Although group A *Streptococcus* (GAS) most commonly causes pharyngitis and soft tissue infections ([@R1]), it also produces severe invasive disease including bacteremia, pneumonia, necrotizing fasciitis (NF), and streptococcal toxic shock syndrome (STSS), especially at the extremes of age ([@R2],[@R3]). In the United States, 9,000--11,000 cases and 1,100--1,800 deaths from invasive GAS infection occur each year ([@R3]). Those [\>]{.ul}65 years of age have the highest incidence and case-fatality rate: nearly a third of all cases and half of all deaths occur in this age group ([@R3]). In addition to advanced age, cardiac and vascular disease, diabetes, skin breakdown, corticosteroid use, and malignancy are associated with increased risk for invasive GAS infection among adults ([@R4]--[@R8]). Because underlying conditions are common among long-term care facility (LTCF) residents, this population may be especially vulnerable to invasive GAS infection. Although outbreaks of invasive GAS infections have been well described among LTCF residents ([@R9]--[@R16]), the extent and characteristics of sporadic invasive GAS infections in this population have not been well defined.

Since 1998, the Active Bacterial Core surveillance (ABCs) of the Emerging Infections Program Network (EIP)---a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and academic centers---has collected information on residence (LTCF vs. community) of invasive GAS case-patients. We used ABCs data to compare incidence, characteristics, and factors contributing to death from invasive GAS infections of elderly LTCF residents and similar-aged persons residing in the community.

Methods
=======

Surveillance
------------

ABCs conducts active laboratory- and population-based surveillance for invasive infections due to GAS and other bacterial pathogens of public health importance. We reviewed ABCs reports of invasive GAS cases among persons [\>]{.ul}65 years of age occurring from January 1, 1998, through December 31, 2003, in the following sites: San Francisco, California (3 counties); Baltimore, Maryland (6 counties); Albany and Rochester, New York (15 counties); Portland, Oregon (3 counties); Chattanooga, Knoxville, Memphis, and Nashville, Tennessee (11 counties); and the entire states of Connecticut, Georgia, and Minnesota. Five counties in the Denver, Colorado, metropolitan area were added in 2000. The total surveillance area encompassed a 2000 Census population of 3,446,404 persons [\>]{.ul}65 years of age (10% of the total US population in this age group).

ABCs methodology has been published previously ([@R2],[@R17]). Briefly, ABCs sites maintain active contact with clinical laboratories to identify all cases and perform audits of laboratory records at least every 6 months to ensure complete reporting. Surveillance officers review case-patient medical records to obtain information on demographic characteristics, clinical syndrome, underlying disease, and illness outcome. Case-patients with GAS-positive blood cultures but without an identifiable clinical syndrome are categorized as having bacteremia without focus. Otherwise, multiple clinical syndromes---including cases of pneumonia, cellulitis, osteomyelitis, non-skin abscesses, and other syndromes ([@R18]) when accompanied by a sterile site isolate---may be reported for each case. Underlying illness information ([@R18]) was not consistently collected in Georgia from 1998--1999, Maryland from 1998--2000, or Tennessee in 1998. Information on smoking status was collected beginning in 2000 and history of cerebrovascular accident (CVA) in 2001.

Case Definitions
----------------

ABCs defines a case of invasive GAS infection as isolation of GAS from a normally sterile site (e.g., blood, cerebrospinal fluid) or from a wound when accompanied by STSS or NF in a resident of an ABCs surveillance area. ABCs defines an LTCF as a skilled nursing facility, nursing home, rehabilitation hospital, or other chronic-care facility in which the patient has been living for at least 30 days before GAS infection. The definition did not include facilities in which the patient receives daily outpatient therapy or prisons, group homes, and assisted living facilities.

To determine whether outbreaks contributed significantly to GAS disease among LTCF residents, we looked for clusters within LTCFs. We defined a GAS LTCF cluster as [\>]{.ul}2 invasive infections with the same *emm* type occurring within 12 months (duration of some previously reported GAS outbreaks \[[@R10]\]) among residents [\>]{.ul}65 years of age living at the same facility. Surveillance staff confirmed the residence of case-patients within each cluster.

Descriptive Epidemiology
------------------------

To describe incidence trends for persons [\>]{.ul}65 years of age (regardless of residence type) from 1998 to 2003, we analyzed GAS cases and deaths reported from 54 ABCs counties that conducted GAS surveillance during the entire 6-year period (1998 population: 1,981,662 persons [\>]{.ul}65 years of age). For annual rate calculations, we used national census and postcensus population estimates for these counties as the annual population denominators.

To calculate incidence of invasive GAS infection among persons [\>]{.ul}65 years of age stratified by residence type, we included ABCs GAS case-patients during the year 2000 and imputed cases with missing residence information on the basis of distribution of cases with known residence. For the denominator we used residence type--specific population estimates from the US Census 2000 Summary File 1 for ABCs counties ([@R19]); census data on residence type were only available for the year 2000. To calculate national estimates of disease, we applied age- and race-specific GAS rates from the ABCs surveillance area to the age and racial distribution of the US population in 2000; we redistributed those of unknown race on the basis of the reported distribution for known cases.

For residence-specific analyses, we excluded cases of invasive GAS infection if residence was missing or unknown. To calculate case-fatality ratios (CFRs) we included only case-patients with known outcomes.

Microbiologic Testing
---------------------

ABCs sites forwarded all available GAS isolates to CDC's Streptococcal Genetics Laboratory. GAS isolates underwent T typing and amplicon restriction profiling of the *emm* gene as described at [www.cdc.gov/ncidod/biotech/strep/protocol_emm-type.htm](http://www.cdc.gov/ncidod/biotech/strep/protocol_emm-type.htm) ([@R20]). Using a reference database containing ≈180 group A streptococcal *emm* sequence types, we categorized an isolate as a given *emm* type if it had [\>]{.ul}92% identity over the first 30 codons encoding the processed M protein with one of the reference *emm* types ([@R21]).

Antimicrobial drug susceptibility testing of available GAS isolates in 1999, 2001, and 2003 was performed at CDC by using broth microdilution. To report antimicrobial susceptibility, we used established Clinical and Laboratory Standards Institute breakpoints for MICs and defined isolates with intermediate or high-level resistance as nonsusceptible ([@R22]).

Statistical Analysis
--------------------

We used SAS version 9.1 (SAS Institute Inc., Cary, NC, USA) for all analyses. To analyze incidence trends, we used Cochran-Armitage calculations for linearity and trend. In univariate analysis, we used Cochran-Mantel-Haenszel statistics to compare case-patient and GAS isolate characteristics stratified by case-patient residence; we also analyzed factors associated with death among LTCF residents and community-based case-patients separately.

