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Despite the availability of effective vaccines against COVID-19, booster vaccinations are needed to maintain vaccine-induced protection against variant strains and breakthrough infections. This study aimed to investigate the efficacy, safety, and immunogenicity of the Ad26.COV2.S vaccine (Janssen) as primary vaccination plus a booster dose.ENSEMBLE2 is a randomised, double-blind, placebo-controlled, phase 3 trial including crossover vaccination after emergency authorisation of COVID-19 vaccines. Adults aged at least 18 years without previous COVID-19 vaccination at public and private medical practices and hospitals in Belgium, Brazil, Colombia, France, Germany, the Philippines, South Africa, Spain, the UK, and the USA were randomly assigned 1:1 via a computer algorithm to receive intramuscularly administered Ad26.COV2.S as a primary dose plus a booster dose at 2 months or two placebo injections 2 months apart. The primary endpoint was vaccine efficacy against the first occurrence of molecularly confirmed moderate to severe-critical COVID-19 with onset at least 14 days after booster vaccination, which was assessed in participants who received two doses of vaccine or placebo, were negative for SARS-CoV-2 by PCR at baseline and on serology at baseline and day 71, had no major protocol deviations, and were at risk of COVID-19 (ie, had no PCR-positive result or discontinued the study before day 71). Safety was assessed in all participants; reactogenicity, in terms of solicited local and systemic adverse events, was assessed as a secondary endpoint in a safety subset (approximately 6000 randomly selected participants). The trial is registered with ClinicalTrials.gov, NCT04614948, and is ongoing.Enrolment began on Nov 16, 2020, and the primary analysis data cutoff was June 25, 2021. From 34 571 participants screened, the double-blind phase enrolled 31 300 participants, 14 492 of whom received two doses (7484 in the Ad26.COV2.S group and 7008 in the placebo group) and 11 639 of whom were eligible for inclusion in the assessment of the primary endpoint (6024 in the Ad26.COV2.S group and 5615 in the placebo group). The median (IQR) follow-up post-booster vaccination was 36·0 (15·0-62·0) days. Vaccine efficacy was 75·2% (adjusted 95% CI 54·6-87·3) against moderate to severe-critical COVID-19 (14 cases in the Ad26.COV2.S group and 52 cases in the placebo group). Most cases were due to the variants alpha (B.1.1.7) and mu (B.1.621); endpoints for the primary analysis accrued from Nov 16, 2020, to June 25, 2021, before the global dominance of delta (B.1.617.2) or omicron (B.1.1.529). The booster vaccine exhibited an acceptable safety profile. The overall frequencies of solicited local and systemic adverse events (evaluated in the safety subset, n=6067) were higher among vaccine recipients than placebo recipients after the primary and booster doses. The frequency of solicited adverse events in the Ad26.COV2.S group were similar following the primary and booster vaccinations (local adverse events, 1676 [55·6%] of 3015 vs 896 [57·5%] of 1559, respectively; systemic adverse events, 1764 [58·5%] of 3015 vs 821 [52·7%] of 1559, respectively). Solicited adverse events were transient and mostly grade 1-2 in severity.A homologous Ad26.COV2.S booster administered 2 months after primary single-dose vaccination in adults had an acceptable safety profile and was efficacious against moderate to severe-critical COVID-19. Studies assessing efficacy against newer variants and with longer follow-up are needed.Janssen ResearchDevelopment.

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis.To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results.Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results.Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count4 × 103 cells/mm3 and procalcitonin0.5 ng/mL.Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

ImportanceBladder-preserving trimodality therapy can be an effective alternative to radical cystectomy for treatment of muscle-invasive bladder cancer (MIBC), but biomarkers are needed to guide optimal patient selection. The DNA repair protein MRE11 is a candidate response biomarker that has not been validated in prospective cohorts using standardized measurement approaches.ObjectiveTo evaluate MRE11 expression as a prognostic biomarker in MIBC patients receiving trimodality therapy using automated quantitative image analysis.Design, Setting, and ParticipantsThis prognostic study analyzed patients with MIBC pooled from 6 prospective phase I/II, II, or III trials of trimodality therapy (Radiation Therapy Oncology Group [RTOG] 8802, 8903, 9506, 9706, 9906, and 0233) across 37 participating institutions in North America from 1988 to 2007. Eligible patients had nonmetastatic MIBC and were enrolled in 1 of the 6 trimodality therapy clinical trials. Analyses were completed August 2020.ExposuresTrimodality therapy with transurethral bladder tumor resection and cisplatin-based chemoradiation therapy.Main Outcomes and MeasuresMRE11 expression and association with disease-specific (bladder cancer) mortality (DSM), defined as death from bladder cancer. Pretreatment tumor tissues were processed for immunofluorescence with anti-MRE11 antibody and analyzed using automated quantitative image analysis to calculate a normalized score for MRE11 based on nuclear-to-cytoplasmic (NC) signal ratio.ResultsOf 465 patients from 6 trials, 168 patients had available tissue, of which 135 were analyzable for MRE11 expression (median age of 65 years [minimum-maximum, 34-90 years]; 111 [82.2%] men). Median (minimum-maximum) follow-up for alive patients was 5.0 (0.6-11.7) years. Median (Q1-Q3) MRE11 NC signal ratio was 2.41 (1.49-3.34). Patients with an MRE11 NC ratio above 1.49 (ie, above first quartile) had a significantly lower DSM (HR, 0.50; 95% CI, 0.26-0.93; P = .03). The 4-year DSM was 41.0% (95% CI, 23.2%-58.0%) for patients with an MRE11 NC signal ratio of 1.49 or lower vs 21.0% (95% CI, 13.4%-29.8%) for a ratio above 1.49. MRE11 NC signal ratio was not significantly associated with overall survival (HR, 0.84; 95% CI, 0.49-1.44).Conclusions and RelevanceHigher MRE11 NC signal ratios were associated with better DSM after trimodality therapy. Lower MRE11 NC signal ratios identified a poor prognosis subgroup that may benefit from intensification of therapy.

