Military Medicine in American Samoa-Connecting With Indo-Pacific Partners.

With the rise of great power competition in the Indo-Pacific, Global Health Engagement can facilitate positive foreign relations. Increasing military medical outreach in American Samoa will provide improved health care in the territory, offer relevant medical training in resource-limited environments, and build connections with a community that has many uniformed members.

Pediatric Infectious Diseases Encountered During Wartime-Part 1: Experiences and Lessons Learned From Armed Conflict in the Modern Era.

PURPOSE OF REVIEW: Armed conflicts occur globally, with some regions experiencing heightened instability for many years. A better understanding of the infectious disease impact on children in armed conflict will allow aid organizations to anticipate and mitigate the most serious problems. RECENT FINDINGS: Armed conflicts are estimated to have caused approximately 30 million civilian deaths during the past 27 years, with two-thirds occurring in women and children. Children are extremely vulnerable to the mass population displacements, experiencing a combined loss of safety, nutrition, shelter, hygiene, and health care. Under these circumstances, the emergence and prevalence of multiple infectious diseases can result in heightened morbidity and mortality long after active conflict ceases. SUMMARY: Factors leading to increased infectious diseases in populations in crisis due to armed conflict and lessons learned from recent outbreaks are discussed in detail. Acute respiratory infections, diphtheria, measles, varicella, and cholera are a few of the more common infectious diseases that take advantage of populations displaced or disrupted by conflict. Key issues include the ability of countries or non-governmental organizations (NGOs) to keep up with basic childhood immunizations, and how rapidly disease outbreaks are recognized and addressed with disease-specific interventions.

Pediatric Hospitalists' Performance and Perceptions of Script Concordance Testing for Self-Assessment.

OBJECTIVES: The cognitive expertise of Pediatric Hospitalists (PH) lies not in standard knowledge but in making decisions under conditions of uncertainty. To maintain expertise, PH should engage in deliberate practice via self-assessments that promote higher-level cognitive processes necessary to address problems with missing or ambiguous information. Higher levels of cognition are purported with Script Concordance Test (SCT) questions compared to Multiple Choice Questions (MCQ). To determine if PH use higher levels of cognition when answering SCT versus MCQ questions and to analyze participants' perceptions of the utility of using SCT self-assessment for deliberate practice in addressing clinical problems encountered in daily practice. METHODS: This is a mixed methods study comparing the cognitive level expressed according to Bloom's Taxonomy by PH answering MCQ versus SCT questions using a "think aloud" (TA) exercise, followed by qualitative analysis of interviews conducted afterward. RESULTS: A significantly greater percentage of comments were coded as higher cognitive processes (apply, analyze, evaluate, and create) for SCT versus MCQ (74% vs 19%) compared with lower order (remember, understand); chi-square P < .00001. Analysis of interviews revealed 6 themes. CONCLUSION: SCT questions elicited higher level cognition essential to clinical reasoning compared to MCQ questions. PH-indicated MCQ questions measure standard knowledge, while SCT questions better measure decision-making under conditions of uncertainty. PH-perceived SCT could be useful for deliberate practice in Pediatric Hospital Medicine decision-making if they could compare their rationale in answering questions with that of experts.

Local Respiratory Viral Surveillance Can Focus Public Health Interventions to Decrease Influenza Disease Burden.

BACKGROUND: Respiratory viruses are an important cause of nonbattle injury disease and contribute to the top seven reasons for medical encounters. In the absence of vaccines that provide complete protection against these viruses, viral surveillance can identify disease burden and target virus-specific preventative measures. Influenza infection, in particular, has significant adverse effects on force readiness. METHODS: We tracked the frequency of 16 respiratory viruses at Walter Reed National Military Medical Center tested for during routine patient care using multiplex polymerase chain reaction and rapid antigen testing. We collected data on the date and location of the testing, as well as the age of the individual tested from two consecutive respiratory viral seasons. RESULTS: During the first year of data compilation (2017-2018), 2556 tests were performed; 342 (13.4%) were positive for influenza A and 119 (4.7%) were positive for influenza B. After influenza, the most common families of viruses identified were rhino/enterovirus (490 [19.2%]). During the second year (2018-2019), 4,458 tests were run; 564 (12.7%) were positive for influenza A and 35 (0.79%) were positive for influenza B, while rhino/enterovirus was identified in 690 (15.4%). Influenza peaked early during the 2017-2018 season and later during the 2018-2019 season. Importantly, during the 2017-2018 season, the vaccine was less effective for the H3N2 strain circulating that year and viral surveillance quickly identified a hospital-specific outbreak and a larger disease burden. This was in contrast to the 2018-2019 vaccine which exhibited higher effectiveness for circulating strains. CONCLUSION: Our data highlight the seasonality of respiratory viruses with a focus on influenza. By tracking respiratory viruses in Department of Defense communities, we may be able to predict when influenza may cause the greatest burden for distinct organizational regions and prescribe with greater precision preventative protocols by location, as well as rapidly determine vaccine efficacy. Our current data suggest that when vaccine strains are mismatched, rapid upfront targeting of antivirals may be warranted, but when the vaccine strains are better matched, late season peaks of disease may indicate waning immunity and should be monitored.

