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The purpose of this study was to determine, in a military population without critical bone loss, the rate of recurrent instability after revision arthroscopic stabilization for failed primary arthroscopic Bankart repair.Forty-one revision arthroscopic stabilizations were performed at a single military institution between 2005 to 2016 for recurrent anterior shoulder instability after primary arthroscopic Bankart repair. Minimum follow-up was 2 years, and shoulders with glenoid bone loss20% were excluded. The primary outcome of interest was the incidence of failure, defined by recurrent instability.Age at revision surgery averaged 22.9 ± 4.3 years, and 88% were either service academy cadets or active duty combat arms soldiers. Mean follow-up was 7.8 years. Twenty-three patients (56%) returned to duty without recurrent instability after revision arthroscopic stabilization. Eighteen patients (44%) experienced recurrent instability after return to duty. Glenoid bone loss averaged 6.2% (95% confidence interval [CI], 3.2%-9.2%) in the successful group and 5.7% (95% CI, 3.1%-8.3%) in the failure group (P = .808).Revision arthroscopic stabilization of failed primary arthroscopic Bankart repair has a failure rate of 44% in a young military population. The similar amounts of bone loss between groups indicates that bone loss is not the primary determinant of failure in revision arthroscopic stabilization.IV, Case Series.

Background China media reported infant deaths following hepatitis B vaccination in late 2013, leading to temporary suspension of hepatitis B vaccine (HepB Event) until the deaths were shown to be coincidental and the vaccine was of standard, good quality. In 2016, a criminal ring in Shandong province that had been purchasing, improperly storing, and reselling Category 2 vaccines (private-sector) to 60 (of 200,000) clinics for 5 years, was exposed, publicized, and prosecuted, and the potential health and epidemiological impacts were investigated to determine whether revaccination was necessary (Shandong Vaccine Event). Methods We assessed parental confidence in vaccines through 9 telephone surveys in 6 and 11 provinces before, during, and after the two events. Provider confidence was assessed through in-person interviews following each event. Vaccine utilization was assessed using Immunization Information Management System data from township clinics. Results In the early stages of each event, approximately 30% of parents indicated vaccine hesitancy and 18% said they would refuse routine immunization. Five and nine months after each event, hesitancy and refusal decreased, but not to pre-event levels. During the Shandong Vaccine Event, 49·1% of parents indicated refusal to use Category 2 vaccines; six months later, the rate was 32·8%. Use of HepB decreased by 21% during the first 2 weeks of the HepB Event and by 12·6% during the first 4 weeks of Shandong Vaccine Event, but returned to baseline in less than 3 months. Use of Category 2 vaccine decreased by 49·5% in the first 3 weeks of the Shandong Vaccine Event and by 28·7% 6 months later. After the Shandong Vaccine Event, 64% of clinicians held high confidence in routine immunization, lower than at baseline. Conclusions The two events caused mistrust, loss of confidence, and decreases in use of vaccines by parents and providers. In addition to ensuring immunization program integrity, effective communications and ongoing monitoring of vaccine use and confidence should be included to restore confidence and trust in vaccines.

Introduction Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated >100 million children in 2010. An increasing proportion of infections now occur among adults and there is concern that persistent susceptibility in adults is an obstacle to measles elimination in China. We performed a case-control study in six Chinese provinces between January 2012 to June 2013 to identify risk factors for measles virus infection and susceptibility among adults. Methods Persons ≥15 years old with laboratory-confirmed measles were age and neighborhood matched with three controls. Controls had blood specimens collected to determine their measles IgG serostatus. We interviewed case-patients and controls about potential risk factors for measles virus infection and susceptibility. Unadjusted and adjusted matched odds ratios and 95% confidence intervals (CIs) were calculated via conditional logistic regression. We calculated attributable fractions for infection for risk factors that could be interpreted as causal. Results 899 cases and 2498 controls were enrolled. Among controls, 165 (6.6%) were seronegative for measles IgG indicating persistent susceptibility to infection. In multivariable analysis, hospital visit and travel outside the prefecture in the prior 1–3 weeks were significant risk factors for measles virus infection. Occupation and reluctance to accept measles vaccination were significant risk factors for measles susceptibility. The calculated attributable fraction of measles cases from hospital visitation was 28.6% (95% CI: 20.6–38.8%). Conclusions Exposure to a healthcare facility was the largest risk factor for measles virus infection in adults in China. Improved adherence to hospital infection control practices could reduce risk of ongoing measles virus transmission and increase the likelihood of achieving and sustaining measles elimination in China. The use of control groups stratified by serological status identified distinct risk factors for measles virus infection and susceptibility among adults.