Opioids are prescribed excessively following surgery. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative opioid use.A quality improvement initiative to reduce inpatient opioid prescribing was launched at a tertiary cancer center. In Phase I (December 2019-July 2020), providers were instructed to start standing acetaminophen. In Phase II (beginning August 2020), education was provided to the entire care team and ordersets were modified to an opioid sparing protocol (OSP). We analyzed the proportion of minimally invasive surgery (MIS) prostatectomy and nephrectomy patients that adhered to an OSP during each phase and compared them to controls from the preceding 2 years.A total of 303, 153, and 839 patients underwent MIS during the Phase I, Phase II, and control periods respectively. The proportion of patients adhering to an OSP increased from 16% at the beginning of Phase I to 76% at the end of Phase II (p-trend0.001). The median total oral morphine equivalents for oral opioids declined from 20 mg and 40 mg at baseline for prostatectomy and nephrectomy patients respectively to 0 mg for both groups (p-trends0.001). Multivariable analysis found that patients received 22% and 81% less oral morphine equivalents during Phase I and II respectively compared to the control period (P0.001).Adherence to an OSP is most effective when initiatives incorporate the entire team and are supported by nudge theory-based structural changes. Using these strategies, most patients following urologic MIS can dramatically reduce opioid use postoperatively.

Background: Urinary tract infections (UTIs) are the most common serious bacterial infection in young febrile infants, and the urinalysis (UA) is an accurate screening test for emergency department (ED) evaluation. Precise estimates of risk of concomitant bacteremia and/or bacterial meningitis (invasive bacterial infections; IBI) in febrile infants ≤ 60 days have been based on presence of UTIs rather than positive UAs, and lack large prospective study. Objective: We sought to determine the prevalence of IBIs in febrile infants 0-28 …

Importance In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

The Flora asteroid family’s size and location on the inner edge of the main belt make it a likely source of NEOs and terrestrial planet impactors; however, reliable determination of Flora membership is inhibited by the family’s age and the presence of a high density of background objects. Dykhuis et al. (Dykhuis et al. [2014]. Icarus 243, 111–128) identified the Flora family as the product of a 950-My-old collision dispersed in semimajor axis as a result of the Yarkovsky effect, and defined the family’s membership and extent in orbital parameter space. The observed preponderance of prograde rotators at semimajor axes greater than that of (8) Flora is consistent with the predictions of the single-collision Yarkovsky dispersion model. Here we extend the available rotational property data for the Flora family via a survey of 21 Flora-region asteroids, using a time-efficient modification of the “epoch method” to determine prograde/retrograde spin sense. Five of the survey asteroids are shown to be prograde; five are shown to be retrograde; six are shown to have spin axes in or near their orbital planes; and five represent other cases for which spin axis information was not determined. The high-semimajor axis component of the Flora family is found to have only prograde and in-plane rotators, consistent with model predictions of Yarkovsky dispersion. Moreover, we confirm a wide range of ecliptic latitudes of the spin axes among these prograde rotators, consistent with models of family evolution in which a significant fraction of the members are captured in spin–orbit resonance. Near the “center” of the family (near the semimajor axis location of (8) Flora), the spin directions are mixed, with a slight preference for retrograde rotators, placing constraints on the efficiency of YORP-cycle spin reorientation for the family. In addition to our spin sense survey, we also report new measurements of the Sloan colors of a number of large inner main belt asteroids.

The Nysa-Polana complex is a group of low-inclination asteroid families in the inner main belt, bounded in semimajor axis by the Mars-crossing region and the Jupiter 3:1 mean-motion resonance. This group is important as the most likely source region for the target of the OSIRIS-REx mission, (101955) Bennu; however, family membership in the region is complicated by the presence of several dynamically overlapping families with a range of surface properties. The large S-type structure in the region appears to be associated with the parent body (135) Hertha, and displays an ($e_\text{P},a_\text{P}$) correlation consistent with a collision event near true anomaly of ~180 degrees with ejecta velocity $v_\text{ej} \sim 285$ m/s. The ejecta distribution from a collision with these orbital properties is predicted to have a maximum semimajor axis dispersion of $\delta a_{ej} = 0.005 \pm 0.008$ AU, which constitutes only a small fraction (7\%) of the observed semimajor axis dispersion, the rest of which is attributed to the Yarkovsky effect. The age of the family is inferred from the Yarkovsky dispersion to be $300^{+60}_{-50}$ My. Objects in a smaller cluster that overlaps the large Hertha family in proper orbital element space have reflectance properties more consistent with the X-type (135) Hertha than the surrounding S-type family. These objects form a distinct Yarkovsky "V" signature in ($a_\text{P},H$) space, consistent with a more recent collision, apparently also dynamically connected to (135) Hertha. The Nysa-Polana complex also contains a low-albedo family associated with (142) Polana (called "New Polana" by Walsh et al. 2013), and two other low-albedo families associated with (495) Eulalia. The second Eulalia family may be a high-$a_\text{P}$, low-$e_\text{P}$, low-$i_\text{P}$ component of the first Eulalia family-forming collision, possibly explained by an anisotropic ejection field., Comment: 20 pages, 15 figures, accepted to Icarus

