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Objective: To determine whether the time lag between blood culture draw and the start of shaking chills is associated with blood culture positivity. Methods: A prospective observational study was undertaken from January 2013 to March 2015 at a referral center in Okinawa, Japan. All enrolled patients were adults with an episode of shaking chills who were newly admitted to the division of infectious diseases. The study exposure was the time lag between blood culture draw and the most recent episode of shaking chills. Results: Among patients whose blood cultures were obtained within 2 h after shaking chills started, the blood culture positivity was 53.6% (52/97), whereas among patients whose blood cultures were obtained after more than 2 h, the positivity was 37.6% (44/117) (p = 0.019). The adjusted odds ratio of blood culture positivity for samples drawn within 2 h after shaking chills was 1.88 (95% confidence interval 1.01–3.51, p = 0.046). Escherichia coli were the most frequently detected bacteria (58/105). Conclusions: The positivity of blood cultures obtained within 2 h after the start of the most recent shaking chills was higher than that for blood cultures obtained after 2 h. Keywords: Blood culture, Shaking chills, Bacteremia, Sepsis, Shivering

The yellow fever 17D vaccine contains live-attenuated virus. Initial efficacy and safety reports were favorable. Recently, however, neurologic and viscerotropic adverse events (AE) were described. We managed a 61-year-old man who experienced meningomyeloradiculitis 18 days after receiving the yellow fever 17D vaccine. The manifestations were atypical. The cerebrospinal fluid contained high titers of anti-yellow fever immunoglobulins M and G and of anti-flavivirus immunoglobulins G. After methylprednisolone (1 g/day for 3 days), intravenous human immunoglobulins (140 g over 5 days), and two plasma exchanges, the symptoms improved only slightly. Neurological adverse events after yellow fever vaccination are rare or underestimated. To our knowledge, this is the first reported case of meningomyeloradiculitis after yellow fever vaccination. A remarkable feature is the intrathecal production of yellow fever antibodies, which probably played a pathogenic role and may have been related to a recent episode of influenza.

Several studies have shown that a considerable proportion of horses are eliminated from endurance rides due to lameness and metabolic problems. Limited information is available on specific veterinary issues in endurance horses and there are no descriptive data on veterinary problems in a large population of endurance horses. The aim of this study was to describe veterinary problems occurring in endurance horses in England and Wales, the regions of the United Kingdom where endurance rides are organised and regulated by Endurance Great Britain (Endurance GB). A comprehensive online self-completed questionnaire was used for data collection (30th December 2015-29th February 2016) All members of Endurance GB who were the main rider of one or more endurance horses were eligible to participate. From the target population of 1209 horses, 190 questionnaires were completed by riders, resulting in a 15.7% response rate. The most common rider-reported veterinary problem was lameness, affecting 152/190 (80.0%) of endurance horses at some point during their careers and 101/190 (53.2%) of horses in the previous 12 months. Detailed information on the most recent episode of lameness was available for 147 horses. Seventy-six percent of these lameness episodes (112/147) had been initially identified by a veterinarian, but only 52% of these lameness episodes were investigated further by a veterinarian, despite the high proportion of horses affected by lameness and the proportion of horses with recurrent lameness episodes. The second most common veterinary problem was thoracolumbar region pain, followed by non-specific cough, skin disease and colic. Education of endurance riders may improve the number, quality and timing of veterinary investigations, especially for lameness and thoracolumbar region pain.

During the past three decades the global oil market has seen significant price volatility. Literature to date has not analysed the cross-country effect of the recent episode of price instability. Previous studies have either not considered this period or have not utilised panel data techniques and therefore have not provided a comparative analysis of developed and developing countries. This paper explores the income and price elasticities between these two country groups and discusses the economic implication of the results. We use a panel data analysis accounting for income and price asymmetry and apply the dynamic fixed-effects methodology to separate panels for developed and developing countries for the period 1980–2012. Sixteen countries are included in this analysis which account for over 65% of total global oil consumption. A particular focus is on the income and substitution effects. The results indicate heterogeneous response to oil price shocks. Developing countries have an income effect 6.3 times stronger than developed countries. The substitution effect in developed countries is 2.1 times stronger than in developing countries. Policy recommendations include the pursuing of oil-efficiency improving technology, and ensuring that regional consumption pattern variations are considered in policy formation.