Objectives To conduct an updated, systematic review of the clinical literature, classify studies based on the strength of research design, and derive consensual, evidence-based clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) or stroke. Data Sources Online PubMed and print journal searches identified citations for 250 articles published from 2009 through 2014. Study Selection Selected for inclusion were 186 articles after initial screening. Fifty articles were initially excluded (24 focusing on patients without neurologic diagnoses, pediatric patients, or other patients with neurologic diagnoses, 10 noncognitive interventions, 13 descriptive protocols or studies, 3 nontreatment studies). Fifteen articles were excluded after complete review (1 other neurologic diagnosis, 2 nontreatment studies, 1 qualitative study, 4 descriptive articles, 7 secondary analyses). 121 studies were fully reviewed. Data Extraction Articles were reviewed by the Cognitive Rehabilitation Task Force (CRTF) members according to specific criteria for study design and quality, and classified as providing class I, class II, or class III evidence. Articles were assigned to 1 of 6 possible categories (based on interventions for attention, vision and neglect, language and communication skills, memory, executive function, or comprehensive-integrated interventions). Data Synthesis Of 121 studies, 41 were rated as class I, 3 as class Ia, 14 as class II, and 63 as class III. Recommendations were derived by CRTF consensus from the relative strengths of the evidence, based on the decision rules applied in prior reviews. Conclusions CRTF has now evaluated 491 articles (109 class I or Ia, 68 class II, and 314 class III) and makes 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines, 11 Practice Options). Evidence supports Practice Standards for (1) attention deficits after TBI or stroke; (2) visual scanning for neglect after right-hemisphere stroke; (3) compensatory strategies for mild memory deficits; (4) language deficits after left-hemisphere stroke; (5) social-communication deficits after TBI; (6) metacognitive strategy training for deficits in executive functioning; and (7) comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke.

Photoinitiated radical chemistry has proven to be useful for breaking covalent bonds within many biomolecules in the gas phase. Herein, we demonstrate that radical chemistry is useful for bond synthesis in the gas phase. Single peptides containing two cysteine residues capped with propylmercaptan (PM) often form disulfide bonds following ultraviolet excitation at 266 nm and loss of both PM groups. Similarly, noncovalently bound peptide pairs where each peptide contains a single cysteine residue can be induced to form disulfide bonds. Comparison with disulfide bound species sampled directly from solution yields identical collisional activation spectra, suggesting that native disulfide bonds have been recapitulated in the gas phase syntheses. Another approach utilizing radical chemistry for covalent bond synthesis involves creation of a reactive diradical that can first abstract hydrogen from a target peptide, creating a new radical site, and then recombine the second radical with the new radical to form a covalent bond. This chemistry is illustrated with 2-(hydroxymethyl-3,5-diiodobenzoate)-18-crown-6 ether, which attaches noncovalently to protonated primary amines in peptides and proteins. Following photoactivation and crosslinking, the site of noncovalent adduct attachment can frequently be determined. The ramifications of these observations on peptide structure and noncovalent attachment of 18-crown-6-based molecules is discussed.