Study objective To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). Methods We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. Results Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections ( E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. Conclusion The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

The Flora family resides in the densely populated inner main belt, bounded in semimajor axis by the $\nu_6$ secular resonance and the Jupiter 3:1 mean motion resonance. The presence of several large families that overlap dynamically with the Floras (e.g., the Vesta, Baptistina, and Nysa-Polana families), and the removal of a significant fraction of Floras via the nearby $\nu_6$ resonance complicates the Flora family's distinction in both proper orbital elements and reflectance properties. Here we use orbital information from the Asteroids Dynamic Site, color information from the Sloan Digital Sky Survey, and albedo information from the Wide-field Infrared Survey Explorer to obtain the median orbital and reflectance properties of the Floras by sampling the core of the family in multidimensional phase space. We find the median Flora SDSS colors to be $a^*$ = 0.126 $\pm$ 0.007 and $i-z = -0.037 \pm 0.007$; the median Flora albedo is $p_V$ = 0.291 $\pm$ 0.012. These properties allow us to define ranges for the Flora family in orbital and reflectance properties, as required for a detailed dynamical study. We use the young Karin family, for which we have an age determined via direct backward integration of members' orbits, to calibrate the Yarkovsky drift rates for the Flora family without having to estimate the Floras' material properties. The size-dependent dispersion of the Flora members in semimajor axis (the "V" plot) then yields an age for the family of $910^{+160}_{-120}$ My, with the uncertainty dominated by the uncertainty in the material properties of the family members (e.g., density and surface thermal properties). We discuss the effects on our age estimate of two independent processes that both introduce obliquity variations among the family members on short (My) timescales: 1) the capture of Flora members in spin-orbit resonance, and 2) YORP-driven obliquity variation., Comment: 60 pages, 18 figures, Icarus, submitted

The surface of Europa displays numerous generations of intersecting arrays of linear ridges. At some locations along these ridges, older ridges on adjacent terrain appear to extend up the flank of a more recent ridge. It has thus been suggested that the ridges may have formed by upturning of that adjacent terrain. However, the newer ridges generally appear to be material deposited over the older terrain. Here we consider how the morphology of the overprinted topography may have been inherited by the more recent ridges. An analogous process occurs along some sediment-starved convergent plate boundaries on Earth, where the poorly consolidated material of a frontal prism of an overriding plate is pushed over preexisting ridges and seamounts on the downgoing plate. The overriding plate inherits the morphology of the downgoing plate even though the actual extension of that topography has been underthrust and buried. A well-studied example lies offshore of Costa Rica where the Caribbean plate overrides the Cocos plate. Experiments show other mechanisms as well: mass-wasting down a flank can result in extensions of adjacent ridges thanks to the geometry imposed by a constant angle of repose; in addition, more pronounced extensions of the older ridges result if the new ridge grows as it is bulldozed from behind (i.e., from the central groove of a double ridge on Europa). The shapes of the ridge extensions are distinctly different in these two cases. If tidal pumping extrudes material to the surface at the center of a double ridge, it might drive the latter mechanism. The ridge extensions observed on the flanks of more recent ridges may provide a crucial diagnostic of dominant ridge-building mechanisms when and if additional images are obtained at high resolution from future exploration. In additional to their morphology, the distribution of ridge extensions at only isolated locales may also provide constraints on ridge formation processes and their diversity.

In a multiplanet system, tides acting on the inner planet can significantly affect the orbital evolution of the entire system. While tides usually damp eccentricities, a novel mechanism identified by Correia et al. (2012) tends to raise eccentricities as a result of the tides' effect on the inner planet's rotation. Our analytical description of this spin-driven tidal (SDT) effect shows that, while the inner planet's eccentricity undergoes pumping, the process is more completely described by an exchange of strength between the two eigenmodes of the dynamical system. Our analysis allows derivation of criteria for two-planet coplanar systems where the SDT effect can reverse tidal damping, and may preclude the effect's being significant for realistic systems. For the specific case quantified by Correia et al., the effect is strong because of the large adopted tidal time lag, which may not be appropriate for the assumed Saturn-like inner planet. On the other hand, the effective Q for any given planet in exotic circumstances is very uncertain, so the SDT effect could play a role in planetary evolution., Comment: Accepted for publication by Celestial Mechanics and Dynamical Astronomy. 23 pages with 3 figures

Classical secular theory can be a powerful tool to describe the qualitative character of multi-planet systems and offer insight into their histories. The eigenmodes of the secular behavior, rather than current orbital elements, can help identify tidal effects, early planet-planet scattering, and dynamical coupling among the planets, for systems in which mean-motion resonances do not play a role. Although tidal damping can result in aligned major axes after all but one eigenmode have damped away, such alignment may simply be fortuitous. An example of this is 55 Cancri (orbital solution of Fischer et al., 2008) where multiple eigenmodes remain undamped. Various solutions for 55 Cancri are compared, showing differing dynamical groupings, with implications for the coupling of eccentricities and for the partitioning of damping among the planets. Solutions for orbits that include expectations of past tidal evolution with observational data, must take into account which eigenmodes should be damped, rather than expecting particular eccentricities to be near zero. Classical secular theory is only accurate for low eccentricity values, but comparison with other results suggests that it can yield useful qualitative descriptions of behavior even for moderately large eccentricity values, and may have advantages for revealing underlying physical processes and, as large numbers of new systems are discovered, for triage to identify where more comprehensive dynamical studies should have priority., Published in Celestial Mechanics and Dynamical Astronomy, 25 pages, 10 figures