Aim To explore the prevalence of residual symptoms (both depressive and manic) and their correlates in subjects with bipolar disorder in clinical remission. Methodology This multicentric cross-sectional study included patients in clinical remission recruited across the 14 centers. The patients were evaluated on the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) for the prevalence of residual symptoms. A score of ≤7 on both scales defined the presence of residual symptoms. Results Four-fifth (79.8%) of the participants had residual symptoms, with 130 (16.8%) having only residual depressive symptoms, 74 (9.6%) having only residual manic symptoms, and 413 (53.4%) having both depressive and manic residual symptoms, on HDRS and YMRS. The residual symptoms were related to the polarity of the most recent episode and the lifetime predominant polarity. Higher numbers of lifetime depressive episodes are associated with higher residual depressive symptoms, and higher numbers of lifetime manic episodes are associated with higher chances of having residual manic symptoms. Conclusions A large proportion of patients with bipolar disorder have residual symptoms during the remission phase. Clinicians need to make efforts to identify and address the same to improve the treatment outcome.

The current study examined event-level characteristics (e.g., contextual factors, risk behaviors) during the most recent episode of Molly use among a sample of college students who reported previously using Molly. Participants ( N = 151; 66.7% female) were drinkers aged 18 to 25 years. Data were collected from October to November 2014, February to April 2015, and September to November 2015. Participants completed measures regarding typical Molly use and items related to context and behaviors during their most recent episode of Molly use. Findings revealed that our sample most commonly reported using Molly earlier in the evening while hanging out with friends or at a party. In addition, sexual and other drug use behaviors commonly occurred when using Molly. Findings provide preliminary information in guiding future work exploring Molly use and potential substance-related issues associated with the context of when and how Molly is consumed.

Separate lines of research find that proaggressive attitudes promote peer aggression and that bystanders play a pivotal role in deterring or facilitating bullying behavior. The current study hypothesized that proaggressive attitudes in middle school would deter students from standing up to bullying and encourage them to reinforce bullying behavior. Middle school students (n = 28,765) in 423 schools completed a statewide school climate survey that included an aggressive attitudes scale and their bystander response to a recent episode of bullying, which was categorized as upstanding, reinforcing, or passive. Multilevel logistic regressions indicated that higher aggressive attitudes were associated with less upstanding behavior at the school level and less upstanding behavior and more reinforcing behavior at the individual level, while controlling for other school and student demographic variables. These findings suggest that antibullying programs might address student attitudes toward aggression as a means of boosting positive bystander intervention.

In this paper we investigate the impact of changes in proved reserves on U.S. stock returns using firm level data of the largest U.S. oil and gas companies. The selected sample covers the period 2009 to 2018 incorporating the recent episode of the shale oil and gas revolution. In contrast to previous studies, our results show that changes in proved oil and gas reserves have no significant effect on stock returns. We also give evidence of the impact of reserves on financial returns being dependent on the level of oil prices. Since oil prices fell abruptly after 2014, we show a significantly lower effect of oil reserves in stock returns in this subperiod and, thus, partly explain the overall insignificant effect.

The recent episode of the financial meltdown has drawn attention to global imbalances, raising concerns about inability to sustain low saving rates in the USA. The objective of this paper is to shed light on the downward trend in household savings in the USA starting in the mid-1990s. In addition to the theoretical determinants of household savings, the paper's innovation is in tracing the effect of the widely tracked consumer sentiment index on savings. Applying the dynamic autoregressive distributed lag model with bounds testing approach, the evidence confirms the relevance of the consumer sentiment index as an important factor that affects household savings, both in the short-run and long-run.

This paper examines the importance of house prices on the US business cycle since the mid-1970s. The point of departure is to construct and estimate a baseline Markov-switching common factor model in which the co-movement of several individual economic series and the inherently different behavior of the economy across expansion/recession phases are accommodated. The importance of house price variables is then evaluated by comparing the results of the baseline model and those of the extended models that have been augmented with the house price variables. Two strands of extended models are considered: one in which house prices directly affect the individual macroeconomic series (and thereby the business cycle) and another in which house prices affect the probabilities of transitions between expansion/recession phases. The results for the first extension support that only house price decreases have nontrivial effects on the movements in macroindicators (and consequently on the business cycle), while house price increases do not. In the second extension, we find strong evidence that changes in house prices significantly affect the transition of the US economy between the recession–expansion phases. It is also reaffirmed that the influence of house price decreases is more important than that of the increases. Finally, the above results are generally robust to using a different data frequency, a subsample of the data excluding the recent episode of housing boom–bust, replacing house price with housing permits, and incorporating financial variables as additional driver of the business cycle.

When more scientists describe independently the same species under different valid Latin names, a case of synonymy occurs. In such a case, the international nomenclature rules stipulate that the first name to appear on a peer-reviewed publication has priority over the others. Based on a recent episode involving priority determination between two competing names of the same fungal plant pathogen, this letter wishes to open a discussion on the ethics of scientific publications and points out the necessity of a correct management of the information provided through personal communications, whose traceability would prevent their fraudulent or accidental manipulation.