Research Objectives Awareness that traumatic brain injury (TBI) can be a chronic condition has increased in the last decade. To manage TBI as a chronic condition, methods to provide clinical surveillance need to be developed. To determine the extent to which participants with TBI were satisfied with, valued, and were able to utilize a surveillance prototype for traumatic brain injury. Design Descriptive study and qualitative content analyses. Setting Community. Participants Adult patients with traumatic brain injury. Interventions All participants were simultaneously participating in a larger RCT investigating the impact of Resource Facilitation (RF). MyBrain© was part of the RF intervention and was offered to all participants randomized to RF. Data was collected from all RF participants utilizing MyBrain©. Main Outcome Measures The Post-Study System Usability Questionnaire (PSSUQ) is a 16-item standardized questionnaire designed to assess users’ perceived satisfaction of software in addition to a customized satisfaction scale designed to target satisfaction with MyBrain© specifically. The custom satisfaction scale is a 12-item Likert scale with five free-response questions. Results 71% of the participants either agreed/strongly-agreed that they were satisfied with MyBrain© overall on the custom satisfaction measure. Satisfaction ratings on the PSSUQ ranged from 70% to 100% across items. Approximately, 71% of the participants also agreed or strongly agreed that access to the self-management applications associated with the surveillance prototype. A variety of qualitative information was obtained to inform revision of the prototype, and the results of qualitative content analyses will also be presented. Conclusions The initial prototype for surveillance was generally found to be feasible and the majority of the participants were satisfied and valued access to the self-management applications. These findings will be used for enhancement of MyBrain© Author(s) Disclosures None.

Environmental heat is a growing public health concern in cities. Urbanization and global climate change threaten to exacerbate heat as an already significant environmental cause of human morbidity and mortality. Despite increasing risk, very little is known regarding determinants of outdoor urban heat exposure. To provide additional evidence for building community and national-scale resilience to extreme heat, we assess how US outdoor urban heat exposure varies by city, demography, and activity. We estimate outdoor urban heat exposure by pairing individual-level data from the American Time Use Survey (2004-2015) with corresponding meteorological data for 50 of the largest metropolitan statistical areas in the US. We also assess the intersection of activity intensity and heat exposure by pairing metabolic intensities with individual-level time-use data. We model an empirical relationship between demographic indicators and daily heat exposure with controls for spatiotemporal factors. We find higher outdoor heat exposure among the elderly and low-income individuals, and lower outdoor heat exposure in females, young adults, and those identifying as Black race. Traveling, lawn and garden care, and recreation are the most common outdoor activities to contribute to heat exposure. We also find individuals in cities with the most extreme temperatures do not necessarily have the highest outdoor heat exposure. The findings reveal large contrasts in outdoor heat exposure between different cities, demographic groups, and activities. Resolving the interplay between exposure, sensitivity, adaptive capacity, and behavior as determinants of heat-health risk will require advances in observational and modeling tools, especially at the individual scale.

Objective To estimate the costs of routine immunization (RI) services in China in 2015, to provide objective data relevant to investment in the Expanded Program on Immunization, and to contribute to global data on costing and financing of RI. Methods The study was conducted between January and March 2016. We selected 276 villages, 138 townships, 46 counties, and 40 prefectures from 15 provinces as investigation sites at random, stratified by eastern, middle, and western regions. Direct cost items included vaccines, personnel, cold chain, surveillance, communication, training, and supervision at the national, provincial, prefecture, county, township, and village levels. We obtained financial data from governmental and external sources. Indirect costs of RI included parents’ transportation costs and productivity lost due to taking their children for vaccination. Results Total direct costs were $92.42 for each child fully immunized ($4.20/dose), which equates to $1529.55 million per birth cohort. RI costs were higher in the eastern region than in the western region, and higher than that of the central region. Vaccination coverage was positively associated with direct routine immunization costs. The cost of the recommended vaccines was $19.08/child and vaccine only accounted for 20.64% of total costs. Operational cost, including surveillance, communication, training and supervision, was $217.31/child, accounting for 14.21% of total cost. The indirect cost per child was $72.86; the total indirect cost was $1205.83 million for the birth cohort. Government investment in RI accounted for about 70% of total costs. Revenue from sales of private-sector vaccine supported the remaining 30% of RI costs. Conclusions While government financing has increased, some operating costs continue to be provided from revenue generated by sales of Category 2 (private-sector) vaccines to families. China could benefit from bringing new and underutilized vaccines into the EPI system based on evidence that includes routine immunization vaccine and operations costs.