Tidal damping of one of the orbits in a planetary system can lead to aligned major axes (the so-called ‘fixed-point’ condition), but currently aligned major axes do not necessarily imply such a history. An example is the nominal orbital solution for the 61 Virginis system where two orbits librate about alignment, but evaluation of the eigenmodes of the secular theory shows it could not be the result of tidal damping but rather of initial conditions. The amplitudes of the eigenmodes suggest that, at most, this system may have undergone some modest degree of tidal damping.

Purpose The management of children presenting with an isolated skull fracture (ISF) posttrauma is highly variable. We sought to estimate the risk of neurologic deterioration in children with a Glasgow coma score (GCS) 15 and ISF to reduce unnecessary hospital admissions. Methods A retrospective review at a level I pediatric trauma referral center was conducted for patients with ISF on head computed tomography from 2003 to 2008. Patients were excluded for injury greater than 24 hours prior, GCS less than 15, intracranial pathology, significant fracture depression, or complex fractures involving facial bones or skull base. Results A total of 235 patients were identified with an ISF. The median age was 11 months, with falls accounting for 87% of the injuries. One hundred seventy-seven patients were admitted, and 58 patients were discharged from the emergency department after a period of observation (median, 3.3 hours). Median length of stay for those admitted to the hospital was 18.2 hours. One patient developed vomiting following overnight observation and a repeat computed tomography scan demonstrated a small extra-axial hematoma that required no intervention. The mean total costs for patients discharged from the emergency department were $291 vs $1447 for those admitted for observation ( P Conclusion Patients with a presenting GCS of 15 and an ISF can be safely discharged from the emergency department after a short period of observation if they are asymptomatic and have a reliable social environment. This could result in significant savings by eliminating inpatient costs.

BACKGROUND: Unrecognized and undertreated septic shock increases morbidity and mortality. Septic shock in children is defined as sepsis and cardiovascular organ dysfunction, not necessarily with hypotension. OBJECTIVE: Cases of unrecognized and undertreated septic shock in our emergency department (ED) were reviewed with a focus on (1) increased recognition at triage and (2) more aggressive treatment once recognized. We hypothesized that septic shock protocol and care guideline would expedite identification of septic shock, increase compliance with recommended therapy, and improve outcomes. METHODS: We developed an ED septic shock protocol and care guideline to improve recognition beginning at triage and evaluated all eligible ED patients from January 2005 to December 2009. RESULTS: We identified 345 pediatric ED patients (49% male, median age: 5.6 years), and 297 (86.1%) met septic shock criteria at triage. One hundred ninety-six (56.8%) had ≥1 chronic complex condition. Hypotension was present in 34% (n = 120); the most common findings were tachycardia (n = 251 [73%]) and skin-color changes (n = 269 [78%]). The median hospital length of stay declined over the study period (median: 181–140 hours; P < .05); there was no change in mortality rate, which averaged 6.3% (22 of 345). The greatest gains in care included more complete recording of triage vital signs, timely fluid resuscitation and antibiotic administration, and serum lactate determination. CONCLUSIONS: Implementation of an ED septic shock protocol and care guideline improved compliance in delivery of rapid, aggressive fluid resuscitation and early antibiotic and oxygen administration and was associated with decreased length of stay.

Objective To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections. Study design Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants. Results Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis. Conclusions Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.

Cerebral sinovenous thrombosis (CSVT) is an increasingly recognized cause of neurological morbidity and mortality within the pediatric population. Unlike its manifestation in the adult population, CSVT in children has a broad and often multifactorial cause. Our case describes an 18-month-old young boy presenting to the emergency department twice during a 48-hour period with vomiting and lethargy. The child was found to have a sagittal sinus venous thrombosis caused by severe dietary iron deficiency anemia. Severe iron deficiency anemia has been linked to CSVT formation in several recent case reports.

CoRoT-7 b is the first confirmed rocky exoplanet, but, with an orbital semi-major axis of 0.0172 AU, its origins may be unlike any rocky planet in our solar system. In this study, we consider the roles of tidal evolution and evaporative mass loss in CoRoT-7 b's history, which together have modified the planet's mass and orbit. If CoRoT-7 b has always been a rocky body, evaporation may have driven off almost half its original mass, but the mass loss may depend sensitively on the extent of tidal decay of its orbit. As tides caused CoRoT-7 b's orbit to decay, they brought the planet closer to its host star, thereby enhancing the mass loss rate. Such a large mass loss also suggests the possibility that CoRoT-7 b began as a gas giant planet and had its original atmosphere completely evaporated. In this case, we find that CoRoT-7 b's original mass probably didn't exceed 200 Earth masses (about 2/3 of a Jupiter mass). Tides raised on the host star by the planet may have significantly reduced the orbital semi-major axis, perhaps causing the planet to migrate through mean-motion resonances with the other planet in the system, CoRoT-7 c. The coupling between tidal evolution and mass loss may be important not only for CoRoT-7 b but also for other close-in exoplanets, and future studies of mass loss and orbital evolution may provide insight into the origin and fate of close-in planets, both rocky and gaseous.

