An active machine learning discovery platform for membrane-disrupting and pore-forming peptides.

Membrane-disrupting and pore-forming peptides (PFPs) play a substantial role in bionanotechnology and can determine the life and death of cells. The control of chemical and ion transport through cell membranes is essential to maintaining concentration gradients. Likewise, the delivery of drugs and intracellular proteins aided by pore-forming agents is of interest in treating malfunctioning cells. Known PFPs tend to be up to 50 residues in length, which is commensurate with the thickness of a lipid bilayer. Accordingly, few short PFPs are known. Here we show that the discovery of PFPs can be accelerated via an active machine learning approach. The approach identified 71 potential PFPs from the 25.6 billion octapeptide sequence space; 13 sequences were tested experimentally, and all were found to have the predicted membrane-disrupting ability, with 1 forming highly stable pores. Experimental verification of the predicted pore-forming ability demonstrated that a range of short peptides can form pores in membranes, while the positioning and characteristics of residues that favour pore-forming behaviour were identified. This approach identified more ultrashort (8-residues, unmodified, non-cyclic) PFPs than previously known. We anticipate our findings and methodology will be useful in discovering new pore-forming and membrane-disrupting peptides for a range of applications from nanoreactors to therapeutics.

Evaluation of Three Automated Nontreponemal Rapid Plasma Reagin (RPR) Tests for the Laboratory Diagnosis of Syphilis.

Automated nontreponemal rapid plasma reagin (RPR) tests were recently introduced in the United States for syphilis testing and limited performance data are available. In collaboration with the Association of Public Health Laboratories, three public health laboratories (PHL) were chosen through a competitive selection process to evaluate the performance of three FDA-cleared automated RPR test systems: BioPlex 2200 Syphilis Total & RPR assay (Bio-Rad Laboratories), AIX 1000 (Gold Standard Diagnostics), and ASI Evolution (Arlington Scientific). Panels prepared at the CDC included: a qualitative panel comprised of 734 syphilis reactive/nonreactive sera; a quantitative panel of 50 syphilis reactive sera (RPR titer 1:64 to 1:1,024); and a reproducibility panel of 15 nonreactive and reactive sera (RPR titer 1:1 to 1:64). Panels were shipped frozen to the PHL and tested on the automated RPR systems following manufacturers' instructions. Prior test results were blinded to all laboratories. When compared to manual RPR (Arlington Scientific) performed at the CDC as a reference test, the qualitative panel results demonstrated an overall concordance of 95.9% for AIX 1000, 94.6% for ASI Evolution, and 92.6% for Bioplex RPR; quantitative panel showed within range titer of 2-fold for 94% of specimens for AIX 1000, 68% for ASI Evolution, and 64% for BioPlex RPR, and the reproducibility testing panel demonstrated point estimates ranging from 69 to 95%. Automated RPR instruments could reduce turnaround time and minimize interpretation errors. However, additional evaluations with more specimens could assist laboratories with implementing automated RPR tests and understanding their limitations.

Mental illness-related stigma among probation officers.

BACKGROUND: Probation officers tend to hold stigmatising attitudes towards individuals on their caseload with mental illnesses. This can result in poor outcomes for justice-involved people with mental illnesses. Though anti-stigma interventions in the general public and among other criminal-legal professionals hold promise, these interventions have not been tested among probation officers. AIMS: To measure levels of stigma towards mental illnesses among probation officers before and after a brief online training related to mental illness. METHODS: Two hundred and seventy-five probation and parole officers in one Midwest state completed a three-module online training programme designed to increase knowledge and skills for working with clients with mental illnesses. Officers completed a pre- and post-training assessment of level of stigmatising attitudes towards individuals with mental illnesses. RESULTS: Officer levels of stigma statistically significantly decreased from pre-test (8.22) to post-test (7.37; p < 0.001, t = 6.13). Nevertheless, pre-training stigma scores were the strongest predictor of stigma levels at post-test (p < 0.001, b = 0.90). CONCLUSIONS: While basic training can significantly decrease mental disorder stigmatising scores for probation officers, the practical effect of this brief online experience was very small. Nevertheless, the fact that such brief and generalised input can have impact at all is encouraging. Implementation could be a useful preliminary to improving the quality of probation supervision of clients with mental illnesses.

