associated with vaccination included not being married, living > or =200% of the federal poverty index, having health insurance, and vaccination with hepatitis B vaccine. HPV vaccination initiation among women aged 27-49 years was 1%., Conclusions: Awareness of HPV and HPV vaccine were high. Two to 5 months after national HPV vaccination recommendations were published, one in ten women 18-26 years old had initiated the HPV vaccine series. Women at a higher socio-economic level were more likely to receive the vaccination. Vaccination initiation and completion will likely increase over the next years. Monitoring uptake is important to identify sub-groups that may not be receiving the vaccination.

This case report describes a patient with prolonged fever following a kidney biopsy. Workup disclosed a large perirenal and retroperitoneal hematoma. Neither imaging nor blood cultures supported an infective cause of his fever. Although the patient was initially treated with antibiotics, fever eventually resolved spontaneously. A review of the literature is provided addressing the association of fever with resorption of hematoma. Fever should be added to the list of potential complications of kidney biopsy. A conservative management is advocated.

We examined the relationship between body mass index (BMI) and measures of tenderness, quality of life, and physical functioning in female fibromyalgia (FMS) patients. A random sample of 100 female FMS patients from a database of 550 FMS individuals was interviewed and assessed according to a structured questionnaire that included FMS-related symptoms, measures of tenderness (point count and dolorimetry), quality of life (SF-36), physical functioning, and BMI. Weight was defined as normal, overweight, and obesity according to BMI. Twenty-seven percent of the FMS patients had normal BMI, 28% were overweight, and 45% were obese. BMI was negatively correlated with quality of life (r = -0.205, P = 0.044) and tenderness threshold (r = -0.238, P = 0.021) and positively correlated with physical dysfunctioning (r = 0.202, P = 0.047) and point count (r = 0.261, P = 0.011). Obese FMS patients display higher pain sensitivity and lower levels of quality of life. In designing studies that explore factors affecting tenderness, BMI should be included in addition to sex, age, etc.

Objectives: Known disparities in pneumococcal vaccination in the community raise the question of whether disparities also exist in the nursing home setting, which is better controlled. This study used nationally representative nursing home data to compare black and white nursing home residents with respect to receiving, not receiving, or having an unknown PPV vaccination status, and to examine the interaction of race with various facility characteristics., Design: Multinomial logistic regression was used to analyze a 2-year merged file (1997 and 1999) of the National Nursing Home Survey, a cross-sectional national probability sample of nursing homes and residents., Setting and Participants: Residents 65 years or older (n = 14,782) residing in nursing homes between July and December of 1997 or 1999., Measurements: Record-based staff report of whether residents ever had a pneumococcal immunization (yes/no/unknown); race measured as black or white., Results: Pneumococcal vaccination rates are lower for black nursing home residents than for white residents, as shown using a merged file of the 1997 and 1999 National Nursing Home Surveys. Participants include 14,303 randomly sampled residents 65 years or older. In this sample, 31% of black residents compared with 24% of white residents 65 years or older had never received pneumococcal vaccination (P < .01). Multivariate logistic regression confirmed that blacks were more likely to be unimmunized than whites (95% CIs), specifically in Medicaid-only facilities and dually certified Medicare and Medicaid facilities. Blacks also had higher odds of unknown vaccination status than whites in Medicaid-only facilities and lower odds of unknown status in government-owned facilities., Conclusions: Results suggest that the racial difference in pneumococcal vaccination exists predominantly in certain facility types. In addition, facility-based interventions such as having an organized PPV immunization program or improving documentation of vaccination status can be effective in increasing vaccination rates for all races.

Successful incorporation of a new vaccine into a nation's vaccination program requires addressing a number of issues, including: 1) establishing national recommendations; 2) assuring education of and acceptance by the public and medical community; 3) establishing and maintaining an appropriate infrastructure for vaccine delivery; 4) financing the vaccine and the program, in addition to political will. This article reviews the early experience with implementation of human papillomavirus (HPV) vaccination programs. It focuses on the United States of America and Canada and provides a brief report on Australia, where introduction is underway.