CoRoT-7 b, a planet about 70% larger than the Earth orbiting a Sun-like star, is the first-discovered rocky exoplanet, and hence has been dubbed a "super-Earth". Some initial studies suggested that since the planet is so close to its host star, it receives enough insolation to partially melt its surface. However, these past studies failed to take into consideration the role that tides may play in this system. Even if the planet's eccentricity has always been zero, we show that tidal decay of semi-major axis could have been large enough that the planet formed on a wider orbit which received less insolation. Moreover, CoRoT-7 b could be tidally heated at a rate that dominates its geophysics and drives extreme volcanism. In this case, CoRoT-7 b is a "super-Io" that, like Jupiter's volcanic moon, is dominated by volcanism and rapid resurfacing. Such heating could occur with an eccentricity of just 10^-5. This small value could be driven by CoRoT-7 c if its own eccentricity is larger than ~10^-4. CoRoT-7 b may be the first of a class of planetary super-Ios likely to be revealed by the CoRoT and Kepler spacecraft., 13 pages, 3 figures, accepted to ApJ Letters

Given the non-spherical shape of Enceladus [Thomas et al., 2007], the satellite will experience gravitational torques that will cause it to physically librate as it orbits Saturn. Physical libration would produce a diurnal oscillation in the longitude of Enceladus’ tidal bulge, which could have a profound effect on the diurnal tidal stresses experienced by the surface of the satellite. Although Cassini ISS has placed an observational upper limit on the amplitude of Enceladus’ libration, smaller amplitudes can still have geologically significant consequences. Here we present the first detailed description of how physical libration affects tidal stresses and how those stresses might then affect geological processes including crack formation and propagation, south polar eruption activity, and tidal heating. Our goal is to provide a framework for testing the hypothesis that geologic features on Enceladus are produced by tidal stresses from diurnal librations of the satellite.

Tectonic patterns on Europa are influenced by tidal stress. An important well-organized component is associated with the orbital eccentricity, which produces a diurnally varying stress as Jupiter's apparent position in Europa's sky oscillates in longitude. Cycloidal lineaments seem to have formed as cracks propagated in this diurnally varying stress field. Maps of theoretical cycloid patterns capture many of the characteristics of the observed distribution on Europa. However, a few details of the observed cycloids distribution have not reproduced by previous models. Recently, it has been shown that Europa has a finite forced obliquity, so Jupiter's apparent positon in Europa's sky will also oscillate in latitude. We explore this new type of diurnal effect on cycloid formation. We find that stress from obliquity may be the key to explaining several characteristics of observed cycloids such as the shape of equator-crossing cycloids and the shift in the crack patterns in the Argadnel Regio region. All of those improvements of the fit between observaiton and theory seem to require Jupiter crossing Europa's equatorial plane 45 deg. to 180 deg after perijove passage. Suggestive of complex orbital dynamics that lock the direction of Europe's pericenter with the direction of the ascending node at the time these cracks were formed.

The habitable zones of main sequence stars have traditionally been defined as the range of orbits that intercept the appropriate amount of stellar flux to permit surface water on a planet. Terrestrial exoplanets discovered to orbit M stars in these zones, which are close-in due to decreased stellar luminosity, may also undergo significant tidal heating. Tidal heating may span a wide range for terrestrial exoplanets and may significantly affect conditions near the surface. For example, if heating rates on an exoplanet are near or greater than that on Io (where tides drive volcanism that resurface the planet at least every 1 Myr) and produce similar surface conditions, then the development of life seems unlikely. On the other hand, if the tidal heating rate is less than the minimum to initiate plate tectonics, then CO_2 may not be recycled through subduction, leading to a runaway greenhouse that sterilizes the planet. These two cases represent potential boundaries to habitability and are presented along with the range of the traditional habitable zone for main sequence, low-mass stars. We propose a revised habitable zone that incorporates both stellar insolation and tidal heating. We apply these criteria to GJ 581 d and find that it is in the traditional habitable zone, but its tidal heating alone may be insufficient for plate tectonics., 13 pages, 2 figures, accepted to ApJ Letters. A version with full resolution images is available at http://www.astro.washington.edu/users/rory/publications/bjgr09.pdf

For studies of tidal evolution, values of the key parameter Q, and its frequency dependence, are often derived from estimates of internal energy dissipation when a satellite, planet, or star is physically distorted. Such estimates come from geophysical or astrophysical modeling, from seismic data, from ad hoc assumptions, or from constraints based on current spins and orbits. In a standard procedure, Q values are used to determine the lag in the response to each Fourier component of the tidal potential. The separate components are then co-added. The basis for this procedure is the analogy of the damped, driven, harmonic oscillator. However, this lag-and-add procedure would not be justifiable even for such a simple system, except for a very specific dependence of Q on frequency. There is no reason to expect the lag-and-add procedure to be relevant for a complex system, because the relationship between dissipation rates and tidal lags is unknown. This widely applied type of model is a reasonable approximation only if the decomposed tidal potential involves a narrow range of frequencies, and thus may only be appropriate for analyses to low order in orbital eccentricity and inclination.