We used logistic regression to characterize factors associated with death, checking for 2-way interactions and collinearity. We included in our model all variables associated with death on univariate analysis (p\<0.15) controlling for age group, race, and sex. We stratified *emm* type into each of the 10 most common *emm* types and an 11th category including all remaining *emm* types ("other"). We classified case-patients with multiple clinical syndromes in the category with the highest CFR. The model was restricted to cases for which information on all variables was available. We considered p values \<0.05 statistically significant.

Results
=======

Disease Incidence and Estimated Disease Impact in the Elderly
-------------------------------------------------------------

From 1998 to 2003, a total of 5,889 cases of invasive GAS infection of all ages were reported, including 1,762 (30%) among persons [\>]{.ul}65 years of age. Incidence of invasive GAS infection in this elderly age group increased from 10.0 cases per 100,000 population in 1998 to 10.9 cases per 100,000 population in 2003 ([Table 1](#T1){ref-type="table"}). Type of residence was available for 1,662 elderly case-patients (94%). Of these, 383 case-patients resided in LTCFs, accounting for 23% of cases in those [\>]{.ul}65 years of age. In 2000 (the only year with reliable US Census population estimates for residence type), the incidence of invasive GAS among LTCF residents was almost 6 times higher than among community-based residents (41.0 vs. 6.9 cases per 100,000 persons, p\<0.01). Projecting to the US population, we estimate that 650 cases among LTCF-residents and 2,250 cases among community-based residents [\>]{.ul}65 years of age occurred nationwide in 2000. Among both LTCF- and community-based residents, GAS incidence was highest among black men (78.9 and 13.8 cases per 100,000 persons, respectively) and lowest among white women (35.1 and 4.9 cases per 100,000 persons, respectively).

###### Invasive group A streptococcal infection cases and deaths among persons age [\>]{.ul}65 y, by site, ABCs areas, 1998--2003\*

                                  1998   1999   2000   2001   2002   2003
  ------------------------------- ------ ------ ------ ------ ------ ------
  No. cases/100,000 population
  CA                              8.4    10.3   11.1   9.8    7.6    9.5
  CT                              8.7    9.4    11.3   9.8    10.2   11.5
  GA                              10.5   7.3    9.7    12.5   6.4    9.5
  MD                              13.7   9.0    9.3    15.4   11.4   15.3
  MN                              11.4   10.5   10.6   13.1   10.3   9.8
  NY                              7.7    12.6   10.3   10.2   12.9   10.2
  OR                              9.2    6.5    4.0    4.6    6.6    9.0
  All sites                       10.0   9.3    10.0   11.1   9.2    10.9
  No. deaths/100,000 population
  All sites                       2.2    1.9    2.3    2.2    2.2    2.6

\*ABCs (Active Bacterial Core surveillance) areas: San Francisco, California (3 counties), Connecticut (entire state), Atlanta, Georgia, metropolitan area (20 counties), Baltimore, Maryland (6 counties), Minneapolis/St. Paul, Minnesota (7 counties), Rochester, New York (7 counties), and Portland, Oregon (3 counties).

Demographic and Clinical Characteristics
----------------------------------------

In comparison to community-based case-patients, LTCF case-patients were older (median 83 years vs. 75 years for community case-patients, p\<0.01) and more frequently female ([Table 2](#T2){ref-type="table"}). Underlying illness information was available for 1,538 (93%) case-patients. Congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease, and atherosclerotic cardiovascular disease were common in both groups. However, LTCF case-patients more frequently had CHF and a history of cerebrovascular accident but less commonly had diabetes mellitus or were current smokers than community-based case-patients. In addition, LTCF residents were less likely to have penetrating trauma preceding the infection (0.8% vs. 2.7%, p\<0.05). Compared to community-based case-patients, LTCF case-patients more commonly had bacteremia without focus and pneumonia but less frequently had cutaneous or soft tissue infections as the possible source of the invasive GAS isolate identified ([Table 3](#T3){ref-type="table"}).

###### Characteristics of persons age [\>]{.ul}65 y with invasive group A streptococcal infection by known residence, ABCs areas, 1998--2003\*

  Characteristic                           No. LTCF
case-patients (%), n = 383   No. community-based
case-patients (%), n = 1,279   p value
  ---------------------------------------- -------------------------------------- --------------------------------------------------- ---------
  Age, y                                                                                \<0.01
  65--74                                   72 (18.8)                              584 (45.7)
  75--84                                   149 (38.9)                             465 (36.3)
  [\>]{.ul}85                              162 (42.3)                             230 (18.0)
  Female sex                               238 (62.1)                             626 (48.9)                                          \<0.01
  Race†                                                                                0.16
  White                                    282 (82.5)                             914 (78.9)
  Black                                    50 (14.6)                              182 (15.7)
  Other                                    10 (2.9)                               63 (5.4)
  Case-fatality†                           124 (32.6)                             268 (21.1)                                          \<0.01
  Hospitalization†                         346 (90.3)                             1211 (94.8)                                         \<0.01
  Presence of underlying illnesses†
  Congestive heart failure                 104 (29.3)                             237 (20.5)                                          \<0.01
  Cerebrovascular accident                 39 (16.8)                              71 (9.4)                                            \<0.01
  Diabetes mellitus                        86 (24.2)                              346 (30.0)                                          \<0.05
  Current smoker                           6 (2.1)                                61 (6.5)                                            \<0.01
  Chronic obstructive pulmonary disease    62 (17.5)                              172 (14.9)                                          0.24
  Atherosclerotic cardiovascular disease   95 (26.7)                              351 (30.4)                                          0.19
  Renal failure/dialysis                   30 (8.5)                               103 (8.9)                                           0.78
  Alcohol abuse                            19 (5.4)                               48 (4.2)                                            0.34
  Immunosuppressive therapy‡               19 (5.4)                               87 (7.5)                                            0.16

\*ABCs, Active Bacterial Core surveillance;LTCF, long-term care facility. Case-patients with missing responses for residence type or individual characteristics were excluded from analysis.
†Data were not available for all case-patients. Denominators by residence varied for the following: race (LTCF 342, community 1,159), outcome (LTCF 380, community 1,270), hospitalization (LTCF 383, community 1,278), underlying illnesses (LTCF 355, community 1,154) except for cerebrovascular accident (LTCF 232, community 758) and current smoker (LTCF 285, community 936).
‡Includes steroids, chemotherapy, and radiation therapy.