The role of adenovirus in respiratory tract infections.

Adenovirus plays a significant role in respiratory tract disease in pediatric and adult patients. It has been linked to outbreaks and epidemics in various patient populations, resulting in considerable morbidity and mortality. In this article, we discuss the epidemiology, pathogenesis, respiratory tract illnesses and complications, and roles of potential treatment options. The role of the past oral adenovirus vaccine and the military implications of its withdrawal from routine use in military recruits is discussed as well.

Infectious Disease Clinical Research Program: Building the Bench.

The role of physicians in the U.S. Armed Forces is diverse, encompassing a wide array of skills and responsibilities to provide superior healthcare to their patients and to advance military medicine. In addition to healthcare delivery and medical education, military physicians are engaged in public health, operational medicine, and cutting-edge medical research. Thus, clinical research is a crucial component of Graduate Medical Education (GME) and supports critical thinking (knowledge, skills, and abilities) and the development of leadership skills among U.S. military physicians. The Infectious Disease Clinical Research Program (IDCRP) education mission was established in 2005 with the overall goal of supporting the development and training of the next generation of clinical researchers in infectious diseases and related public health disciplines in the Armed Forces using several strategies, including didactic learning, mentored research, and research engagement. Through involvement in the IDCRP, infectious disease fellows, residents (e.g., surgical, internal medicine, and pediatrics), and Master of Public Health (MPH) students have continued their education and gained valuable skills related to clinical research. Trainees either conduct research with IDCRP mentors or participate in IDCRP-led practicum experiences, with research projects ranging from epidemiologic studies to microbiological assessments. Consistent with the needs of the Military Health System (MHS), and in accordance with Accreditation Council for Graduate Medical Education goals, the IDCRP provides opportunities for medical and graduate students, residents, and infectious disease fellows to conduct mentored research within the MHS, as well as gain important leadership skills in the conduct of clinical research. Overall, IDCRP continues to further infectious disease research through the support and education of the next generation of active-duty infectious disease researchers in the MHS.

The Acute Respiratory Infection Consortium: A Multi-Site, Multi-Disciplinary Clinical Research Network in the Department of Defense.

INTRODUCTION: Acute respiratory infections (ARI) result in substantial annual morbidity among military personnel and decrease operational readiness. Herein, we summarize the research efforts of the Infectious Disease Clinical Research Program (IDCRP) related to ARIs. METHODS: The ARI Research Area of the IDCRP was established in response to the 2009 emergence of pandemic influenza A/H1N1. That year, IDCRP investigators deployed the ARI Consortium Natural History Study (ARIC NHS), a multi-centered, longitudinal observational study to assess etiology, epidemiology, and clinical characteristics of influenza-like illness (ILI) and severe acute respiratory infections (SARI) in the U.S. military. The success of this initial effort spurred implementation of several new initiatives. These include the FluPlasma trial, designed to evaluate the efficacy of hyperimmune anti-influenza plasma for the treatment of severe influenza; the self-administered live-attenuated influenza vaccine (SNIF) trial, which assessed the immunogenicity and acceptance of a self-administered live-attenuated influenza vaccine in military personnel; the Study to Address Threats of ARI in Congregate Military Populations (ATARI), a prospective study of ILI transmission, etiology and epidemiology in recruits; and the Flu Breath Test (FBT) study, a preliminary study of exhaled volatile organic compounds (VOC) in influenza patients. In addition, the InFLUenza Patient-Reported Outcome (FLU-PRO) survey, a daily diary to measure influenza symptoms during clinical trials, was developed. Lastly, the Pragmatic Assessment of Influenza Vaccine Effectiveness in the DoD (PAIVED) study, a two-year randomized trial designed to compare the effectiveness of the three types of licensed vaccines, launched in Fall 2018. RESULTS: The on-going ARIC NHS has enrolled over 2000 ILI and SARI cases since its inception, providing data on burden and clinical manifestations of ARI in military personnel and their families. The FluPlasma 2 trial concluded subject enrollment in 2018. Preliminary results from ATARI study show a high frequency of respiratory viruses circulating during the first two weeks of recruit training. Based on assessment of FLU-PRO responses, which were found to be reliable and reproducible, the survey may be a useful tool in clinical trials and epidemiological studies. The Flu Breath Study will complete enrollment in 2019. Findings from PAIVED are intended to provide evidence needed for assessing influenza vaccination policy in the military. CONCLUSIONS: The ARI burden in the armed services remains significant every year and the threat is dynamic given emergent and evolving threats, such as influenzas. With strong successes to date, future initiatives of the ARI Research Area will focus on interventional studies, ARI transmission dynamics in congregate military settings, and determinants of risk of pandemic influenza and other emergent respiratory viruses.