The known extrasolar multiple-planet systems share a surprising dynamical attribute: they cluster just beyond the Hill stability boundary. Here we show that the planet-planet scattering model, which naturally explains the observed exoplanet eccentricity distribution, can reproduce the observed distribution of dynamical configurations. We calculated how each of our scattered systems would appear over an appropriate range of viewing geometries; as Hill stability is weakly dependent on the masses, the mass-inclination degeneracy does not significantly affect our results. We consider a wide range of initial planetary mass distributions and find that some are poor fits to the observed systems. In fact, many of our scattering experiments overproduce systems very close to the stability boundary. The distribution of dynamical configurations of two-planet systems actually may provide better discrimination between scattering models than the distribution of eccentricity. Our results imply that, at least in their inner regions which are weakly affected by gas or planetesimal disks, planetary systems should be "packed", with no large gaps between planets., Comment: Accepted to ApJ Letters. 5 pages, 2 figures, 2 tables

An intriguing discovery of the NEAR imaging and laser-ranging experiments was the ridge system known as Rahe Dorsum and its possible relation with global-scale internal structure. The curved path of the ridge over the surface roughly defines a plane cutting through Eros. Another lineament on the other side of Eros, Calisto Fossae, seems to lie nearly on the same plane. The NEAR teams interpret Rahe as the expression of a compressive fault (a plane of weakness), because portions are a scarp, which on Earth would be indicative of horizontal compression, where shear displacement along a dipping fault has thrust the portion of the lithosphere on one side of the fault up relative to the other side. However, given the different geometry of Eros, a scarp may not have the same relationship to underlying structure as it does on Earth. The plane through Eros runs nearly parallel to, and just below, the surface facet adjacent to Rahe Dorsum. The plane then continues lengthwise through the elongated body, a surprising geometry for a plane of weakness on a battered body. Moreover, an assessment of the topography of Rahe Dorsum indicates that it is not consistent with displacement on the Rahe plane. Rather, the topography suggests that Rahe Dorsum results from resistance of the Rahe plane to impact erosion. Such a plane of strength might have formed in Eros parent body by a fluid intrusion (e.g., a dike of partial melt) through undifferentiated material, creating a vein of stronger rock. Albedo, color and near-infrared spectra could be consistent with a distinct material composition and such a history, although the instruments resolution was not adequate for a definitive detection of such a spatially limited component. However the plane of strength formed, such structural reinforcing might have enabled and controlled the elongated irregular shape of Eros, as well as Rahe Dorsum.

The relationship between the boundaries for Hill and Lagrange stability in orbital element space is modified in the case of resonantly interacting planets. Hill stability requires the ordering of the planets to remain constant while Lagrange stability also requires all planets to remain bound to the central star. The Hill stability boundary is defined analytically, but no equations exist to define the Lagrange boundary, so we perform numerical experiments to estimate the location of this boundary. To explore the effect of resonances, we consider orbital element space near the conditions in the HD 82943 and 55 Cnc systems. Previous studies have shown that, for non-resonant systems, the two stability boundaries are nearly coincident. However the Hill stability formula are not applicable to resonant systems, and our investigation shows how the two boundaries diverge in the presence of a mean-motion resonance, while confirming that the Hill and Lagrange boundaries are similar otherwise. In resonance the region of stability is larger than the domain defined by the analytic formula for Hill stability. We find that nearly all known resonant interactions currently lie in this extra stable region, i.e. where the orbits would be unstable according to the non-resonant Hill stability formula. This result bears on the dynamical packing of planetary systems, showing how quantifying planetary systems' dynamical interactions (such as proximity to the Hill-stability boundary) provides new constraints on planet formation models., Comment: 13 pages, 3 figures, 2 tables, accepted for publication in ApJ Letters. A version with full resolution figures is available at http://www.lpl.arizona.edu/~rory/research/xsp/resstab.pdf

The process of tide-driven walking, proposed as a major mechanism for strike–slip displacement on Europa, is modeled using a finite-element numerical simulation of the behavior of viscoelastic material. For material parameters that are plausible for the water ice composing Europa's crust, the simulation confirms earlier analytic results for strike–slip displacement along a crack that penetrates down to the liquid water substrate. The finite element code permits testing other cases as well. Of considerable interest is whether tidal walking can operate if a crack penetrates not to liquid but only as far as warm, relatively viscous ice. In such a case, significant displacement can be driven, but only if the threshold value of the compressive force needed to lock the fault is near the value of the overburden stress at the bottom of the crack. Such special conditions are not needed for displacement if the crack penetrates to the underlying ocean.

Cycloidal crack patterns on Europa are influenced by tides induced by orbital eccentricity, which in turn is driven by the Laplace orbital resonance. Their shapes potentially record the location of their formation (relative to the direction of Jupiter), as well as the parameters of crack formation. Hoppa et al. [Hoppa, G., Tufts, B.R., Greenberg, R., Geissler, P., 1999a. Icarus 141, 287–298] modeled several cycloid chains using a fixed set of material parameters, but some details did not fit. We now allow material parameters to vary for each arc of an observed cycloid. In general, with minimal variation of model parameters between the arcs, fits are greatly improved. Furthermore, accounting for tidal stress accumulated during non-synchronous rotation, in addition to diurnal stress, allows even better fits. Even with the added freedom in the model our fits allow us to better constrain the location where each cycloid may have formed. Our results support Hoppa et al.'s finding that only a few cracks form ridges per cycle of non-synchronous rotation in the region examined, probably because cracking relieves built up stress until further substantial rotation occurs.