The U.S.-based Financial Accounting Standards Board (FASB) emphasizes that accounting standard-setting is not and should not be regarded as a �political process.� Employing the case of accounting for stock compensation, I examine a recent debate in which FASB appears to have successfully established and maintained a boundary between a technical accounting process and politics. This case is interesting because an earlier, failed effort to expense stock compensation was described as highly politicized. However, the boundary between technical and political processes was maintained in the more recent episode. I find that a focus on due process, characterizations of existing accounting requirements as anomalous and available measurement methods as reliable, and warnings about the dangers of injecting �politics� into standard-setting were important to this boundary work. I also find that the boundary work required considerable interpretive flexibility in selecting (or ignoring) the evidence to be used in justifying the standard-setting project and its conclusions. I conclude by suggesting that a different understanding of what it means to be involved in a �political process� might help all parties understand more fully what is taking place during the accounting standard-setting process. Attention could be turned to developing processes to facilitate debates over which values should guide decisions occurring throughout the standard-setting process. To this end, an enhanced standard-setting process might allow for increased participation in agenda setting, in framing and scoping standard-setting projects, and in providing opportunities for nonexperts to participate.

We assessed sexually transmitted infection risk behaviours and desire to discuss mental health, as reported by 426 HIV-infected men who have sex with men receiving HIV care in eight urban clinics. Most of these patients (90%) had begun HIV care >1 year ago. In the past year, 74% had multiple sexual partners, 75% engaged in anal intercourse, 48% had >1 HIV-uninfected partner and 82% used illegal psychoactive drugs. Among those reporting anal intercourse, approximately 61 % reported using a condom during the most recent episode. Among all patients, 70% wanted to talk with their clinicians about how they felt mentally or emotionally. Using a two-tailed chi-squared test, we found that patients who engaged in unprotected receptive anal sex were more likely to want such a conversation than those who did not (80% versus 62%, P < 0.01); and those who engaged in unprotected insertive anal sex were also more likely to want such a conversation (81 % versus 63%, P < 0.01). The findings highlight the prevalence of risky sexual behaviour and of mental health concerns in the participating patient population. Patients reporting risky sexual behaviour were more likely to want to discuss how they felt mentally or emotionally than those not reporting such behaviour.

Background: Patients with acute pulmonary embolism (APE) with concomitant chronic heart failure (CHF) are characterized by higher mortality rates than APE patients without CHF. The aim of this study is to evaluate the potential impact of APE on early and long-term prognosis in patients with CHF. Methods: This study included 87 patients with CHF with suspected APE. Patients were divided into two groups according to spiral computed tomography results: one group with confirmed APE and one with excluded APE. Total and cardiovascular mortality in patients of both groups during a 6- and 36-month follow up period was assessed. Potential risk factors for mortality in patients with CHF in short and long-term observations were identified. Results: APE was diagnosed in 35 patients, and excluded in the remaining 52 patients. Total and cardiovascular 6-month mortality was higher in APE patients than in patients without APE: 34.3% and 28.5% vs. 13.4% and 11.5%, p = 0.02, p = 0.02, respectively. In 6-month follow-up the only independent risk factor for mortality was the presence of APE (HR = 2.7, 95% CI 1.1–24.4, p = 0.04). However, in the 36-month follow-up APE had no effect on mortality. Conclusions: Patients with CHF and acute episode of PE are characterized by a higher 6-month total and cardiovascular mortality rate following discharge from hospital compared to patients hospitalized due to acute CHF decompensation. Moreover, recent episode of PE in patients with CHF is an independent risk factor for early mortality in a 6-month follow-up.

Background: Few studies have evaluated the supernatural beliefs of patients with schizophrenia. This study aimed to study the personal beliefs, aetiological models and help seeking behaviour of patients with schizophrenia using a self-rated questionnaire. Materials and Methods: Seventy three patients returned the completed supernatural Attitude questionnaire. Results: 62% of patients admitted that people in their community believed in sorcery and other magico-religious phenomena. One fourth to half of patients believed in ghosts/evil spirit (26%), spirit intrusion (28.8%) and sorcery (46.6%). Two-third patients believed that mental illness can occur either due to sorcery, ghosts/evil spirit, spirit intrusion, divine wrath, planetary/astrological influences, dissatisfied or evil spirits and bad deeds of the past. 40% of the subjects attributed mental disorders to more than one of these beliefs. About half of the patients (46.6%) believed that only performance of prayers was sufficient to improve their mental status. Few patients (9.6%) believed that magico-religious rituals were sufficient to improve their mental illness but about one-fourth (24.7%) admitted that during recent episode either they or their caregivers performed magico-religious rituals. Conclusion: Supernatural beliefs are common in patients with schizophrenia and many of them attribute the symptoms of mental disorders to these beliefs.