###### Clinical syndromes among persons [\>]{.ul}65 y with invasive group A streptococcal infection, by residence and overall CFR, ABCs areas, 1998--2003\*

  Clinical syndrome          No. LTCF case-patients (%),
N = 383   No. community-based
case-patients (%), N = 1,279   p value   Overall
CFR, %
  -------------------------- ------------------------------------- --------------------------------------------------- --------- ----------------
  Bacteremia without focus   145 (37.9)                            406 (31.7)                                          \<0.05    25.1
  Pneumonia†                 97 (25.3)                             225 (17.6)                                          \<0.01    34.0
  Cellulitis†                121 (31.6)                            498 (38.9)                                          \<0.01    16.3
  Septic arthritis†          20 (5.2)                              90 (7.0)                                            0.21      11.8
  Osteomyelitis†             7 (1.8)                               26 (2.0)                                            0.80      6.1
  STSS                       15 (3.9)                              82 (6.4)                                            0.07      55.7
  Necrotizing fasciitis      15 (3.9)                              80 (6.3)                                            0.08      36.6
  Abscess†‡                  8 (2.3)                               47 (3.9)                                            0.15      14.5

\*CFR, case-fatality ratio; ABCs, Active Bacterial Core surveillance; LTCF, long-term care facility; STSS, streptococcal toxic shock syndrome. Case-patients with missing responses for residence type, outcome, or clinical syndrome were excluded from analysis. Data for case**-**patients could be categorized under [\>]{.ul}1 syndrome except for case-patients identified as having bacteremia without a focus.
†Occurring in conjunction with isolation of group A streptococcal infection from a sterile site (e.g., blood culture).
‡Data not available for all years. Denominators: LTCF 349; community 1,205.

Isolate Characteristics
-----------------------

GAS was identified from blood cultures in 1,491 (90%) of the 1,662 elderly case-patients with known residence. Of the remaining 171 nonbacteremic patients, GAS was most commonly isolated from joint fluid (n = 57) and surgical specimens (n = 51). GAS was identified from multiple body sites in 125 (8%) case-patients.

GAS isolates were available in 1,414 (85%) of the 1,662 case-patients. From a total of 63 *emm* types identified, 5 (*emm1*, *emm3*, *emm12*, *emm28*, and *emm89*) accounted for most infections (57% among LTCF residents; 62% among community-based residents) ([Table 4](#T4){ref-type="table"}). Antimicrobial susceptibility testing was performed on 781 GAS isolates including 187 isolates from LTCF case-patients. Fourteen (7%) isolates from LTCF case-patients and 34 (6%) from community-based case-patients were not susceptible to erythromycin (p = 0.38). Three isolates from LTCF case-patients and 5 from community case-patients were not susceptible to levofloxacin; 2 from community case-patients were not susceptible to clindamycin. No isolates were resistant to penicillin, ampicillin, cefazolin, vancomycin, or cefotaxime.

###### Most common *emm* types identified in persons [\>]{.ul}65 y with invasive group A streptococcal infection, by residence, ABCs areas, 1998--2003\*

  *emm* type   No. LTCF case-patients (%), N = 324   No. community-based case-patients (%), N = 1,090
  ------------ ------------------------------------- --------------------------------------------------
  1            55 (17.0)                             233 (21.4)
  3            44 (13.6)                             141 (12.9)
  28           39 (12.0)                             122 (11.2)
  12           21 (6.5)                              116 (10.6)
  89           27 (8.3)                              61 (5.6)
  77           9 (2.8)                               39 (3.6)
  6            12 (3.7)                              22 (2.0)
  18           6 (1.9)                               28 (2.6)
  11           10 (3.1)                              23 (2.1)
  4            11 (3.4)                              21 (1.9)

\*ABCs, Active Bacterial Core surveillance; LTCF, long-term care facility. Case-patients with missing responses for residence type and *emm* type were excluded from analysis. Table stratified by overall frequency.

Predictors of Death
-------------------

The CFR among case-patients [\>]{.ul}65 years of age was 24%. CFR increased with age among both LTCF- and community-based case-patients. However, when compared to the CFR for the 65- to 74-year-old group, the CFR among 75- to 84-year-old persons and those [\>]{.ul}85 years of age was significantly greater only among community-based case-patients ([Figure](#F1){ref-type="fig"}). LTCF case-patients were 1.5 times as likely to die from the infection as community-based GAS case-patients (33% vs. 21%, p\<0.01); however, this group was less often hospitalized (90% vs. 95%, p\<0.01). CFRs among hospitalized and nonhospitalized case-patients were comparable in both LTCF (33% vs. 33%, p = 0.92) and community case-patients (21% vs. 25%, p = 0.44).

![Comparison of case-fatality ratio from invasive group A streptococcal infections among persons by age group and residence, Active Bacterial Core surveillance areas, 1998--2003. Blank square, long-term care facility case-patient; black square, community-based case-patient. Case-patients with missing responses for residence type and outcomes were excluded from analysis. \*p\<0.05 for long-term care facility case-patients versus community-based case-patients. †p\<0.05 indicates significance between the following groups: 75--84-year age group versus 65--74-year age group, or [\>]{.ul}85-year age group versus 65--74-year age group.](07-0303-F){#F1}

Univariate analysis of LTCF case-patients showed that those with CHF had significantly higher CFR (42% with CHF died vs. 27% without CHF, p\<0.01) as did those with infections caused by *emm1* (51% vs. 28%, p\<0.01) or *emm3* (45% vs. 30%, p\<0.05) when compared to other *emm* types. We also observed higher CFR among LTCF case-patients with STSS (73% vs. 31%, p\<0.01), NF (64% vs. 31%, p\<0.05), or pneumonia (42% vs. 30%, p\<0.05) than those with other syndromes. Sex, race, and hospitalization of LTCF case-patients were not significantly associated with death. These same variables were associated with significantly higher case-fatality rates among community-based case-patients.

In the final multivariate logistic regression model, independent predictors of death included LTCF residence; lack of hospitalization; infection due to *emm1*, *emm3*, or *emm12*; disease manifesting as STSS, NF, pneumonia, or bacteremia without focus; and interaction between female sex and presence of congestive heart failure ([Table 5](#T5){ref-type="table"}). Age was not a significant risk factor associated with death.