Socio-Environmental Conditions Associated with Geospatial Clusters of Urothelial Carcinoma: A Multi-Institutional Analysis.

PURPOSE: The interaction between sources of industrial byproducts and environmental pollutants (IBP/EP) and the prevalence of urothelial carcinoma (UC) in surrounding communities has been infrequently explored. The purpose of this research is to identify microregional UC hotspots and associated industrial and environmental risk factors. MATERIALS AND METHODS: We retrospectively queried a multi-institutional database for UC patients diagnosed between 2008 and 2018. Addresses were geocoded and used to perform hotspot analysis on the census block level. Demographic and clinicopathological characteristics, census data and proximity to sources of IBP/EP were compared between patients who did vs did not reside in a hotspot. Associations were tested using multilevel logistic regression models using 95% confidence intervals. RESULTS: A total of 5,080 patients met inclusion criteria and 148 (2.9%) were identified as living in 1 of 3 UC hotspots. In univariate analyses, race, tobacco and alcohol use, household income, IBP/EP exposure and proximity to traffic, industrial discharge and airports were significantly associated with UC hotspots. Multivariable analysis demonstrated that polycyclic aromatic hydrocarbon exposure (OR: 48.09, p ≤0.001) and proximity to high-density traffic (OR: >999, p ≤0.001) increased the odds of living in a hotspot. Patients living in a hotspot were significantly less likely to be white (OR: 0.06, p ≤0.001) or tobacco users (OR: 0.39, p=0.031) on multivariate analysis. CONCLUSIONS: Spatially related clusters of UC may be associated with locoregional environmental exposures rather than tobacco exposure and may also be correlated with socioeconomic disparities. Geospatial analysis can help to identify at-risk populations, offering the opportunity to better focus preventive and diagnostic interventions.

Variation in Criminogenic Risks by Mental Health Symptom Severity: Implications for Mental Health Services and Research.

Although a growing body of literature has demonstrated that justice-involved people with mental illnesses have criminogenic risk factors at similar or elevated rates as compared to justice-involved people without mental illnesses, more information about how criminogenic risks vary by intensity of mental health symptoms is needed. This information is particularly important for probation agencies who supervise the vast majority of justice-involved individuals with mental illnesses and who are increasingly implementing specialty mental health supervision approaches. To this end, this study examines the relationship between criminogenic risk and intensity of self-reported symptoms of mental illnesses among 201,905 individuals on probation from a large southeastern state. Self-report measures of symptoms of mental illnesses were categorized as low, moderate or high and criminogenic risks were compared among the following three groups: (1) those with no or low self-reported symptoms of mental illness; (2) those reporting moderate levels of symptoms; and (3) those reporting high or elevated levels of symptoms. Our findings suggest that the strength of relationships between symptoms of mental illnesses and criminogenic risks varies by type of criminogenic risk. Also, elevated symptoms of mental illness are associated with higher levels of criminogenic risks. More research about interventions that address mental illnesses and criminogenic risks is needed to inform practice and policy.

A novel, safe, fast and efficient treatment for Her2-positive and negative bladder cancer utilizing an EGF-anthrax toxin chimera.

Bladder cancer is the sixth most common cancer in the United States, and it exhibits an alarming 70% recurrence rate. Thus, the development of more efficient antibladder cancer approaches is a high priority. Accordingly, this work provides the basis for a transformative anticancer strategy that takes advantage of the unique characteristics of the bladder. Unlike mucin-shielded normal bladder cells, cancer cells are exposed to the bladder lumen and overexpress EGFR. Therefore, we used an EGF-conjugated anthrax toxin that after targeting EGFR was internalized and triggered apoptosis in exposed bladder cancer cells. This unique agent presented advantages over other EGF-based technologies and other toxin-derivatives. In contrast to known agents, this EGF-toxin conjugate promoted its own uptake via receptor microclustering even in the presence of Her2 and induced cell death with a LC50 < 1 nM. Furthermore, our data showed that exposures as short as ≈3 min were enough to commit human (T24), mouse (MB49) and canine (primary) bladder cancer cells to apoptosis. Exposure of tumor-free mice and dogs with the agent resulted in no toxicity. In addition, the EGF-toxin was able to eliminate cells from human patient tumor samples. Importantly, the administration of EGF-toxin to dogs with spontaneous bladder cancer, who had failed or were not eligible for other therapies, resulted in ~30% average tumor reduction after one treatment cycle. Because of its in vitro and in vivo high efficiency, fast action (reducing treatment time from hours to minutes) and safety, we propose that this EGF-anthrax toxin conjugate provides the basis for new, transformative approaches against bladder cancer.

Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015.

OBJECTIVES: To examine differences in rates of opioid overdose death (OOD) between former North Carolina (NC) inmates and NC residents and evaluate factors associated with postrelease OOD. METHODS: We linked NC inmate release data to NC death records, calculated OOD standardized mortality ratios to compare former inmates with NC residents, and calculated hazard ratios to identify predictors of time to OOD. RESULTS: Of the 229 274 former inmates released during 2000 to 2015, 1329 died from OOD after release. At 2-weeks, 1-year, and complete follow-up after release, the respective OOD risk among former inmates was 40 (95% confidence interval [CI] = 30, 51), 11 (95% CI = 9.5, 12), and 8.3 (95% CI = 7.8, 8.7) times as high as general NC residents; the corresponding heroin overdose death risk among former inmates was 74 (95% CI = 43, 106), 18 (95% CI = 15, 21), and 14 (95% CI = 13, 16) times as high as general NC residents, respectively. Former inmates at greatest OOD risk were those within the first 2 weeks after release, aged 26 to 50 years, male, White, with more than 2 previous prison terms, and who received in-prison mental health and substance abuse treatment. CONCLUSIONS: Former inmates are highly vulnerable to opioids and need urgent prevention measures.

Incisional hernia after cystectomy: incidence, risk factors and anthropometric predisposition.

INTRODUCTION: Postoperative incisional hernias (PIH) are an established complication of abdominal surgery with rates after radical cystectomy (RC) poorly defined. The objective of this analysis is to compare rates and risk factors of PIH after open (ORC) and robotic-assisted (RARC) cystectomy at a tertiary-care referral center. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing ORC and RARC from 2000-2015 with pre and postoperative cross-sectional imaging available. Images were evaluated for anthropometric measurements and presence of postoperative radiographic PIH (RPIH). Patient demographics, type of urinary diversion and postoperative hernia repair (PHR) were also assessed. RESULTS: Of the patients that met inclusion criteria (n = 469), the incidence of RPIH and PHR were 14.3% and 9.0%, respectively. Between ORC and RARC, analysis revealed no statistically significant differences in rates of RPIH (13.6% versus 20.3%, p = 0.152) or PHR (8.2% versus 12.5%, p = 0.214). Body mass index was associated with a slightly increased likelihood of RPIH on univariate analysis alone (OR 1.08, p = 0.008). Ileal conduit was associated with a decreased likelihood of RPIH (OR 0.42, p = 0.034) and PHR (OR 0.36, p = 0.023). Supraumbilical rectus diastasis width (RDW) was an independent predictor of both RPIH (OR 1.52, p = 0.023) and PHR (OR 1.43, p = 0.039) on multivariate analysis. CONCLUSIONS: Patients undergoing RC are at significant risk of RPIH and PHR regardless of surgical approach. Anthropomorphic factors and urinary diversion type appear to be associated with PIH risk. Further research is needed to understand how risks of PIH can be reduced in patients undergoing cystectomy.

Complications of the neovagina in male-to-female transgender surgery: A systematic review and meta-analysis with discussion of management.

Gender-affirmation surgery is often the final gender-confirming medical intervention sought by those patients suffering from gender dysphoria. In the male-to-female (MtF) transgendered patient, the creation of esthetic and functional external female genitalia with a functional vaginal channel is of the utmost importance. The aim of this review and meta-analysis is to evaluate the epidemiology, presentation, management, and outcomes of neovaginal complications in the MtF transgender reassignment surgery patients. PUBMED was searched in accordance with PRISMA guidelines for relevant articles (n = 125). Ineligible articles were excluded and articles meeting all inclusion criteria went on to review and analysis (n = 13). Ultimately, studies reported on 1,684 patients with an overall complication rate of 32.5% and a reoperation rate of 21.7% for non-esthetic reasons. The most common complication was stenosis of the neo-meatus (14.4%). Wound infection was associated with an increased risk of all tissue-healing complications. Use of sacrospinous ligament fixation (SSL) was associated with a significantly decreased risk of prolapse of the neovagina. Gender-affirmation surgery is important in the treatment of gender dysphoric patients, but there is a high complication rate in the reported literature. Variability in technique and complication reporting standards makes it difficult to assess the accurately the current state of MtF gender reassignment surgery. Further research and implementation of standards is necessary to improve patient outcomes. Clin. Anat. 31:191-199, 2018. © 2017 Wiley Periodicals, Inc.