Altered Sex Ratios in Offspring of U.S. Submariners Urban Legend or Fact - Do Submariners Have More Daughters?

INTRODUCTION: There is a widespread and long-held belief in the submarine community that submariners father more daughters than the general population. The U.S. Sex Ratio at birth (males/females) has remained around 1.05 since the early 2000s. Limited evidence exists that certain environmental exposures including chemicals, heavy metals, radiation and g-forces may influence sex ratio at birth. A reduction in male births in a population has been associated with lower male fertility. A 1970 single site study showed a higher ratio of female offspring in personnel serving aboard U.S. Navy nuclear submarines than the general population. A 2004 study concluded that this was probably not true. However, this study was small, and did not evaluate the difference between children conceived during sea duty versus shore duty. They did note a higher chance of female offspring correlated with a longer time in the community, as well as an increased ratio in sonar technicians. These findings warrant further investigation. METHODS: An electronic survey was e-mailed to submariners, after receiving required IRB and Navy approvals. Participants were asked birth year, year they entered submarine service, and how many children they had. For each child they were asked sex, child's birth year, mother's birth year, and whether they were on sea duty or shore duty at the time of conception. Those who were on sea duty at the time of conception were asked what their job was, where they were stationed and what type of submarine they were on. Those who were on shore duty at the time of conception were asked whether they were in contact with submarines on a regular basis, whether they were officer or enlisted, and what region they were stationed in for shore duty. RESULTS: Four thousand eight hundred responses were received with a total of 6,958 children included in the analysis. Respondents had a SR of 0.95 compared to 1.05 U.S. population in 2015 (p < 0.0001). Submariners on sea duty had a SR of 0.88 compared to 1.02 on shore duty (p = 0.007). Those who had regular submarine contact on shore duty had a SR of 0.72 compared to 1.17 in those who did not (p < 0.001). Geographical location during shore duty did show differences that were statistically significant (p = 0.018). Geographical location during sea duty did not show significant differences. No significant differences were seen for paternal age, maternal age, job during sea duty, type of submarine assigned to or time in community. CONCLUSION: The submariners surveyed reported greater numbers of daughters than the general population, especially when on sea duty or in regular contact with submarines during shore duty. Further study should be done to confirm results and explore possible etiologies of differences in sex ratio.

Polymicrobial bloodstream infection in pediatric patients: risk factors, microbiology, and antimicrobial management.

BACKGROUND: Few studies focus on polymicrobial bloodstream infections (PBSIs) in children. In previous reports, children with PBSI frequently had complex underlying medical conditions and a high incidence of specific microorganisms, but systematic evaluation with controls was not performed. We postulated that specific clinical risk factors are associated with an increased risk of PBSI, and that illness may be more severe with these infections. Additionally, we suspected that routine empiric antimicrobial therapy may frequently be inadequate to treat the variety of pathogens in PBSI. METHODS: Positive blood cultures from 1998 to 2004 were reviewed. Patients whose cultures grew >1 organism were age-matched with monomicrobial bloodstream infection controls. Records were reviewed to compare their underlying medical conditions, organisms isolated, adequacy of therapy, and clinical characteristics of illness. RESULTS: Twenty-nine episodes of PBSI were identified in 18 subjects. PBSI patients were more likely to have chronic medical conditions, chronic gastrointestinal pathology, central venous catheters, and to be receiving parenteral nutrition than controls. Pathogens found more commonly in PBSI episodes included Enterococcus spp., coagulase-negative staphylococci, and Candida spp. Empiric antimicrobial therapy was less likely to be adequate in patients with PBSI. PBSI patients were hospitalized longer, required longer intensive care and had prolonged bloodstream infection. Subjects with PBSI had prolonged duration of fever and had higher degrees of sepsis than controls. CONCLUSIONS: Chronic medical conditions, particularly gastrointestinal disease, are risk factors for PBSIs. Because clinical illness may be more severe, alteration of the empiric antimicrobial regimen should be considered in some of these patients.