###### Results of multivariate logistic regression analysis of factors associated with death from invasive group A streptococcal infection among case-patients [\>]{.ul}65 y of age, ABCs areas, 1998--2003\*

  Characteristic                 Adjusted odds ratio (95% CI)
  ------------------------------ ------------------------------
  Age group, y
  [\>]{.ul}85                    1.4 (0.9--2.1)
  75--84                         1.2 (0.8--1.8)
  65--74                         Reference
  Race
  Black                          0.8 (0.5--1.2)
  Other than black               Reference
  Residence
  **Long-term care facility**    **1.6 (1.1--2.2)**
  Community                      Reference
  Hospitalized
  **Hospitalized**               **0.5 (0.3--0.9)**
  Not hospitalized               Reference
  Syndrome
  **Bacteremia without focus**   **2.6 (1.7--3.8)**
  **Pneumonia**                  **3.7 (2.4--5.8)**
  **Necrotizing fasciitis**      **3.6 (1.7--7.4)**
  **STSS**                       **11.1 (6.4--19.3)**
  Other syndrome                 Reference
  *emm* type
  ***emm1***                     **2.3 (1.4--3.6)**
  ***emm3***                     **1.9 (1.1--3.1)**
  *emm4*                         1.7 (0.6--4.5)
  *emm6*                         0.6 (0.2--2.1)
  *emm11*                        0.4 (0.1--2.0)
  ***emm12***                    **1.9 (1.1--3.4)**
  *emm18*                        1.3 (0.5--3.9)
  *emm28*                        0.9 (0.5--1.7)
  *emm77*                        1.3 (0.5--3.4)
  *emm89*                        1.5 (0.8--3.0)
  Other *emm* types              Reference
  Sex and history of CHF†
  **Females with CHF**           **2.4 (1.5--3.8)**
  Females without CHF            0.9 (0.7--1.4)
  Males with CHF                 1.2 (0.7--2.0)
  Males without CHF              Reference

\*ABCs, Active Bacterial Core Surveillance; CI, confidence interval; STSS, streptococcal toxic shock syndrome; CHF, congestive heart failure. A total of 1,140 case-patients with complete data were included in the final model. Significant results are shown in **boldface**.
†Interaction between sex and history of CHF.

Clustering of Cases
-------------------

We identified 18 GAS clusters comprising a total of 40 cases (10% of LTCF cases). Fourteen clusters consisted of only 2 cases; the other 4 clusters had 3 cases each. The median interval between the first and second cases was 2.5 months (range 0.2--9.2 months). The most common *emm* types identified were *emm28* and *emm89*, which caused 4 and 3 clusters, respectively. Case-patients in clusters were of similar age (median 85.5 years), sex (68% female), and race (75% white) to overall LTCF GAS case-patients [\>]{.ul}65 years of age. The most common syndromes of clustered patients were cellulitis (40%) and bacteremia without focus (38%). Fifteen case-patients died (CFR 38%).

Discussion
==========

Although the elderly have the highest rates of disease and death due to invasive GAS infection ([@R2]--[@R4]), we demonstrated that a subset of persons [\>]{.ul}65 years of age has an even greater risk. Invasive GAS infection was almost 6 times as likely to develop in elderly LTCF residents. Moreover, such case-patients were 1.5 times more likely to die from this infection than elderly persons living in the community. LTCF case-patients with invasive GAS infection were more likely to be older, female, have a history of CHF or CVA, and have pneumonia or bacteremia without focus compared to community-based case-patients. We found no significant differences in *emm* type distributions and antimicrobial resistance patterns among GAS isolates that caused infections in LTCF- or community-based case-patients.

The increased risk for death among elderly case-patients living in LTCFs compared to case-patients in the community remained significant on multivariate analysis and is likely attributable, in part, to the fact that LTCF residence is a proxy measure of individual frailty. While this surveillance system collects information such as age and underlying conditions, measurements of functional status such as the Karnofsky score or activities of daily living are not obtained. The common use of advanced directives among LTCF residents may also contribute to the higher CFR. Because some directives preclude aggressive clinical management, this may also explain the lower frequency of hospitalization among LTCF case-patients.

Other factors associated with higher CFR included specific *emm* types and several clinical syndromes. These findings are consistent with past studies in which disease due to *emm* types 1 and 3 as well as the clinical syndromes pneumonia or STSS were independent predictors of death among all age groups ([@R2]). Although advancing age has been found previously to contribute to overall case-fatality rates ([@R2],[@R23]), our analysis showed advancing age (e.g., age 75--84 years or [\>]{.ul}85 years) was no longer significant once presence of CHF, residence type, and *emm* type were included in the statistical model.

The true extent of severe GAS infections in the LTCF population is likely greater than our study estimates. First, ABCs identifies only culture-confirmed invasive GAS infections, limiting recognition of GAS syndromes such as cellulitis, for which cultures are not commonly obtained. Furthermore, current guidelines developed through expert opinion do not recommend obtaining blood cultures in residents of LTCFs, largely because of the low yield of blood cultures in this setting ([@R24]). Consequently, many LTCF practitioners do not routinely obtain blood cultures in residents with fever; residents are either treated empirically or transferred to an acute-care facility ([@R25],[@R26]). In our analysis of hospitalized LTCF case-patients, only 8% of positive GAS cultures were obtained before the day of hospitalization. Second, ABCs surveillance personnel have noted that residence-type is not always recorded in medical records, potentially leading to misclassification of LTCF residents as community residents. However, this misclassification would also underestimate the extent of severe GAS illness in the LTCF population.

We used available data to estimate the frequency of clusters of invasive GAS infection occurring in LTCFs. Although other studies suggest that many cases of invasive GAS may represent secondary transmission ([@R4],[@R23],[@R27]), we found that only 10% of cases among LTCF residents occurred within documented clusters. This finding likely represents underreporting for several reasons: use of empiric antimicrobial agents in LTCFs for mild and moderate infections; presence of disease manifestations for which cultures are not routinely obtained (e.g., cellulitis); and absence of GAS isolates (15%) for *emm* typing, a criterion we used to define a cluster.

Nonetheless, this study augments findings from other studies that note greater frequency of invasive bacterial infections among the elderly ([@R27]--[@R29]). Prior analyses of invasive group B streptococcal (GBS) and *S. pneumoniae* infections found that these infections were ≈4 times more common in LTCF residents than in community-dwelling elderly ([@R28],[@R29]), likely due to the advanced age, multiple underlying conditions, and immobility in this population ([@R30]). Crowded living quarters may also play a role, as clusters of invasive GAS among healthy persons living in close proximity have been reported previously ([@R31],[@R32]). Although less prevalent within nursing homes than illnesses such as urinary tract infection, invasive GAS, GBS, and pneumococcal diseases remain substantial causes for concern given the associated illness and higher deaths with these infections, the risk for outbreaks, and emerging antimicrobial resistance.