During the recent financial crisis dedicated short bias (DSB) hedge funds exhibited extremely strong results while many other hedge fund strategies suffered badly. This article, prompted by this recent episode, investigates DSB hedge fund performance over an extended sample period, from January 1994 to December 2008. Performance and risk evaluation are carried out on an equally weighted DSB hedge fund portfolio using three different factor model specifications and both linear and nonlinear estimation techniques. The authors conclude that DSB hedge funds are a significant source of diversification for equity market investors and produce statistically significant levels of alpha. Their findings are robust to the specification of traditional and alternative risk factors, nonlinearity, and the omission of the crisis periods, which are particularly favorable for the DSB strategy.

We report the case of a patient with a long history of dysthymia and major depressive episodes requiring repeated hospitalization. We describe the most recent episode, associated with catatonia symptomatology and features suggestive of cognitive impairment. The absence of a clear initial psychopharmacological response alongside the clinical severity made the patient a potential candidate for electroconvulsive therapy (ECT). A regional cerebral blood flow SPECT (SPECT-rCBF), performed to rule out concomitant Alzheimer disease (AD), revealed a markedly decreased neocortical uptake, with no definitive pattern of concomitant primary cognitive impairment. Because a gradual clinical improvement was observed in the patient, with evidence of enhanced cerebral reperfusion in a second SPECT-rCBF study at two weeks after admission, the application of ECT was discounted and an expectant attitude was adopted.

The current study tested hypotheses derived from Joiner's (2005) interpersonal theory of suicide, which proposes that deliberate self-harm (DSH) becomes increasingly more reinforcing with repetition. One hundred six participants with a history of DSH completed questionnaires about their emotions and experience of physical pain during their most recent DSH episode. Consistent with prediction, people with more numerous past DSH episodes felt more soothed, more relieved, and calmer following their most recent episode of DSH. Contrary to prediction, greater numbers of past DSH episodes were associated with more intense physical pain during the most recent episode. The findings suggest that the emotion regulation functions of DSH may become more reinforcing with repetition.

Long–short hedge funds are often very highly levered, despite the costs of leverage that became apparent during the LTCM crisis in 1998 and the more recent episode in 2008. This note explores potential market imperfections that may explain the use of leverage.

To assess the long-term risk of developing permanent AF in relation to the signal-averaged P wave duration (SAPWD) and clinical and echocardiographic characteristics.In an observational study design we studied 131 patients with earlier ECG-documented AF and successfully restored sinus rhythm attending a long-term, follow-up visit at hospital or at home. Established permanent AF was examined in relation to primary clinical, echocardiographic, and electrophysiological parameters.Only prolonged SAPWD (p=0.006) was associated with an increased risk of development of permanent AF. The risk of permanent AF after 3 years follow-up was 0.72 with an SAPWD equal to 180 ms versus 0.39 with a normal SAPWD (130 ms). We found no prognostic effect of age, gender, dilated left atrium, long duration of AF history, or long duration of the most recent episode of AF. Co-existing hypertension reduced the risk of permanent AF; this could be explained by concomitant treatment with angiotensin-converting-enzyme-inhibitors.Prolonged SAPWD (a marker of atrial remodelling) appears to be a risk factor for long-term development of permanent AF.

Since the early 1980s, private, for‐profit corporations have become increasingly involved in all aspects of scientific research, especially of biomedical research. In this essay, I argue that there are dangerous epistemic consequences of this trend, which should be more thoroughly examined by social epistemologists. In support of this claim, I discuss a recent episode of pharmaceutical research involving the painkiller Vioxx. I argue that the research on Vioxx was epistemically problematic and that the primary cause of these inadequacies was faulty institutional arrangements. More specifically, the research was organized in such a way as to allow short‐term commercial interests to compromise epistemic integrity. Thus, the Vioxx case study, in conjunction with numerous case studies developed elsewhere, provides strong reasons for believing that the privatization of the biomedical sciences is epistemically worrisome, and it suggests that the primary response to this situation should be a social, or organiza...

Young injectors are a group with high-risk behaviours, particularly with respect to HIV infection and hepatitis C. A leading strategy to prevent these infections could be the prevention of injection, especially among the youngest individuals. We report analyses on initiation into drug injection from a prospective cohort study of street youth conducted in Montreal, Canada. Among 118 non-injector participants under 18 years of age followed for an average of 1.31 years, we estimated an incidence rate of injection of 22.7 per 100 person-years. Independent predictors of initiation were: a lifetime history of use of ≥4 types of drugs, recent daily alcohol drinking, a recent episode of homelessness, a lifetime history of rape, and recent involvement in survival sex. The observed high rate of initiation into injection clearly indicates that interventions to prevent injection should target especially adolescent street youth. These interventions should address simultaneously individual and structural factors, such ...