The aim of the study was to assess the impact of an observation unit (OU) on hospital resource utilization for patients with croup.A retrospective review with the use of a historical control was performed for 2 years of nondischargeable emergency department (ED) patients with croup.The total number of ED patients with croup was 694 in the first year and 789 in the second year. Hundred seventy patients were enrolled, 66 in the first year and 104 in the second year (76 admitted to the OU and 33 admitted to the ward). There was a reduction in the ward admission rate from 9.5% to 4.2% (P.0001) from the first to the second year. The median length of stay for the pre-OU group was 27.2 vs 21.3 hours for the post-OU group (P = .03). The median charge for the pre-OU group was $1685 vs $1327 for the post-OU group (P = .03).After the introduction of the OU, hospitalization was reduced, and the overall resource utilization for the care of nondischargeable ED patients with croup was reduced.

High-resolution images of a region near the south pole of Europa allow reconstruction of a series of events, tectonic and thermal, that displaced and modified the surface. This approach is complementary to regional geological mapping, which is based on less detailed images, but covers a broader sample of the surface. The events reconstructed in this locale resurfaced about half the area or more, so they probably ranged over a substantial fraction of the age of Europa's surface, which in itself is quite young (

O'Brien and Greenberg [O'Brien, D.P., Greenberg, R., 2005. Icarus 178, 179–212] developed a self-consistent numerical model of the collisional and dynamical evolution of the main-belt and NEA populations that was tested against a diverse range of observational and theoretical constraints. In this paper, we use those results to update the asteroid cratering model of Greenberg et al. [Greenberg, R., Nolan, M.C., Bottke, W.F., Kolvoord, R.A., Veverka, J., 1994. Icarus 107, 84–97; Greenberg, R., Bottke, W.F., Nolan, M., Geissler, P., Petit, J., Durda, D.D., Asphaug, E., Head, J., 1996. Icarus 120, 106–118], and show that the main-belt asteroid population from the O'Brien and Greenberg collisional/dynamical evolution modeling is consistent with the crater records on Gaspra, Ida, Mathilde, and Eros, the four asteroids that have been observed by spacecraft.

Extrasolar planetary systems display a range of behavior that can be understood in terms of the secular theory of classical celestial mechanics, including the motions of the major axes. Four planet pairs in the seventeen known extrasolar planetary systems with multiple planets (υ And, 47 UMa, 55 Cnc, and HD 128311), have trajectories in orbital element space that lie close to the separatrix between libration and circulation. Here we examine the dynamics of the first two, which are not in mean motion resonance. The basics of secular theory are reviewed in order to develop insight into this behavior. The definition of a secular resonance is discussed, correcting misconceptions in the literature; it is not synonymous with libration and is not a commensurability of eigenfrequencies. The behavior of these two near-separatrix systems is evaluated with updated orbital elements by comparing both analytical and numerical results. We find that the apsidal motion from secular theory does not match the predictions from N-body simulations and conclude that first-order secular theory should be used with caution on extrasolar planetary systems. While the existence of one near-separatrix system could be explained simply by chance initial conditions, the fact that there are several is improbable unless some physical process tends to set up systems near the separatrix. Explanations based on an impulsive increase in the eccentricity of one planet are promising, but key issues remain open.

Impact-induced seismic vibrations have long been suspected of being an important surface modification process on small satellites and asteroids. In this study, we use a series of linked seismic and geomorphic models to investigate the process in detail. We begin by developing a basic theory for the propagation of seismic energy in a highly fractured asteroid, and we use this theory to model the global vibrations experienced on the surface of an asteroid following an impact. These synthetic seismograms are then applied to a model of regolith resting on a slope, and the resulting downslope motion is computed for a full range of impactor sizes. Next, this computed downslope regolith flow is used in a morphological model of impact crater degradation and erasure, showing how topographic erosion accumulates as a function of time and the number of impacts. Finally, these results are applied in a stochastic cratering model for the surface of an Eros-like body (same volume and surface area as the asteroid), with craters formed by impacts and then erased by the effects of superposing craters, ejecta coverage, and seismic shakedown. This simulation shows good agreement with the observed 433 Eros cratering record at a Main Belt exposure age of 400 ± 200 Myr , including the observed paucity of small craters. The lowered equilibrium numbers (loss rate = production rate) for craters less than ∼100 m in diameter is a direct result of seismic erasure, which requires less than a meter of mobilized regolith to reproduce the NEAR observations. This study also points to an upper limit on asteroid size for experiencing global, surface-modifying, seismic effects from individual impacts of about 70–100 km (depending upon asteroid seismic properties). Larger asteroids will experience only localized (regional) seismic effects from individual impacts.