Background: The temporal behavior of the coronary microcirculation in acute myocardial infarction may affect outcome. Diastolic deceleration time and early systolic flow reversal derived from coronary artery blood flow velocity patterns reflect microcirculatory function., Objectives: To assess left anterior descending coronary artery flow velocity patterns using Doppler transthoracic echocardiography after primary percutaneous coronary intervention, in patients with anterior AMI., Methods: Patterns of flow velocity patterns of the LAD were obtained using transthoracic echocardiography-Doppler in 31 consecutive patients who presented with anterior AMI. Measurements were done at 6 hours, 36-48 hours, and 5 days after successful PPCI. Measurements of DDT and pressure half times (Pt%), as well as observation for ESFR were performed., Results: In the first 2 days following PPCI, the average DDT (600 +/- 340 msec) was shorter than on day 5 (807 +/- 332 msec) (P < 0.012), FVP in the first 2 days were dynamic and bidirectional: from short DDT (< 600 msec) to long DDT (> 600 msec) and vice versa. On day 5 most DDTs became longer. Pt1/2 at 6 hours was not different than at day 2 (174 +/- 96 vs. 193 +/- 99 msec, P = NS) and became longer on day 5 (235 +/- 98 msec, P = 0.012). Bidirectional patterns were also observed in the ESFR in 6 patients (19%) at baseline, in 4 (13%) at 36 hours, and in 2 (6.5%) on day 5 after PPCI., Conclusions: Flow velocity patterns of the LAD after PPCI in AMI are dynamic and reflect unpredictable changes in microcirculation.

Myocardial bridging (MB) is defined as an intramural segment of a coronary artery that normally courses epicardially. MB is usually a benign condition; however, some cases resulting in myocardial ischaemia, infarction and sudden death have been reported. We describe a case of myocardial infarction related to MB in a young healthy woman with no risk factors for coronary artery disease. The bridge was demonstrated in detail by coronary CT angiography using multiplanar reconstruction and three-dimensional volume-rendered techniques.

Frequent varicella outbreaks with sizable impact on the US public health system have continued to occur despite the success of the country's 1-dose varicella vaccination program. The Advisory Committee on Immunization Practices recently recommended adding a routine second dose of varicella vaccine and weighed economic projections as well as public health goals in their deliberations. This decision-tree-based analysis was conducted to evaluate the economic impact of the projected 2-dose varicella vaccination program as well as the existing 1-dose program. The analysis used population-based vaccination coverage and disease incidence data to make projections for a hypothetical US birth cohort of 4,100,000 infants born in 2006. Compared with no vaccination, both the 1-dose program (societal benefit-cost ratio [BCR], 4.37) and 2-dose program (BCR, 2.73) were estimated to be cost saving from the societal perspective. Compared with the 1-dose program, the incremental second dose was not cost saving (societal incremental BCR, 0.56). The incremental cost-effectiveness ratio for the second dose was $343 per case prevented, or approximately $109,000 per quality-adjusted life-year saved, and these results were sensitive to assumptions about vaccine effectiveness and prices.

Objective: The goal was to estimate the population effect of 7-valent pneumococcal conjugate vaccine on rates of acute otitis media-related ambulatory visits and antibiotic prescriptions for <2-year-old children enrolled in private insurance plans., Methods: We performed a retrospective analysis of a defined population by using the 1997-2004 MarketScan databases, which included an average of >500,000 person-years of observations for children <2 years of age. Trends in rates of International Classification of Diseases, Ninth Revision-coded ambulatory visits and antibiotic prescriptions attributable to acute otitis media were evaluated, and the national direct medical expenditures for these outcomes were estimated., Results: In a comparison of 2004 with 1997-1999 (baseline period), rates of ambulatory visits and antibiotic prescriptions attributable to acute otitis media decreased from 2173 to 1244 visits per 1000 person-years (42.7% reduction) and from 1244 to 722 prescriptions per 1000 person-years (41.9% reduction), respectively. Total, estimated, national direct medical expenditures for acute otitis media-related ambulatory visits and antibiotic prescriptions for children <2 years of age decreased from an average of $1.41 billion during 1997 to 1999 to $0.95 billion in 2004 (32.3% reduction)., Conclusions: Acute otitis media-related health care utilization and associated antibiotic prescriptions for privately insured young children decreased more than expected (on the basis of efficacy estimates in prelicensure clinical trials) after the introduction of routine 7-valent pneumococcal conjugate vaccine immunization. Although other factors, such as clinical practice guidelines to reduce antibiotic use, might have contributed to the observed trend, 7-valent pneumococcal conjugate vaccine may play an important role in reducing the burden of acute otitis media, resulting in substantial savings in medical care costs.