The series of directly observed sunspot numbers is nearly 400 years long. We stress that the recently compiled group sunspot number series is an upgrade of the old Wolf series and should always be used before 1850. The behavior of solar activity on longer time scales can be studied only using indirect proxies. Such proxies as aurorae occurrence or naked-eye sunspot observations are qualitative indicators of solar activity but can be hardly quantitatively interpreted. Cosmogenic isotope records provide a basis for quantitative estimate of the past solar activity. Here we overview the main methods of the long-term solar activity reconstruction on the centennial to multimillennia time scale. We discuss that regression-based reconstructions of solar activity lead to very uncertain results, while recently developed physics-based models raise solar activity reconstruction to a new level and allow studying its behavior on a multimillennia time scale. In particular, the reconstructions show that the recent episode of high solar activity is quite unusual in the multimillennia time scale.

Fusarium infections are important problem worldwide, cause a broad spectrum of infections in human including superficial infections as well as locally invasive and disseminated infections. We report a rare case of perinephric abscess caused by Fusarium chlamydosporum in a child who had a recent episode of pyelonephritis. This case illustrates the ever increasing spectrum of rare but offending pathogenic fungi in an immunocompetent host. Fungal infections should always be suspected in patients having one or the other underlying risk factor or who are unresponding to antibacterial therapy. Early diagnosis of infection with a specific pathogen may lead to changes in antifungal therapy and may be critical for an improved outcome.

Acute otitis media (AOM) is the most frequent bacterial disease and leading cause of antibacterial prescriptions in infants and children. Although AOM resolves spontaneously in most patients, antibacterial treatment is believed to be indicated in most industrial countries, particularly for infants, to prevent severe complications and relieve symptoms more rapidly. The classical duration of oral antibacterial therapy has been 10 days. During the last decade, the efficacy of shortened course antibacterial therapy has been demonstrated in many trials. Advantages of shorter treatment periods include less expense, better compliance, and potentially less impact on the commensal flora. However, short course antibacterial therapy may not be appropriate for children

The patient was a single, 36year-old white man. He was admitted to our institution due to agitated behavior and psychosis, with a diagnosis of bipolar I disorder from his most recent episode, which was mixed and severe with moodincongruent psychotic features. He presented with depressed mood of 3 weeks’ duration, associated with early and intermittent insomnia, decreased energy, racing thoughts, and psychomotor agitation. Furthermore, he exhibited persecutory delusions, believing that people were “out to get him,” and was thus physically aggressive to those he encountered. He denied any suicidal or homicidal ideations, and substance abuse screens returned with negative results. The patient was diagnosed with myasthenia gravis at 19 years, but because he was “living on the streets,” he failed to receive adequate treat

MARK VONNEGUTThirty-eight years ago, in the midst of a psychotic illness that included hearing voices and paranoid ideation, I was diagnosed with schizophrenia. During my most recent episode 24 yea...

Culp (1994) provides a defense for a form of experimental reasoning entitled ‘robustness’. Her strategy is to examine a recent episode in experimental microbiology—the case of the mistaken discovery of a bacterial organelle called a ‘mesosome’—with an eye to showing how experimenters effectively used robust experimental reasoning (or could have used robust reasoning) to refute the existence of the mesosome. My plan is to criticize Culp's assessment of the mesosome episode and to cast doubt on the epistemic significance of robustness. In turn, I present a different account of the experimental reasoning microbiologists used in arriving at the conclusion that mesosomes are artifacts. I call this form of reasoning ‘reliable process reasoning’, and close the paper with a brief discussion of how experimental microbiologists justify the claim that an experimental process is reliable.

During the last 500 years large numbers of herring have occasionally appeared in winter along the Swedish Skagerrak coast. These “Bohuslan” herring periods, sometimes lasting for several decades, were probably caused by a temporary shift of the over-wintering grounds of North Sea herring. In normal years North Sea herring over-winter in the adjacent waters of the northeastern North Sea. As yet there is no commonly accepted explanation for the occasional shifts of the over-wintering grounds towards the Skagerrak.The environmental cause of the Bohuslan herring periods was investigated by looking at the most recent episode of herring invasions in the Skagerrak. In the winters of 1962-1965 large numbers of North Sea herring again entered the Skagerrak and these invasions showed many features of the old Bohuslan herring periods. The only anomalous environmental parameter at this time was a high frequency of easterly winds in the autumns of 1962 and 1963. It is assumed that these easterly winds forced surface water out of the Skagerrak and thereby strengthened the subsurface Norwegian Trench Current that flows into the Skagerrak. This current could easily transport herring from the normal over-wintering area near Egersund Bank towards the Skagerrak. It is shown that former Bohuslan or Skagerrak herring periods started in years when the North Atlantic Oscillation was in a negative phase and when easterly winds must have dominated in autumn too.Bohuslan herring periods were more persistent than the periods of easterly winds. The persistence of the herring migrations is explained by “site-fidelity” of the older herring. Once a new migration has been adopted by the population it is repeated in subsequent years even when the original environmental cause has disappeared. An existing migration pattern can be changed only by a new, strong year class, that has not yet developed an attachment to the traditional over-wintering area. It is shown that the two most recent episodes of Skagerrak invasions were indeed initiated by strong recruiting year classes.