Factor structure, factorial invariance, and validity of the Multidimensional Shame-Related Response Inventory-21 (MSRI-21).

We describe 2 studies designed to evaluate scores on the Multidimensional Shame-related Response Inventory-21 (MSRI-21), a recently developed instrument that measures affective and behavioral responses to shame. The inventory assesses shame-related responses in 3 categories: negative self-evaluation, fear of social consequences, and maladaptive behavior tendency. For Study 1, (N = 743) undergraduates completed the MSRI-21. Confirmatory factor analysis supported the validity of the MSRI-21 3-factor structure. Latent variable modeling of coefficient-α provided strong evidence for the internal consistency of scores on each scale. In Study 2, (N = 540) undergraduates completed the instrument along with 5 concurrent measures chosen for clinical significance. Achievement of factorial invariance supported the use of MSRI-21 scale scores to make valid mean comparisons across gender. In addition, MSRI-21 scale scores were associated as expected with scores on measures of self-harm, suicide, and other risk factors. Taken together, results of 2 studies support the internal consistency reliability, factorial validity, factorial invariance, and convergent validity of scores on the MSRI-21. Further work is needed to assess the temporal stability of the MSRI-21 scale scores, invariance across clinical status and other groupings, item-level measurement properties, and viability in highly symptomatic samples. (PsycINFO Database Record

A Longitudinal Outcome Evaluation of a Prison-Based Sex Offender Treatment Program.

Sex offender outcome studies continue to produce mixed results. A common critique of these studies is their lack of methodological rigor. This study attempts to address this critique by adhering to the standards established by the Collaborative Outcome Data Committee (CODC) aimed at increasing the quality and confidence in outcome studies. We examined recidivism outcomes for a sample of formerly incarcerated sex offenders who participated in a state prison-based cognitive-behavioral-skills-based treatment program. We used propensity score analysis to compare treatment participants with a matched sample of non-participants. The final sample post-matching ( n = 512) was observed for a minimum of 4 years and a maximum of 14 years. Using survival analysis, findings indicate that there were no differences in recidivism rates between treatment participants and non-participants in sexual or violent crimes. However, participants demonstrated significantly lower rates of recidivism for non-violent crimes. We discuss strengths, limitations of the study, and implications of these findings.

The active form of E6-associated protein (E6AP)/UBE3A ubiquitin ligase is an oligomer.

Employing 125I-polyubiquitin chain formation as a functional readout of ligase activity, biochemical and biophysical evidence demonstrates that catalytically active E6-associated protein (E6AP)/UBE3A is an oligomer. Based on an extant structure previously discounted as an artifact of crystal packing forces, we propose that the fully active form of E6AP is a trimer, analysis of which reveals a buried surface of 7508Å2 and radially symmetric interacting residues that are conserved within the Hect (homologous to E6AP C terminus) ligase superfamily. An absolutely conserved interaction between Phe(727) and a hydrophobic pocket present on the adjacent subunit is critical for trimer stabilization because mutation disrupts the oligomer and decreases kcat 62-fold but fails to affect E2 ubiquitin binding or subsequent formation of the Hect domain Cys(820) ubiquitin thioester catalytic intermediate. Exogenous N-acetylphenylalanylamide reversibly antagonizes Phe(727)-dependent trimer formation and catalytic activity (Ki12 mM), as does a conserved-helical peptide corresponding to residues 474­490 of E6A Pisoform 1 (Ki22M) reported to bind the hydrophobic pocket of other Hect ligases, presumably blocking Phe(727) intercalation and trimer formation. Conversely, oncogenic human papillomavirus-16/18 E6 protein significantly enhances E6AP catalytic activity by promoting trimer formation (Kactivation 1.5 nM) through the ability of E6 to form homodimers. Recombinant E6 protein additionally rescues the kcat defect of the Phe(727) mutation and that of a specific loss-of-function Angelman syndrome mutation that promotes trimer destabilization. The present findings codify otherwise disparate observations regarding the mechanism of E6AP and related Hect ligases in addition to suggesting therapeutic approaches for modulating ligase activity.