In addition to improved LTCF infection control practices, invasive GAS infections could be prevented with the use of an effective GAS vaccine. In the past, development of a GAS vaccine targeting the M protein, a major virulence determinant, has been halted over concerns of possible induction of antibodies that cross-react with brain, joint, and cardiac tissues ([@R33],[@R34]). However, current vaccine candidates avoid the risks for cross-reactivity ([@R35],[@R36]). Our analysis shows that 82% and 85% of strains causing invasive disease in both LTCF and community elderly, respectively, would be covered by the 26-valent M protein-based vaccine recently tested in phase II trials. If this vaccine also induces a protective response among older adults, it could substantially benefit LTCF residents.

In conclusion, our analysis noted that all older adults, but particularly those living in LTCFs, have significantly higher rates of disease and death from invasive GAS infection. This institutionalized population represents a unique opportunity for prevention through enhanced surveillance to improve case detection and secondary disease prevention, stringent infection control measures, and annual immunization against influenza, a disease for which GAS is a known secondary infection ([@R14],[@R16],[@R23]). Finally, vaccination of this population with an effective GAS vaccine may be highly beneficial.

*Suggested citation for this article*: Thigpen MC, Richards CL Jr, Lynfield R, Barrett NL, Harrison LH, Arnold KE, et al. Invasive group A streptococcal infection in older adults in long-term care facilities and the community, United States, 1998--2003. Emerg Infect Dis \[serial on the Internet\]. 2007 Dec \[*date cited*\]. Available from <http://www.cdc.gov/EID/content/13/12/zzz.htm>

We thank Elizabeth Zell, Carolyn Wright, and Ben Kupronis for their substantial contributions to the statistical analysis for this article; Delois Jackson, Varja Sakota, and other members of CDC's Streptococcus Laboratory for streptococcal typing; and the participating clinical laboratories and ABCs staff within each EIP site who made this study possible.

Funding for this study came from the Emerging Infections Program, CDC, Atlanta, Georgia.

Dr Thigpen works for the Division of HIV/AIDS Prevention at CDC. He developed this project to analyze national data from CDC's ABCs system to determine the incidence and case-characteristics of invasive GAS among the elderly.


description: programmatically install apache cordova plugins

full_name: alunny/pluginstall


Armillaria tabescens

Armillaria tabescens is a species of fungus in the family Physalacriaceae. It is a plant pathogen. The mycelium of the fungus is bioluminescent.

Hosts and symptoms
Armillaria species infect a wide variety of woody plants. In a survey of 250 permanent plots of trees in Albania, Armillaria tabescens affected multiple species of trees including fir species, where it invaded when the plant was stressed. Tsopelas et al. reported Armillaria tabescens to be more prevalent in areas where the trees were stressed due to limited moisture. In oak trees, it was slightly more damaging and could kill young trees. Armillaria tabescens was also recorded in poplar and eucalyptus plantations, and almond trees were found to be very susceptible to infection. The results of the study by Lushaj et al. showed that Armillaria tabescens was most frequently recorded on fruit and ornamental trees compared to the other species.

Armillaria tabescens causes separation of the bark from the wood by the production of mycelial fans in the trunk, a common sign of Armillaria root rot. It also causes gummosis, patches of gummy material on the surface of plants, which occurs in response to an external stimulus which causes the plant to ooze sap. Other common symptoms are soft rot of cortex, dwarfing, dieback, wilting, and abnormal coloring of the leaves. Small trees are killed rapidly by Armillaria tabescens and the symptoms aren’t noticeable until the leaves wilt. However, on larger trees symptoms occur earlier and start as a thin crown with small leaves. A crown of a tree refers to any branches or foliage that are growing out from the trunk. Therefore, thinning of the crown would mean reduced branches and leaves. The trees eventually start yellowing and defoliating followed by fast wilting and dying of limbs. The fungus is a white rot so it breaks down lignin in the wood. The breaking down of the lignin leads to the trees becoming hollow.

Environment
Armillaria tabescens is found in warm and dry regions, so it tends to be in southern areas. It has also been found in altitudes ranging from sea level to . Studies in Europe have found that it exists in south-east England, France, Hungary, Italy, Portugal, Greece and, rarely, Germany and Switzerland. In Japan, it is very rare; only one isolate of Armillaria tabescens was found out of 59 sites surveyed.

Armillaria tabescens grows quickly at  and more slowly at . If the soil is moist, fruiting bodies are abundant. It is the first to fruit in September, compared to Armillaria mellea and Armillaria gallica. The fruiting bodies can be seen even earlier if the season has been exceptionally wet. Armillaria tabescens grows poorly on sand and produces shorter rhizomorphs. Rhizomorphs are threadlike structures in fungi that are made up of hyphae. Hyphae are branching structures that release enzymes to absorb nutrients from the host.

Pathogenesis
Armillaria tabescens is a heterothallic species of Armillaria. Heterothallic species perform anastomosis when haploid monokaryon come in contact with one another. Anastomosis is the connection or opening between two things, in this case the mycelium. Mycelium is the vegetative part of the fungus that consists of hyphae. If the two monokaryons are sexually compatible they form a clamp connection. This results in a mycelium consisting of dikaryotic cells. The dikaryon cells predominate in the vegetative phase. In the basidia karyogamy occurs before meiosis and then the formation of basidiospores.  The basidiospores then infect the host plant.

Armillaria tabescens is found to attack trees that are already stressed or have a wound. The pathogen can spread its mycelia and get into the trunk or root of a tree. The fungus has the ability to spread its mycelia throughout the root and trunk system and form mycelial mats. Mycelia is damaging to trees because they absorb the nutrients by secreting enzymes to breakdown the plant material. It specifically breaks down lignin because it is a white rot.

No rhizomorphs have been found for Armillaria tabescens in nature. However, Rishbeth and Kile did find rhizomorphs buried in the soil on inocula. Since the species doesn't produce rhizomorphs commonly in the nature, infected roots must come into contact with other potential hosts for infection to occur. So, root grafting provides an effective pathway for the spread of this pathogen. Tsopelas conducted an experiment of inoculating almond trees with Armillaria tabescens and two other Armillaria species. The result of the experiment was that basidiocarps developed 6–8 weeks after the inoculation. The basidiocarps are recognized by not having an annulus around the stalk of the basidium. The basidiospores infect the trees. After two years, it only killed 3 out of the 16 trees and two other trees had symptoms of dieback.