SummaryThe object of this study was to analyse the results of laparoscopic cholecystectomy (LC) without previous endoscopic retrograde cholangiopancreatography (ERCP) in mild acute biliary pancreatitis (ABP) patients once the acute attack had resolved. Seventy-six patients were operated on after a recent episode of mild ABP, as determined by the presence of three or less positive Ranson-Imrie criteria (ABP-Group). Depending on the proximity of LC to the ABP attack, the ABP-Group was further divided into two subgroups. Forty patients were operated on during the first 2 weeks after the onset of pancreatic symptoms (early-LC subgroup), and 36 were operated on between 16 and 60 days (delayed-LC subgroup). The results are compared with 411 patients who underwent LC for uncomplicated cholelithiasis (Control-Group) during the same period. The operative time and incidence of common bile duct stones were significantly superior in the ABP-Group (p

W i d c l YOUR PATIENTS will be asking you about awareness under anesthesia quite a bit more in the near future. That’s because the subject has been a popular point of discussion in Hollywood. A recent episode of the TV series Nip/ Tuck dealt with awareness and, of course, the big blockbuster movie Awake (Fig 1) will be coming out in the fall. Anyone who has watched the medical dramas ER or Grey’s Anatomy knows that sometimes certain liberties are taken with the facts; however, many of our patients do not know that. The bloggers are already complaining that anesthesia healthcare providers have engaged in a conspiracy of keeping the problem of anesthetic awareness secret from the general public.

A bill came before the Senate in 1995 that was designed to "pro tect" the American flag. The measure failed to pass, but for many Americans, the attempt was only the most recent episode in a long and tragic story of flag protectionism which belies what the flag stands for. One part of this story, a practice called pledging allegiance to the American flag, has been part of American school ritual for decades.1 Few Americans object to this exercise; most persons willingly partici pate because they see it as purposeful in instilling a sense of loyalty and devotion to their country. Some religious groups, though, strongly ob ject to taking part. These include the Jehovah's Witnesses,2 some Men nonite groups,3 the Jehovites, the Elijah Voice Society, the Church of God, the Amish, the Christadelphians, and the Molokans.4 The Jeho vah's Witnesses (often called Witnesses) claim American adherents of

ObjectivesBipolar I most recent episode-manic (BP-I-M) is an important cause of morbidity and mortality in hospitalized patients. While BP-I-M has been extensively studied in the past, the contemporary data for impact of BP-I-M on cost of hospitalization are largely lacking.MethodsWe queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS) dataset between 1998–2011 using the ICD-9 codes. Severity of comorbid conditions was defined by Deyo modification of Charlson comorbidity index. Primary outcome was in-hospital mortality and secondary outcome was total charges for hospitalization. Using SAS 9.2, Chi2 test, t-test and Cochran-Armitage test were used to test significance.ResultsA total of 10,875 patients were analyzed; 57.13% were female and 42.87% were male (P < 0.0001); 74.78% were white, 14.51% black and 10.71% of other race (P < 0.0001). Rate of hospitalization increased from 528.71/million to 588.76/million from 1998–2011. Overall mortality was 0.42% and mean cost of hospitalization was 22,215.77$. The in-hospital mortality increased from 0.37% to 0.82% (P < 0.0001) and mean cost of hospitalization increased from 10,580.54$ to 40,737.65$. Total spending on BP-I-M related admissions have increased from $44.24 million/year to $187.00 million/year.ConclusionsWhile mortality has slightly decreased from 1998 to 2011, the cost has significantly increased from $44.24 million/year to $187.00 million/year, which leads to an estimated $ 142.76 million/year additional burden to US health care system from. In the era of cost conscious care, preventing BP-I-M related hospitalization could save billions of dollars every year. Focused efforts are needed to establish preventive measures for BP-I-M related hospitalization.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Differences between early- and delayed-responders to antipsychotic medication as a marker of subsequent symptom change to 18months are unknown.To examine the association between initial non-, early- and delayed-response and subsequent symptom change up to 18months in the antipsychotic treatment of the symptoms of recent-episode schizophrenia.Participants were from a double-blind randomized clinical trial of recent episode schizophrenia (n=263). Based on attainment of a 20% PANSS total change in the initial four weeks, the following groups were created and compared: "non-" (i.e., no-response): "early-" (i.e. within 2weeks) and "delayed-" (i.e. 3-4weeks) responders. Mixed modeling was used to predict PANSS percent change with group, time and the time-group interaction.Analysis of the PANSS total percent change showed significant (p.01) group, time, and time-group interaction effects. Compared to non-responders, early-responders maintained significantly greater total response from week 5 to 44, and delayed-responders from week 5 to 20. After this time, non-responders and the other groups did not significantly differ on change. Generally, differences between the delayed- and early-responders were not statistically significance. Results were similar on the PANSS positive, negative and general psychopathology symptom subscales.Early-response is marked by up to 39weeks of longer subsequent symptom response than non-response, and infrequently differs to delayed-response. This has implications for consideration of switching and clinical trial design.