Convergent evolution in the assembly of polyubiquitin degradation signals by the Shigella flexneri IpaH9.8 ligase.

The human pathogen Shigella flexneri subverts host function and defenses by deploying a cohort of effector proteins via a type III secretion system. The IpaH family of 10 such effectors mimics ubiquitin ligases but bears no sequence or structural homology to their eukaryotic counterpoints. Using rates of (125)I-polyubiquitin chain formation as a functional read out, IpaH9.8 displays V-type positive cooperativity with respect to varying concentrations of its Ubc5B∼(125)I-ubiquitin thioester co-substrate in the nanomolar range ([S]½ = 140 ± 32 nm; n = 1.8 ± 0.1) and cooperative substrate inhibition at micromolar concentrations ([S]½ = 740 ± 240 nm; n = 1.7 ± 0.2), requiring ordered binding to two functionally distinct sites per subunit. The isosteric substrate analog Ubc5BC85S-ubiquitin oxyester acts as a competitive inhibitor of wild-type Ubc5B∼(125)I-ubiquitin thioester (Ki = 117 ± 29 nm), whereas a Ubc5BC85A product analog shows noncompetitive inhibition (Ki = 2.2 ± 0.5 µm), consistent with the two-site model. Re-evaluation of a related IpaH3 crystal structure (PDB entry 3CVR) identifies a symmetric dimer consistent with the observed cooperativity. Genetic disruption of the predicted IpaH9.8 dimer interface reduces the solution molecular weight and significantly ablates the kcat but not [S]½ for polyubiquitin chain formation. Other studies demonstrate that cooperativity requires the N-terminal leucine-rich repeat-targeting domain and is transduced through Phe(395). Additionally, these mechanistic features are conserved in a distantly related SspH2 Salmonella enterica ligase. Kinetic parallels between IpaH9.8 and the recently revised mechanism for E6AP/UBE3A (Ronchi, V. P., Klein, J. M., and Haas, A. L. (2013) E6AP/UBE3A ubiquitin ligase harbors two E2∼ubiquitin binding sites. J. Biol. Chem. 288, 10349-10360) suggest convergent evolution of the catalytic mechanisms for prokaryotic and eukaryotic ligases.

Assessing the implementation and influence of policies that support research and innovation systems for health: the cases of Mozambique, Senegal, and Tanzania.

BACKGROUND: Without good policies it will be difficult to provide guidance to research and innovation systems. However, policies need to be followed through and implemented to have the desired effect. We studied the policies and strategies in place to support research and innovation systems for health in Mozambique, Senegal, and Tanzania, and looked at the extent to which these policies and strategies have been implemented. METHODS: We reviewed documents and reports and conducted in-depth interviews with 16 key informants representing various actors of the national research for health systems. RESULTS: The results illustrate that there are various policies and strategies governing research and innovation for health in the three countries. However, implementation of these policies and strategies is generally rated as being poor. The reasons highlighted for this include lack of policy coherence, lack of enforcement and accountability mechanisms, and a lack of financing for implementing the policies. These contextual factors seem to be of such importance that even the increased stakeholder involvement and political leadership, as mentioned by the interviewees, cannot guarantee policy implementation. CONCLUSIONS: We conclude that due to the contextual realities of the study countries, there is need for greater focus on policy implementation than on developing additional policies. Government institutions should play a central role in all stages of the policy process, and should ensure implementation of defined policies. Strong mechanisms, including financing, that strengthen the position and role of government in policy coordination and the oversight of the policy process will help increase efficient and impactful implementation of research and innovation for health policies.

Developing outcomes assessments for collaborative, cross-institutional benchmarking: progress of the Australian Medical Assessment Collaboration.