See also
 List of Armillaria species
 List of bioluminescent fungi

References

Category:Fungal plant pathogens and diseases
tabescens
Category:Bioluminescent fungi
Category:Fungi described in 1772
Category:Fungi of Europe


LEWIS TOWNSHIP, Pa. — A former patrol K-9 handler who worked alongside soldiers in Afghanistan was reunited with his partner. With so much energy, most wh...

LEWIS TOWNSHIP, Pa. -- A former patrol K-9 handler who worked alongside soldiers in Afghanistan was reunited with his partner.

With so much energy, most who have cared for Kelly the Belgian Malinois will tell you it's normal. This 9-year-old dog just won't sit still.

But Wednesday morning, Robert William Nacy found himself pacing around, too.

"When I got the last text saying you guys were all, I almost lost my mind walking around the hotel," Nacy said.

Back in 2010, Nacy worked alongside soldiers in Afghanistan. He was a bomb-sniffing dog handler. His K-9 partner was Kelly.

"We lost a few dogs over there and a few handlers that unfortunately got hurt, but we were lucky to have her and all the explosive K-9s out there. They are doing some amazing work," said Nacy.

Nacy left Afghanistan in 2011, but Kelly stayed. After more than six years of service, Kelly officially retired and was brought back to the United States. She has been staying with Anne Gibbs at nonprofit Canine Hero Haven near Sunbury.

"It's just so exciting to see these dogs retire and actually start enjoying life," Gibbs said.

Then came the moment Nacy was officially reunited with his newly adopted pet Kelly.

"It took my breath away. It's been a long time," Nacy said.

Nacy traveled from Arizona to pick her up in Selinsgrove.

"I would have gone anywhere for her. I would have gone back to Afghanistan for her. I don't care," said Nacy.

After the years working over in Afghanistan, he thinks it's about time this dog has a well-deserved retirement.


---
author:
- 'Juan Estrada, Fermilab (On behalf of the DØ collaboration)'
title: 'Optimal use of Information for Measuring $M_t$ in Lepton+jets $t\overline{t}$ Events.'
---

The observation of the top ($t$) quark served as one of the major confirmations of the validity of the standard model (SM) of particle interactions [@cdfPRD1; @d0PRD2]. Through radiative corrections of the SM, the mass of the top quark, along with that of the W boson [@pdg3], provide the best indication for the value of the mass of the hypothesized Higgs boson [@lepEWWG4]. The mass of the W is known to a precision of $< 0.1$%, while the uncertainty on the mass of the top quark is at the 4% level [@pdg3]. Improvements in both measurements are required to limit the range of mass that the Higgs boson can assume in the SM, and, of course, to check whether that agrees with expectation. It is therefore important to develop techniques for extracting the mass of the top quark that can provide the sharpest values possible.

Measurement of $M_t$ {#measurement-of-m_t .unnumbered}
====================

We report on a new preliminary measurement of the mass of the top quark from $t \bar t$ data in lepton+jets channels accumulated by the DØ experiment in Run-1 of the Tevatron. The luminosity corresponds to 125 events/pb, and this analysis is based on the same data sample that was used to extract the mass of the top quark in our previous publication [@massPRD5]. Information pertaining to the detector and to the older analysis can be found in Refs. [@d0NIM6] and [@massPRD5], respectively.

After offline selections on lepton transverse energies ($E_T > 20$ GeV) and angles ($|\eta_{\mu}| < 1.7$, and $|\eta_{e}| < 2.0$, for muon and electron channels, respectively), on jet transverse energies ($E_T > 15$ GeV) and angles ($|\eta| < 2.0$), imbalance in transverse momentum (missing-$E_T >20$ GeV), and after applying several less important criteria [@massPRD5], the event sample consisted of 91 events with one isolated lepton and four or more jets. (Unlike the previous analysis, we do not distinguish between events that have or lack a muon associated with one of the jets, signifying the possible presence of a $b$-quark jet in the final state.) The new analysis involves a comparison of the data with a leading-order matrix element for the production and decay process, and to minimize the effect of higher-order corrections we therefore restrict the study to events containing only four jets. This requirement reduces data sample to 71 events.

(80,80)(0,0) (0,0)[![Discriminator $D=P_{signal}/(P_{signal}+P_{backg.})$ for the new analysis, and (inset) for the two versions of the analysis included in the previous DØ publication [@massPRD5].[]{data-label="fig:discr"}](discr.eps "fig:"){width=".6\textwidth"}]{} (10,35)[![Discriminator $D=P_{signal}/(P_{signal}+P_{backg.})$ for the new analysis, and (inset) for the two versions of the analysis included in the previous DØ publication [@massPRD5].[]{data-label="fig:discr"}](discr_old.eps "fig:"){width=".5\textwidth"}]{}

In the previous analysis, the four jets with highest $E_T$ were assumed to represent the four quarks in the events (two $b$ quarks from the initial $t\rightarrow W+b$ decays, and the $q' \bar q$ decays of one of the $W$ bosons). These, along with the lepton and the missing $\nu$ (from the decay of the other $W$ boson) were fitted to the kinematic hypothesis $p \bar p \rightarrow t \bar t \rightarrow W W b \bar b$, subject to the constraints of overall momentum-energy conservation, the known mass of the $W$ boson, and the fact that the unknown mass of the top quark ($M_t$) had to be identical for the top and antitop quarks in the event. With 12 ways to permute the jets, there were 12 possible fits, and the solution with the lowest $\chi^2$ (but $<$ 10) was chosen as the best hypothesis, thereby defining the fitted mass $m_{fit}$ for the event, as well as the longitudinal momentum of the $\nu$. The same procedure was used for generating templates in variables of interest, as a function of input mass of the top quark. This was based on the Monte Carlo (MC) HERWIG program [@herwig7], which was used to generate events that were passed through full event-reconstruction in the detector [@d0geant8]. The background, which consisted mainly of all-jet production (20%) and $W$+jets (80%) was also processed in a similar manner. The background from all-jet production was based on data, and the background from $W$+jets was based on events generated with VECBOS [@vecbos9]. A discriminant was formed based on differences in distributions in four variables predicted for $t \bar t$ signal and background, and this defined the probability that any event represented signal as opposed to background. A probability density was defined as a function of the discriminant ($D$) and $m_{fit}$, and a comparison of data and MC via a likelihood was used to determine the most likely mass of the top quark.