Antibody contributes to heterosubtypic protection against influenza A-induced tachypnea in cotton rats.

BACKGROUND: Influenza virus infection or vaccination evokes an antibody response to viral hemagglutinin (HA) and neuraminidase (NA) surface glycoproteins, which results in immunity against influenza A viruses of the same HA and NA subtype. A heterosubtypic immune response that offers some protection against different influenza A subtypes has been suggested from epidemiologic studies in human influenza outbreaks, and has been induced in experimental animal models. Original studies of such cross-protection showed that cytotoxic T lymphocytes (CTL) protect H3N2-immune mice from a lethal H1N1 infection. More recent studies in mice demonstrate that antibodies also contribute to heterosubtypic immunity (HSI). We previously demonstrated that HSI in cotton rats (Sigmodon hispidus) is characterized by protection of H3N2-immune animals from influenza H1N1-induced increase in respiratory rate (tachypnea). Alternatively, H1N1-immune animals are protected from H3N2-induced tachypnea. The experiments described in this report were designed to elucidate the immune mechanism that prevents this very early sign of disease. RESULTS: Our results show that cotton rats provided with H1N1-immune serum prior to challenge with an H3N2 virus were protected from influenza-associated tachypnea, with the degree of protection correlating with the antibody titer transferred. Immunization with an inactivated preparation of virus delivered intramuscularly also provided some protection suggesting that CTL and/or mucosal antibody responses are not required for protection. Antibodies specific for conserved epitopes present on the virus exterior are likely to facilitate this protection since prophylactic treatment of cotton rats with anti-M2e (the extracellular domain of M2) but not anti-nucleoprotein (NP) reduced virus-induced tachypnea. CONCLUSION: In the cotton rat model of heterosubtypic immunity, humoral immunity plays a role in protecting animals from influenza-induced tachypea. Partial protection against respiratory disease caused by different influenza A subtypes can be attained with either live virus administered intranasally or inactivated virus delivered intramuscularly suggesting that either vaccine regimen may provide some protection against potential pandemic outbreaks in humans.

Developing the Next Generation of Physicians.

To improve health care, the USA needs to create a longitudinal medical education system that will develop physicians able to lead the transformation of health care toward a focus on the promotion of healthy behaviors aimed at preventing disease. The development of patient-centered care has been an important step in promoting healthy behaviors. However, to truly develop a meaningful relationship with a patient, a physician must first see them as a person, not as a list of diseases. Medical education should develop physicians able to provide person-centered care - moving beyond patient-centered care to focus more broadly on the entirety of the person, for whom being a patient is merely one aspect of their personhood. Restructuring medical education begins with the admission process itself, followed by longitudinal changes at the undergraduate, graduate, and continuing professional development levels that will reinforce the attributes critical for future physicians. The authors view this longitudinal approach through the theoretical framework of situated cognition, exploring personal, environmental, and social factors leading to success; outline several key stages of medical education from matriculation through continuing professional development; and identify potential areas that merit longitudinal efforts to develop future physicians able to promote positive health behaviors.

Health Maintenance Deficits in a Fully Insured Population of Adolescents With Chronic Medical Conditions.

The current national monitoring of routine wellness care and vaccine uptake does not provide data on health maintenance among pediatric populations with chronic medical conditions. In this case-control study that analyzes wellness visits and vaccine uptake among adolescents, ages 16 to 18 years, we identified 938 without (controls) and 74 with (cases) 1 of 12 specific chronic medical conditions. The PPSV23 (23-valent pneumococcal polysaccharide vaccine) is recommended by the Advisory Committee on Immunization Practices for these 12 conditions and served as a measure of uptake for medically indicated vaccines. Our controls were twice as likely as cases to have a documented well visit in the past year, and there was a significantly higher proportion of controls than cases vaccinated with Tdap (tetanus toxoid, reduced diphtheria toxoid, acellular pertussis), MCV-4 (quadrivalent meningococcal conjugate), and HPV (human papillomavirus), all P < .05. More than 60% of cases failed to receive PPSV23. Adolescents with chronic medical conditions are at high risk of neglecting routine health maintenance.