Moreno Glacier has been consistently advancing during a period of general glacier retreat this century, and has repeatedly dammed an arm of Lago Argentino. The most recent episode of ice-dam failure and catastrophic lake drainage occurred in 1988. However, the recent periodicity of this behaviour has now been interrupted, and the current characteristics of the terminus suggest a future retreat. Because of the nature of calving dynamics, such a retreat would be rapid and irreversible in the short term. Neighbouring Ameghino Glacier, after almost a century of near-stagnation, commenced calving in a newly formed proglacial lake in about 1967 and then retreated 3 km at a mean rate of 334myr-1 for the next nine years in a fashion analagous to that predicted for Moreno Glacier. The behaviour of these glaciers cannot be related directly to regional climate trends; terminus response is more closely controlled by the interplay between calving dynamics and topography. Calving is therefore a potentially significant factor in glacio-climatic reconstruction, even in 'terrestrial' settings.

Thai traditional massage is a widely used massage technique in Thailand and is presently accepted by local Thai Ministry of Public Health. The technique is promoted but not well accepted internationally. There is a concern about the effectiveness as well as safety of this local wisdom. After a recent episode of concurrent acute heart attack and Thai traditional massage in a patient, the issue of possible adverse effects of Thai traditional massage is being widely discussed.

In contrast to the trial design of acute mania studies, there is no standard design for bipolar maintenance studies. Over the past 15 years, the design of monotherapy maintenance studies in bipolar disorder has evolved significantly, but recent study designs continue to differ in important ways.We reviewed the design of recent controlled bipolar maintenance studies, using PubMed, from August 2006 to August 2009, examining the strengths and weaknesses of different study design features.Design differences are sufficiently important that the disparate results across maintenance studies may reflect either true differences in medication efficacy or the effects of these design differences on outcome. Design elements such as recent episode polarity, stabilization criteria, using enriched versus nonenriched samples, length of stabilization before randomization, length of experimental phase, and recurrence outcome criteria are critical factors that differ widely across studies and likely play a role in study outcome.As consensus for trial designs for bipolar maintenance therapy is developed, it will be easier to develop algorithms for maintenance treatment based on results from studies as opposed to clinical opinions.

The Llobregat River is a basic drinking water resource for the city of Barcelona, meeting 40% of the demand. The river runs through a densely populated industrial area, so that it has in its history experienced various episodes due to industrial spills. The present work deals with a recent episode involving diacetyl. To the best of our knowledge this episode is the first time that this compound has been identified as an odour-causing compound in water. In a previous work the analytical method used for the identification of the compound causing the episode was described. The present work focuses its attention on how the episode was handled: action taken at the Sant Joan Despí water treatment plant and the sampling strategy on the river that led to the identification of the company responsible for the spill, a paper mill. It also deals with the role played by the FPA panel in the resolution of the episode: organoleptic description of samples of the problem in the initial phase of the episode (from the treatment plant, distribution network and customer complaints) and, once the compound responsible was identified, the determination of its organoleptic characteristics (odour threshold, odour descriptors, Weber-Fechner curve).