The new analysis is also based on a likelihood, but this likelihood is a function of all measured variables in the event, with the exception of the unclustered energy in the calorimeter that is used to define the missing $E_T$. Our method is similar to that suggested for $t \bar t$ dilepton decay channels [@dgk10], and used in previous mass analyses of dilepton events [@dilep11]. We define a probability for background purely in terms of the matrix element contained in VECBOS, and for signal in terms of the leading-order matrix element for $t \bar t$ production and decay. This is convoluted with a transfer function that relates objects at the parton level to the objects observed (fully reconstructed) in the detector. We assume that the observed electrons correspond to the produced electrons, and that the muons are smeared with their known resolution. The angles of the jets are assumed to reflect the angles of the partons in the final state, and we ignore any transverse momentum for the incident partons. We use a large MC sample of $t \bar t$ events (generated with masses between 140$-$200 GeV in HERWIG, and processed through the DØ detector-simulation package) to determine a set of ten parameters that correlate any jet $E_T$ with its parton value. The parameters used for $b$ quarks are different than for the lighter quarks, and there are therefore 20 parameters in all.

We can write the probability for $t \bar t$ production in terms of the following elements: $$P_{t \bar t}= \int d\rho_1 dm_1^2 dM_1^2 dm_2^2 dM_2^2 \sum_{\mbox{perm.},\nu}
               |M|^2 \frac{f(q_1)f(q_2)}{|q_1||q_2|} \Phi_6 W(x,y)$$ where the sum is over all 12 permutations of the jets, and all possible values of $\nu$ momenta. $|M|^2$ is the matrix element for the process, $f(q_1)$ and $f(q_2)$ are the parton distribution function (PDF) for the incident particles, $\Phi_6$ is the phase-space factor for the 6-object final state and $W(x,y)$ correspond to a function that parameterizes the mapping between parton level quantities $y$ and detector measurements $x$. With two incident parton energies (we take these partons to be quarks, and ignore the $\approx 10\% $ contribution from gluon fusion), and six objects in the final state, the integrations over the essentially fifteen sharp variables (3 components of lepton momentum, eight jet angles, and four $\delta$-functions representing energy-momentum conservation), leaves five integrals that must be performed to obtain the probability that any event represents $t \bar t$ production for some specified value of top mass $m_t$. Four of the variables chosen for the remaining integrations, namely the masses of the $W$ bosons and of the top quarks in the event, are economical in CPU time, because the value of $|M|^2$ is essentially negligible except at the peaks of the four Breit-Wigner terms in the matrix element.

![Distribution for background probability calculated for the 71 4-jets $t \bar t$ candidates (data points). Only the events to the left of the vertical line ($\ln[P_{backg}]<-11,0$) are considered for further analysis. The data is compared with the expected results from MC-simulated samples (dashed histrogram) formed with a mixture of 16 signal (left-hatched histrogram) and 55 background (right-hatched histogram) events.[]{data-label="fig:backgprob"}](backprob.eps){width=".6\textwidth"}

Introducing an analogous expression for the background, the likelihood as a function of $m_t$ can be written as: $$\begin{aligned}
-ln L(\alpha) = &-& \sum_{i=1}^N \ln[c_1 P_{t \bar t}(x_i; \alpha) + c_2 P_{bkg}(x_i)] \nonumber \\
                &+& N\int A(x) [c_1 P_{t \bar t}(x; \alpha) + c_2 P_{bkg}(x)] dx\end{aligned}$$ where $A(x)$ is the acceptance of the detector in terms of the parton variables (and contains the transfer function), and the sum over the probabilities for the individual events reflects the product of the probabilities for final sample of $N$ of events. The best values of $\alpha$, representing $m_t$, and the parameters $c_i$, are all defined by the most probable value of the likelihood.

The main difference between this method and the previous analysis is that each event now has its individual probability as a function of the mass parameter. This probability, reflecting both signal and background, depends on all measured variables in the event (excepting unclustered energy), with well-measured events contributing more sharply to the extraction of the mass of the top quark than those poorly measured. The fact that so much of the information in each event is retained in the probability provides a far better separation of signal and background. Figure \[fig:discr\] displays the effective difference in the discriminating power for the parameter $D$ in the current and in the previous analyses. In all these analyses, this parameter is not used to select regions of high signal-probability, but the comparison is instructive in showing the greater power of the present method.

![a) Negative of the log of the likelihood as a function of the mass of the top quark for the 22 $t \bar t$ candidates in our final sample. b) Probability distribution determined from the likelihood, with the hatched area corresponding to the 68% probability interval, from which we determine $M_t = 179.9 \pm 3.6$ GeV. A 0.5 GeV upward bias correction has been included based on the results of MC ensemble tests.[]{data-label="fig:likelihood"}](likemt_2.eps){width=".9\textwidth"}

Studies on samples of HERWIG MC events used in the previous analysis indicate that the expected uncertainty using the new method would be capable of yielding almost a factor of two reduction in the uncertainty of the extracted top mass. However, the method appears to be sensitive to a systematic shift of the mass (of about 2 GeV) as a function of the [*a priori*]{} sample purity, whose true value cannot be determined in the analysis. To minimize the impact of this limiting systematic uncertainty, we proceed as follows. Figure \[fig:backgprob\], shows the probability that each event corresponds to background (VECBOS), and we compare that to a sample of 71 MC events corresponding to the mixture of 16 signal and 55 background events found in the data sample. From MC studies we fibd that eliminating from further consideration in the analysis those events that have a high probability of being background, reduces markedly the dependence on the extracted mass on sample purity. We consequently retain for further study only those events that have a poor probability of being background. This selection is shown in Fig \[fig:backgprob\], and its imposition leaves a sample of only 22 events, 12 of which are signal and 10 background, after the recalculation of the new minimum in the likelihood, the result of which is shown in Fig. \[fig:likelihood\]

Another aspect of this analysis is that it provides a natural method for measuring any other parameter in the $t \bar t$ differential cross section. As an example we, show in Fig. \[fig:likemw\] the likelihood as a function of the mass of the $W$ boson ($M_W$) for the same sample of events. This suggests the very interesting possibility of checking the jet energy scale (JES) in this events, which corresponds to the largest contribution to the systematic uncertainty in the current and previous analyses. The next step in this analysis is, in fact, to utilize the information on JES contained in these events. However, in this preliminary result, we only estimate this uncertainty using the previous analysis [@massPRD5], where the JES calibration from $\gamma+jet$ events was used to match the energy scale in the experiment to that in the MC simulation. Here we estimate the uncertainty in $M_t$ coming from JES as follows. The analysis is performed before and after applying this correction, and the difference defined as the systematic uncertainty due to JES. Table \[tb:sys\] summarizes all the systematic uncertainties in this preliminary result.