Increasing clindamycin resistance among methicillin-resistant Staphylococcus aureus in 57 northeast United States military treatment facilities.

BACKGROUND: Increasing community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has led many to use clindamycin for CA-MRSA disease, whereas others suggest caution because of inducible clindamycin resistance and rely on drugs such as trimethoprim-sulfamethoxazole (TMP-SMX). AIM: To analyze the change in antibiotic susceptibility pattern of S. aureus isolates from 2001 to 2004 in a closed health care system, a period during which clindamycin and TMP-SMX use increased 99 and 62%, respectively. METHODS: S. aureus cultures from 57 military hospitals and clinics from 2001-2002 and 2003-2004 were compared for body site and antibiotic sensitivity, particularly the potentially inducible clindamycin-susceptible erythromycin-resistant pattern. A portion was evaluated by a double disk diffusion test (D test). RESULTS: Numbers of S. aureus-positive cultures obtained from "wound" sites rose significantly in both pediatric (138 to 215, P < 0.001) and adult (715 to 972, P < 0.001) isolates, with a rise in MRSA in children (6 of 138 to 60 of 215, P < 0.001) and in adults (161 of 715 to 324 of 972, P < 0.001). Clindamycin resistance increased among pediatric S. aureus isolates (1 of 207 to 13 of 327, P < 0.05), whereas >96% remained TMP-SMX-susceptible. Five methicillin-susceptible S. aureus (MSSA), 2 MRSA of 41 pediatric and 36 MSSA, 43 MRSA of 437 adult S. aureus specimens were D test-positive. CONCLUSIONS: In late 2004, most S. aureus from our region are still beta-lactam-susceptible. Most of the MRSA are still susceptible to clindamycin and do not appear to have inducible resistance. We must closely monitor the rates of constitutive and inducible clindamycin resistance as well as consider treatment alternatives that may slow the rate of clindamycin resistance.

History of U.S. military contributions to the study of respiratory infections.

History reveals a tremendous impact of respiratory pathogens on the U.S. military, dating back to the time of the Revolutionary and Civil Wars, during which 90% of casualties were for nonbattle injury, including several respiratory illnesses such as measles, whooping cough, and complicated pneumonia. The devastating impact of the influenza pandemic at the end of World War I led to a more proactive approach to research into the etiologies and potential preventive measures for such diseases. The development of the Armed Forces Epidemiological Board, with its subordinate commissions, coincided with the massive mobilization for World War II. Efforts of the board during and after the war led to significant progress against many common pathogens, such as the landmark studies of group A Streptococcus among young trainees at Warren Air Force Base, which led to the development of highly effective prophylactic and therapeutic strategies to prevent rheumatic fever. Military pediatricians contributed greatly to this work, as well as subsequent investigations into both the pathogenesis of and prophylactic therapy for a variety respiratory pathogens, including pertussis and respiratory syncytial virus. The momentum of this work continues to this day, among researchers from all three military branches.

WITHDRAWN: Abstract.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.cppeds.2015.06.007. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Neuraminidase inhibitor therapy in a military population.

BACKGROUND: Although neuraminidase inhibitors (NI) are the mainstay of treatment for influenza infection, prescribing practice for these agents is not well described. Additionally, benefit is contested. OBJECTIVES: We examined provider prescriptions of NI during the 2009 pandemic and post-pandemic periods. We also evaluated the effectiveness of NI in reducing severity of influenza infection. STUDY DESIGN: Data on NI prescription and severity of influenza infection were compiled in healthy pediatric and adult beneficiaries enrolled in a prospective study of influenza like illness conducted at five military medical centers over five years. Subjects underwent nasal swabs to determine viral etiology of their infection. Demographic, medication and severity data were collected. Subjects with positive influenza were included. RESULTS: Two hundred sixty three subjects were influenza positive [38% [H1N1] pdm09, 38.4% H3N2, and 20.5% B); 23.9% were treated with NI. NI were initiated within 48h in 63% of treated subjects. Although NI use increased over the five years of the study, early use declined. Most measures for severity of illness were not significantly reduced with NI; adults treated within 48h had only a modest reduction in duration and severity of some of their symptoms. CONCLUSIONS: NI use in our population is increasing, but early use is not. NI use resulted in no reduction in complications of illness. Resolution of symptoms and reduction in severity of some symptoms were slightly better in adults who were treated early. These modest benefits do not support routine treatment with NI in otherwise healthy individuals with influenza.