BACKGROUND: The Australian Medical Assessment Collaboration (AMAC) began in 2010. This article charts the development of the collaboration over its initial years. AIMS: AMAC was instigated as a way of improving the quality of medical education through the recognition of the need for tools for comparison and evaluation of learning outcomes, acknowledgement of the need for high quality assessment, and to share expertise in these areas. In a climate of increasing regulation and accountability, this collaboration was formed as a means of increasing assessment practices by, with and for medical schools. METHOD: This article provides an overview of the background issues stimulating the development of AMAC, discussion of the formation of the collaboration and reflection on the lessons learnt through these processes. RESULTS: In a relatively short space of time, AMAC has fostered substantial collaboration among schools; developed an Assessment Framework, items and an online assessment; and provided benchmarking reports to students and schools. CONCLUSION: The intention here is to provide guidance for others (within the medical education community and those in other disciplines) with similar intentions and aims, by outlining the developmental pathway of the project and the systematic lessons that the collaboration team has learnt in establishing AMAC.

Same admissions tools, different outcomes: a critical perspective on predictive validity in three undergraduate medical schools.

BACKGROUND: Admission to medical school is one of the most highly competitive entry points in higher education. Considerable investment is made by universities to develop selection processes that aim to identify the most appropriate candidates for their medical programs. This paper explores data from three undergraduate medical schools to offer a critical perspective of predictive validity in medical admissions. METHODS: This study examined 650 undergraduate medical students from three Australian universities as they progressed through the initial years of medical school (accounting for approximately 25 per cent of all commencing undergraduate medical students in Australia in 2006 and 2007). Admissions criteria (aptitude test score based on UMAT, school result and interview score) were correlated with GPA over four years of study. Standard regression of each of the three admissions variables on GPA, for each institution at each year level was also conducted. RESULTS: Overall, the data found positive correlations between performance in medical school, school achievement and UMAT, but not interview. However, there were substantial differences between schools, across year levels, and within sections of UMAT exposed. Despite this, each admission variable was shown to add towards explaining course performance, net of other variables. CONCLUSION: The findings suggest the strength of multiple admissions tools in predicting outcomes of medical students. However, they also highlight the large differences in outcomes achieved by different schools, thus emphasising the pitfalls of generalising results from predictive validity studies without recognising the diverse ways in which they are designed and the variation in the institutional contexts in which they are administered. The assumption that high-positive correlations are desirable (or even expected) in these studies is also problematised.

Does volunteering for sex offender treatment matter? Using propensity score analysis to understand the effects of volunteerism and treatment on recidivism.

A common critique of program evaluations of prison-based sex offender treatment holds that the samples inherently show selection bias because the participants typically volunteer for treatment. To address this critique, we used propensity score analysis to assess the influence of volunteerism on treatment effects. We examined recidivism outcomes for a sample of participants who volunteered for treatment, of whom some participated in treatment (n = 161) and some did not (n = 282) and compared these outcomes to the recidivism rate of a matched sample of nonvolunteers for treatment (n = 443). The primary finding is that offenders who volunteered for treatment did not demonstrate any differences in recidivism rates when matched with and compared to inmates who did not volunteer to participate in treatment. Furthermore, our results revealed that there were a number of significant differences between unmatched volunteers and unmatched nonvolunteers, perhaps most importantly in their risk for future recidivism as measured by the STATIC-99 risk assessment. We discuss study strengths and limitations and present the implications of the findings for policy, practice, and research.

Perceptions of vaccine safety and hesitancy among incarcerated adults and correctional staff in the rural midwest.

Objectives: This project assessed vaccine hesitancy among staff and incarcerated adults in one rural medium-security prison in the Midwestern United States and identified differences in hesitancy across sociodemographic and work-related variables. Methods: 610 prison staff and people incarcerated completed a cross-sectional survey in May 2021. The vaccine hesitancy scale (VHS) identified perceived risk and confidence in vaccination. A single item assessed whether people typically follow public health protocols in the prison. A combination of analyses was utilized, including ANOVA, Chi-Square, and Pearson's correlation. Results: Vaccine hesitancy was moderate to high for both populations. Incarcerated people had more confidence in vaccination than staff; differences did not reach statistical significance. Incarcerated people had statistically significantly higher perceptions of risk compared to staff. Both populations reported doing their best to follow public health protocols. For both populations, vaccine hesitancy varied by education and veteran status. Among staff, hesitancy varied by gender and political beliefs. For people incarcerated, it varied by pre-incarceration income and visit frequency. Conclusions: Results support the need for public health policy and procedural interventions to reduce hesitancy towards vaccination in correctional settings.