Learning Point for Clinicians Ischaemic strokes are a cause of pathological laughter (PL). PL can be an acute or delayed presentation of strokes. Several neuroanatomical sites have been implicated in PL. PL can be mood incongruent or it can be exaggeration of a normal response. As with action and cognition, acute disturbance of emotional expression should also be recognized as having a neural basis. Serotonin reuptake inhibitors have been used in the management of delayed-onset PL after strokes. A 58-year-old man was referred to clinic with a complaint of episodic laughter. He had been playing charades with his family at Christmas when he found himself unable to continue owing to uncontrollable laughter. Though the game had been lively, nothing especially amusing had occurred. He thought little of it, until the episode recurred at a funeral, where he laughed throughout the service without any cause, and was profoundly embarrassed. The most recent episode was while visiting …

A 19-year-old young man presents in your outpatient clinic with a history of palpitations. He had had one episode a few weeks ago but that episode terminated spontaneously. Another, more recent episode, had to be terminated in the hospital. His medical history is unremarkable and his family history reveals a pacemaker implant at age 42 in his mother’s brother. Physical examination reveals no abnormalities. His ECG is shown in Fig. 1. What would be your diagnosis? Fig. 1 ECG at presentation Answer You will find the answer elsewhere in this issue.

A 60-year-old woman underwent computed tomography imaging of her chest because of a recent episode of hemoptysis. The scan did not show any abnormalities in the thorax. However, unenhanced scans showed a strikingly hyperdense spleen (mean attenuation value 174 [normal 56–65] Hounsfield units) ([

According to data from the 1991 National Survey of Adolescent Males condom use is likely to be highest at the beginning of relationships and to decline as the relationship continues. The proportion of sexually active men aged 17-22 who used a condom with their most recent partner declined from 53% the first time they had intercourse with that partner to 44% at the most recent episode. Condom use also decreases with age; 59% of 17-18 year olds used a condom the first time they had intercourse with their most recent partner compared with 56% of 19-20 year olds and 46% of 21-22 year olds. However the probability that the female partner used the pill the first time that the couple had sex increased with the mans age--from 21% among 17-18 year olds to 35% among 21-22 year olds. Young men were more likely to have used a condom if they thought their partner was sexually inexperienced and less likely to have done so if they suspected their partner was at high risk for an STD. (authors)

Summary. The case is presented of a boy with an autoimmune haemolytic anaemia of 10 years duration. He had a positive direct antiglobulin test with IgG and complement detected on the red cells and with IgG autoantibodies in the serum. During a recent episode of severe haemolysis, the Hb level fell to 3.8 g/dl and the direct antiglobulin test became negative although his autoantibodies still reacted with all the red cells in a panel. The serum reacted more strongly with C- and e-positive cells. The Rh phenotype of the patient was CcDee as it had always been. Possible explanations of the unexpected findings are discussed.

SUMMARYOutbreaks of epidemic keratoconjunctivitis have occurred among workers in shipyards and other industrial concerns in the West of Scotland in 1956, 1967 and 1971–72. In the most recent episode 220 persons were known to be affected and those mainly involved were shipyard personnel working on the open decks of ships under construction; only a few non-industrial workers were affected. As in previous outbreaks adenovirus type 8 was shown to be the causal organism. It is likely that spread of the virus was probably facilitated in some of the patients by such procedures as first aid measures to remove foreign bodies from the eye. A survey of the family contacts of those affected in 1971–72 revealed that only 2% were secondarily infected. This was probably due to propaganda measures to discourage the use of communal face towels, etc.Despite close virological surveillance over a period of 6 years of patients attending opthalmic clinics in the West of Scotland, there is as yet no clue to the whereabouts of adenovirus type 8 during interepidemic periods. It is suggested that travellers might be responsible for the introduction of the infection into an area.

Presentation of Case A 65-year-old woman was admitted to the hospital because of a question of recurrent pancreatitis. She was well until five years earlier, when she experienced an attack of pain in the epigastrium, right upper quadrant, and back, accompanied by nausea and jaundice. Laboratory studies showed abnormal results of liver-function tests and an elevated amylase level. The episode subsided, but four bouts of identical symptoms occurred during the succeeding five years. Four months before admission, after the most recent episode of pain, an attempted endoscopic retrograde cholangiopancreatographic (ERCP) examination performed at another hospital revealed a submucosal mass in . . .

An 18-year-old male developed recurrent myoglobinuria after prolonged physical exertion. Histochemical analysis of biopsied muscle revealed complete absence of carnitine palmityltransferase. Significant ultrastructural abnormalities of muscle were present, but these could be the result of the recent episode of rhabdomyolysis. Recurrent myoglobinuria can occur in several disorders of glycogen and lipid metabolism in muscle, and such disorders should be suspected in cases of unexplained recurrent myoglobinuria.

Presentation of Case A thirty-eight-year-old man was admitted to the hospital because of diarrhea. During the four years before entry there were four or five episodes of diarrhea, each persisting for two or three weeks except for the most recent episode, which lasted for about ten weeks. During these episodes the patient passed five or six loose or watery stools daily, including nightly bowel movements. There was no blood or mucus or associated vomiting. Abdominal pain rarely occurred. He lost 14 pounds in weight and was weak. Iodoquin therapy afforded no relief, although he believed that it had occasionally been . . .