Epidemiologic, clinical, and virologic characteristics of human rhinovirus infection among otherwise healthy children and adults: rhinovirus among adults and children.

BACKGROUND: human rhinovirus (HRV) is a major cause of influenza-like illness (ILI) in adults and children. Differences in disease severity by HRV species have been described among hospitalized patients with underlying illness. Less is known about the clinical and virologic characteristics of HRV infection among otherwise healthy populations, particularly adults. OBJECTIVES: to characterize molecular epidemiology of HRV and association between HRV species and clinical presentation and viral shedding. STUDY DESIGN: observational, prospective, facility-based study of ILI was conducted from February 2010 to April 2012. Collection of nasopharyngeal specimens, patient symptoms, and clinical information occurred on days 0, 3, 7, and 28. Patients recorded symptom severity daily for the first 7 days of illness in a symptom diary. HRV was identified by RT-PCR and genotyped for species determination. Cases who were co-infected with other viral respiratory pathogens were excluded from the analysis. We evaluated the associations between HRV species, clinical severity, and patterns of viral shedding. RESULTS: eighty-four HRV cases were identified and their isolates genotyped. Of these, 62 (74%) were >18 years. Fifty-four were HRV-A, 11HRV-B, and 19HRV-C. HRV-C infection was more common among children than adults (59% vs. 10%, P<0.001). Among adults, HRV-A was associated with higher severity of upper respiratory symptoms compared to HRV-B (P=0.02), but no such association was found in children. In addition, adults shed HRV-A significantly longer than HRV-C (P trend=0.01). CONCLUSIONS: among otherwise healthy adults with HRV infection, we observed species-specific differences in respiratory symptom severity and duration of viral shedding.

Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn.

BACKGROUND: In May 1996, the CDC recommended obtaining a complete blood count and blood culture (BC) from all asymptomatic "at risk" newborns; those > or =35 weeks gestation born to mothers with group B streptococcal vaginal colonization or those with maternal fever, premature rupture of membranes or previous infant with group B streptococcal disease; who did not receive adequate intrapartum antibiotic prophylaxis. DESIGN/METHODS: During the study period (May 1996 to July 1999), a complete blood count and BC were obtained within 4 h from all asymptomatic at risk newborns of > or =35 weeks gestation. White blood cell count (WBC) and BC results and prevalence of clinical or culture-proven sepsis were obtained by chart review. We determined the sensitivity/specificity and likelihood ratios of an abnormal WBC (total >30 000 or <5000/mm3; absolute neutrophil count <1500/mm3, or a band form-polymorphonuclear cell ratio of >0.2) to distinguish between clinically septic vs. nonseptic term at risk newborns. RESULTS: Of 20 554 deliveries 1665 were initially asymptomatic at risk newborns; 17 (1.0%) developed early onset sepsis, all within 48 h. WBC was abnormal in 7 of 17 (41%) and in 447 of 1648 (27%) who remained nonseptic. None of the 1665 term at risk newborns had a positive BC. The sensitivity and specificity of an abnormal WBC in predicting which at risk newborns would develop sepsis were 41 and 73%, respectively. The positive likelihood ratio was 1.52, whereas the negative likelihood ratio was 0.81, with an odds ratio of 1.88. CONCLUSIONS: Since the implementation of the CDC guidelines for maternal intrapartum antibiotic prophylaxis, culture-proved sepsis has become rare at our institution. Although BC did not aid in the diagnosis of sepsis among asymptomatic at risk newborns, close observation in the first 24 h remained critically important.

Age-dependent replication of respiratory syncytial virus in the cotton rat.

Despite the documented disease burden of respiratory syncytial virus (RSV) in the elderly, little is known about the underlying risk factors or pathogenesis of RSV in a geriatric population. This report describes an age-dependent change of RSV clearance in the lung and nose of the cotton rat. Six days postinfection with RSV, lung and nose viral titers were significantly higher in all older age groups as compared with 4- to 6-week old cotton rats (P < 0.05). When comparing the 4- to 6-week old animals to the 15- to 16-month old animals 6 days postinfection, there was over an 800- and 100-fold increase in lung and nose viral titers, respectively. The cotton rat may prove to be a useful model in eliciting mechanisms of severe RSV disease in the elderly.