Column chromatographic methods have been developed to separate no-carrier-added 111Ag from proton irradiated thorium targets and associated fission products as an ancillary process to an existing 225Ac separation design. Herein we report the separation of 111Ag both prior and subsequent to 225Ac recovery using CL resin, a solvent impregnated resin (SIR) that carries an organic solution of alkyl phosphine sulfides (R3P = S) and alkyl phosphine oxides (R3P = O). The recovery yield of 111Ag was 93 ± 9% with a radiochemical purity of 99.9% (prior) and 87 ± 9% with a radiochemical purity of 99.9% (subsequent to) 225Ac recovery. Both processes were successfully performed with insignificant impacts on 225Ac yields or quality. Measured equilibrium distribution coefficients for silver and ruthenium (a residual contaminant) on CL resin in hydrochloric and nitric acid media are reported, to the best of our knowledge, for the first time. Additionally, measured cross sections for the production of 111Ag and 110mAg for the 232Th(p,f)110m,111Ag reactions are reported within.

Research Objectives This study tested the hypothesis that participants with acute traumatic brain injury (TBI) randomly assigned to Resource Facilitation (RF) would demonstrate decreased levels of disability and increased levels of health related quality of life (HRQOL) when compared to patients randomly assigned to the treatment as usual (TAU) control group. Medical comorbidities and health outcomes will also be compared across the groups. This study is the first to study the efficacy of RF for health outcomes and comorbidities. Design Randomized Controlled Trial. Setting Acute Care, Post-acute Rehabilitation Hospital, and Community. Participants A total of 48 participants with TBI were recruited prior to discharge from their acute care hospital. An unequal randomization ratio was used favoring the treatment group resulting in 30 participants randomized to the treatment group and 18 participants randomized to the control group. All participants, regardless of group assignment, received follow up calls every three months to collect outcome measures. Interventions Resource Facilitation is an evidence based service navigation intervention that has been shown to improve employment rates, level of disability, and decrease unmet needs in the post-acute brain injury population. In this study, we also employed a collaborative care resource facilitation model. Main Outcome Measures Level of disability was assessed with the Mayo-Portland Adaptability Inventory-IV (MPAI-4) which is a measure developed specifically for people with TBI and provides multiple indices of recovery and level of disability. HRQOL was measured with the Patient-Reported Outcomes Measurement Information System (PROMIS) resulting in a total score as well several individual measures of HRQOL including fatigue, physical functioning, emotional health, and pain. Results Final results will include comparisons between the RF and TAU groups on level and trajectory of disability, HRQOL, medical comorbidities, and health outcomes. Conclusions Pending completion of statistical analyses. Author(s) Disclosures None.

Practitioners and researchers use vulnerability indices to understand the conditions that influence hazard risk. However, there has been little research on how well such indices depict household-scale vulnerability to specific hazards. We examined relationships between an all-hazard index and a hazard-specific index with household-level adaptive resources, adaptive behaviors, proximate sensitivities, and self-reported health outcomes related to extreme heat. Household measures were drawn from a stratified random sample survey conducted in Phoenix, Arizona, USA (n = 163). The results point to different experiences between households in more and less heat vulnerable areas. The largest differences between households stratified by the hazard-specific index (Heat Vulnerability Index) primarily involved adaptive resources and behaviors, whereas indicators of proximate sensitivity were more strongly differentiated by the all-hazard index (Social Vulnerability Index). Differences in health outcomes between more and less vulnerable neighborhoods were more evident using HVI than SoVI, although effect sizes using either index were small and confidence intervals were wide. The relationship between vulnerability indices and several survey measures varied across four study sites. The specific ways in which more and less vulnerable communities differ from one another varies based on the adaptation, sensitivity, or outcome measure of interest, location within the city, and choice of vulnerability index.