The size distribution of main belt of asteroids is determined primarily by collisional processes. Large asteroids break up and form smaller asteroids in a collisional cascade, with the outcome controlled by the strength–size relationship for asteroids. In addition to collisional processes, the non-collisional removal of asteroids from the main belt (and their insertion into the near-Earth asteroid (NEA) population) is critical, and involves several effects: strong resonances increase the orbital eccentricity of asteroids and cause them to enter the inner planet region; chaotic diffusion by numerous weak resonances causes a slow leak of asteroids into the Mars- and Earth-crossing populations; and the Yarkovsky effect, a radiation force on asteroids, is the primary process that drives asteroids into these resonant escape routes. Yarkovsky drift is size-dependent and can modify the main-belt size distribution. The NEA size distribution is primarily determined by its source, the main-belt population, and by the size-dependent processes that deliver bodies from the main belt. All of these effects are simulated in a numerical collisional evolution model that incorporates removal by non-collisional processes. We test our model against a wide range of observational constraints, such as the observed main-belt and NEA size distributions, the number of asteroid families, the preserved basaltic crust of Vesta and its large south-pole impact basin, the cosmic ray exposure ages of meteorites, and the cratering records on asteroids. We find a strength–size relationship for main-belt asteroids and non-collisional removal rates from the main belt such that our model fits these constraints as best as possible within the parameter space we explore. Our results are consistent with other independent estimates of strength and removal rates.

Using photoclinometry, topographic profiles across europan ridges have been produced. These profiles allow the identification of bulges in the terrain adjacent to the ridges. The bulges are assumed to have been produced by flexure of the elastic lithosphere due to the load of the ridges, which lie along cracks in the crust. The distance from the crack to these “fore-bulges” depends on the thickness of the elastic plate being flexed. Based on a survey of ridges in Galileo images with resolution

The tectonic sequence in the anti-jovian area covered by regional mapping images from Galileo's orbit E15 is determined from a study of cross-cutting relationships among lineament features. The sequence is used to test earlier results from orbit G1, based on lower resolution images, which appeared to display a progressive change in azimuthal orientation over about 90° in a clockwise sense. Such a progression is consistent with expected stress variations that would accompany plausible non-synchronous rotation. The more recent data provide a more complete record than the G1 data did. We find that to fit the sequence into a continual clockwise change of orientation would require at least 1000° (>5 cycles) of azimuthal rotation. If due to non-synchronous rotation of Europa, this result implies that we are seeing back further into the tectonic record than the G1 results had suggested. The three sets of orientations found by Geissler et al. now appear to have been spaced out over several cycles, not during a fraction of one cycle. While our more complete sequence of lineament formation is consistent with non-synchronous rotation, a statistical test shows that it cannot be construed as independent evidence. Other lines of evidence do support non-synchronous rotation, but azimuths of crack sequences do not show it, probably because only a couple of cracks form in a given region in any given non-synchronous rotation period.

The formation sequence of prominent ridges and other tectonic lineaments on the southern portion of the leading hemisphere of Europa is determined from cross-cutting relationships. These selected features formed fairly recently relative to most of the surface; older lineaments no longer retain clear evidence of cross-cutting. If we assume that this sequence represents the order of formation of cracks that underlie each lineament, and that the orientation of each crack was determined by tidal stress whose azimuth varies monotonically counter-clockwise with time, the azimuth must have rotated more than 740°, which would correspond to the change in tidal stress over two periods of nonsynchronous rotation (relative to the direction of Jupiter). However, that interpretation is not necessarily compelling, because the observed orientations of cross-cutting lineaments are not densely spaced over these cycles; in fact, the sequence would fit nearly as well into an arbitrary model with rotation in the opposite sense from that predicted by theory. This tectonic record may have formed over many more rotational cycles, such that typically only a few cracks form per cycle, which would be consistent with evidence from considerations of cycloidal crack patterns. Sets of cracks that cluster near certain azimuth orientations appear to be parts of globe-encircling lineament systems and may result from other effects, perhaps polar wander that occurred rapidly relative to nonsynchronous rotation.

The dilemma of the surface-area budget on Europa is resolved by identification of sites of crustal convergence, which have balanced the continual and common creation of new surface along dilational bands and pull-aparts. Convergence bands are characterized by a distinctive, albeit subdued, morphology. The prominent, unusual lineament Agenor is one of several examples. We also find diametrically opposite Agenor a similar bright linear feature surrounded by markings that allow reconstruction, which shows it to be a convergence feature. Until recently, identification of convergence sites was difficult because these features are subtle and do not exhibit structures (like the Himalayas or plate subduction) familiar from convergence of thick solid crusts on terrestrial planets.

Background Enhanced ability to reliably identify risk factors for suicidal behavior permits more focused decisions concerning treatment interventions and support services, with potential reduction in lives lost to suicide. Methods This study followed 980 patients at high risk for suicide in a multicenter prospective study for 2 years after randomization to clozapine or olanzapine. A priori predictors related to diagnosis, treatment resistance, and clinical constructs of disease symptoms were evaluated as possible predictors of subsequent suicide-related events. Results Ten baseline univariate predictors were identified. Historical predictors were diagnosis of schizoaffective disorder, history or current use at baseline of alcohol or substance abuse, cigarette smoking, number of lifetime suicide attempts, and the number of hospitalizations in the previous 36 months to prevent suicide. Predictive clinical features included greater baseline scores on the InterSePT scale for suicidal thinking, the Covi Anxiety Scale, the Calgary Depression Scale (CDS), and severity of Parkinsonism. Subsequent multivariate analysis revealed the number of hospitalizations in the previous 36 months, baseline CDS, severity of Parkinson’s, history of substance abuse, and lifetime suicide attempts. Clozapine, in general, was more effective than olanzapine in decreasing the risk of suicidality, regardless of risk factors present. Conclusions This is the first prospective analysis of predictors of suicide risk in a large schizophrenic and schizoaffective population judged to be at high risk for suicide. Assessment of these risk factors may aid clinicians in evaluating risk for suicidal behaviors so that appropriate interventions can be made.