Objective: To estimate the effect of 7-valent pneumococcal conjugate vaccine (PCV7) on rates of pneumonia-related health care utilization and costs in children younger than 2 years., Design: Retrospective population study., Setting: Approximately 40 large employers each year, from 1997 to 2004., Participants: Enrollees in the MarketScan databases collected by Thomson Medstat., Main Exposure: Pneumococcal conjugate vaccine immunization program., Main Outcome Measures: Rates of International Classification of Diseases, Ninth Revision-coded hospitalizations and ambulatory visits due to all-cause and pneumococcal pneumonia and their medical expenditures., Results: Comparing the rates in 2004 with those in the baseline period of 1997 to 1999 among children younger than 2 years, hospitalizations due to all-cause pneumonia declined from 11.5 to 5.5 per 1000 children (52.4% decline; P < .001) and ambulatory visits due to all-cause pneumonia declined from 99.3 to 58.5 per 1000 children (41.1% decline; P < .001). Rates of hospitalizations due to pneumococcal pneumonia declined from 0.6 to 0.3 per 1000 children (57.6% decline; P < .001) and rates of ambulatory visits declined from 1.7 to 0.9 per 1000 children (46.9% decline; P < .001). Projecting from these data to the US population, the total estimated direct medical expenditures for all-cause pneumonia-related hospitalizations and ambulatory visits in young children were reduced from an annual average of $688.2 million during the period of 1997 to 1999 to $376.7 million in 2004 (45.3% decline and approximately $310 million decrease)., Conclusions: In children younger than 2 years, the age group targeted for vaccination, pneumonia-related health care utilization in a privately insured population declined substantially following PCV7 introduction. These results suggest that PCV7 may play an important role in reducing the burden of pneumonia, resulting in major savings in medical care cost.

Objective: To determine how child characteristics and immunization coverage levels differ among children using public and private providers., Methods: Immunization coverage rates between 1996 and 2004 were compared among children aged 19-35 months, using data from the National Immunization Survey. Coverage was based on the 4:3:1:3:3 vaccine series: four or more doses of diphtheria, tetanus toxoids, acellular pertussis vaccine; three or more doses of poliovirus vaccine; one or more doses of measles-mumps-rubella vaccine; three or more doses of Haemophilus influenzae type b vaccine; and three or more doses of hepatitis B vaccine. Coverage differences were examined by provider types (child vaccinated by private, public, or a mix of providers), and stratified by child's race/ethnicity, area of residence, and household income level., Results: Between 1996 and 2004, the proportion of children seeing exclusively private providers increased (58%-61%; P < .05); the proportion seeing only public providers decreased (19%-15%; P < .01). Coverage levels increased among children seeing all provider types. Coverage levels were higher for children using private providers than those using public providers in 2004 (83% vs 79%; P <.05). Except for White race (coverage was higher among those using private providers vs public providers), coverage levels by demographic variables did not significantly differ between children using only public or only private providers in 2004., Conclusions: Equal emphasis should be placed on the efforts of public providers and private providers to increase coverage among children of all race/ethnicity, income, and residential groups.

Clinical practice guidelines (CPGs) are the best available synthesis of research in providing clinical care, yet the degree of adoption remains less than optimal. One reason may be that the routes of dissemination and the mode of construction do not match the needs of the typical healthcare practice. This study uses a systems approach in understanding the interplay between routes of CPG dissemination, the construction of CPGs, and the likelihood that healthcare organizations will adopt these guidelines.

Background: Since 1996, hepatitis A vaccine has been recommended for persons at risk for infection and children living in communities with the highest disease rates. In 1999, this recommendation was expanded to include all children in 17 states with high incidence compared to a national baseline period. Reported hepatitis A incidence has decreased substantially since 1999; however, comprehensive data on changes in hospital and outpatient utilization have not been reported., Objective: To analyze a health insurance claims database to examine impacts of the hepatitis A vaccination program on medical visits and associated expenditures., Methods: We conducted a retrospective study of the 1996-2004 Medstat MarketScan databases, which include enrollees of more than 100 health insurance plans offered by approximately 40 large employers each year, using 1996 and 1997 as the pre-vaccination baseline. Trends in rates of medical care visits were analyzed using Poisson regression method., Results: From the pre-vaccination era to 2004, hospitalizations due to hepatitis A declined by 68.5% (from 0.81 to 0.26 per 100,000 population, P<0.001) and ambulatory visits declined by 41.5% (from 12.9 to 7.5 per 100,000 population, P<0.001). Ambulatory visits declined in all age groups, with the greatest declines among children<18 years old. Declines were greater among enrollees who resided in the 17 vaccinating states (58.5%) than those in non-vaccinating states (32.7%, P<0.001). After adjusting to the US population, using data derived from a privately insured population, total estimated direct medical expenditures for hepatitis A-related hospitalizations and ambulatory visits declined by 68.1%, from an average of $29.1 million in 1996 and 1997 to $9.3 million in 2004., Conclusions: Since the introduction of the hepatitis A vaccination program, hospitalizations, ambulatory visits, and their associated expenditures due to hepatitis A disease have declined substantially among all age groups across the US. Greater declines were seen in the 17 states with vaccination recommendations for hepatitis A.