![a) Negative of the log of the likelihood as a function of the mass of the $W$ boson for the 22 $t \bar t$ candidates in our final sample. b) Probability distribution determined from the likelihood, with the hatched area corresponding to the 68%. probability interval.[]{data-label="fig:likemw"}](likemw_2.eps){width=".9\textwidth"}

Conclusion {#conclusion .unnumbered}
==========

We have presented a new preliminary measurement of the mass of the top quark using a method that compares each individual event with the differential cross section for $t \bar t$ production and decay. We obtain a significant improvement over the statistical uncertainty of the previous measurement [@massPRD5], that is equivalent to having a factor of 2.4 more data. The new preliminary result is: $$M_t=179.9 \pm 3.6 \mbox{(stat)} \pm 6.0 \mbox{(sys)} \mbox{ GeV}$$

The possibility of checking the value of the $W$ mass in the same events offers the possibility of redoing the largest systematic uncertainty, of the same events provides a new handle on controlling the largest systematic, namely the jet energy scale.

  --------------------------------- ---------
  Model for $t \bar t$              1.5 GeV
  Model for backgound($W$+jets)     1.0 GeV
  Noise and multiple interactions   1.3 GeV
  Jet energy scale                  5.6 GeV
  Parton distribution function      0.2 GeV
  Acceptance correction             0.5 GeV
  Total                             6.0 GeV
  --------------------------------- ---------

  : Table of systematic uncertainties for the measurement of $M_t$

\[tb:sys\]

Aknowledgements {#aknowledgements .unnumbered}
===============

We thank F. Canelli, G. Gutierrez and T. Ferbel for their important contributions to this analysis.

[8.]{}

CDF Collaboration, F. Abe et al., Phys. Rev. Lett. [**74**]{}, 2626 (1995)

DØ Collaboration, S. Abachi et al., Phys. Rev. Lett. [**74**]{}, 2632 (1995).

K. Hagiwara et al., Phys. Rev. D [**66**]{}, 01001 (2002).

LEP Working Group for Higgs, LEPEWWG/2002-1 (2002).

DØ Collaboration, B. Abbott, et al., Phys. Rev. D [**58**]{}, 052001 (1998).

DØ Collaboration, B. Abachi et al., Nucl. Instrum. Methods Phys. Res. A [**338**]{}, 185 (1994).

G. Marchesini et al., Comput. Phys. Commun. [**67**]{}, 467 (1992).

DØ Collaboration, J. Womersley, in Proceedings of the XXVI International Conference on High Energy Physics, Dallas, Texas, edited by R. Sanford, AIP Conf. Proc. No. 272 (AIP, New York, 1993), p. 1800.

F. A. Berends, H. Kuijf, B. Tausk and W. T. Giele, Nucl. Phys. [**B357**]{}, 32 (1991).

R. H. Dalitz and G. R. Goldstein, Proc. R. Soc. Lond. A [**445**]{}, 2803 (1999), and refecenced therein; K. Kondo et al., J. Phys. Soc. Jap. [**62**]{}, 1177 (1993).

DØ Collaboration, B. Abbott, et al., Phys. Rev D [**60**]{}, 052001 (1999).


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Chris Northrop

Christopher Scott Northrop is an American actor. He is best known for playing Meth-Head Charlie, a recurring role on Unbreakable Kimmy Schmidt.

Career

Northrop participated in a summer acting conservatory program at the T. Schreiber Studio. In 2007, he played a "blonde male modie" in the Ugly Betty episode "Things Fall Apart" and a bar patron in the music video for Kelly Willis' single "Teddy Boys". He guest-starred in Law & Order: SVU in the episode "Wildlife".

In 2010, Northrop was set to play an albino henchman named Bachmeyer in Max Payne 3. Following the completion of facial motion capture, the project was delayed, the producer and key members of his team left production. Northrop remained with the game and participated in motion capture rehearsals, but the new director and team replaced Northrop's character with a corrupt Brazilian police officer and recast him as a result.

Northrop made his feature film debut as the character Death Metal Kid in Camp Hell. On March 16, 2012, Chris Northrop appeared in the segment "Man With Albinism Under Attack" on Primetime: What Would You Do?. It dealt with albino discrimination with Northrop acting out scenarios that included bullying. He also did an interview news correspondent John Quinones about albinism.

In 2014, Northrop played a pizza delivery guy for an episode of The Mysteries of Laura. The following year, he worked on Broad City and High Maintenance and appeared in a lead role for dance rock band Echo Black's music video for "Burn Another Day". He played a zombie breaking a taxi cab window for an AT&T commercial. For the advertisement, it took four hours to apply his make-up and he performed his own stunts. In 2016, Northrop portrayed a stoner in Baked in Brooklyn, alongside Alexandra Daddario and Josh Brenner, and played an Arkham Asylum inmate on Gotham. Between 2016 and 2018, Northrop appeared in a recurring role on Unbreakable Kimmy Schmidt as Meth-Head Charlie.

Filmography

References

Category:Year of birth missing (living people)
Category:Living people
Category:American male film actors
Category:American male television actors


538 U.S. 691 (2003)
BREUER
v.
JIM'S CONCRETE OF BREVARD, INC.
No. 02-337.
Supreme Court of United States.
Argued April 2, 2003.
Decided May 19, 2003.
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT.
*692 SOUTER, J., delivered the opinion for a unanimous Court.
Donald E. Pinaud, Jr., argued the cause for petitioner. With him on the briefs was Eric Schnapper.
*693 Andrew S. Hament argued the cause for respondent. With him on the brief was Gregory Williamson.
Lisa S. Blatt argued the cause for the United States as amicus curiae urging affirmance. With her on the brief were Solicitor General Olson, Deputy Solicitor General Kneedler, Howard M. Radzely, Allen H. Feldman, and Edward D. Sieger.[*]
JUSTICE SOUTER delivered the opinion of the Court.
The question is whether the provision of the Fair Labor Standards Act of 1938 (FLSA or Act), that suit under the Act "may be maintained ... in any Federal or State court of competent jurisdiction," 52 Stat. 1069, as amended, 29 U.S.C. § 216(b), bars removal of a suit from state to federal court. We hold there is no bar.

I
Petitioner, Phillip T. Breuer, sued respondent, his former employer, Jim's Concrete of Brevard, Inc., in a state court of Florida for unpaid wages, liquidated damages, prejudgment interest, and attorney's fees. Section 216(b) provides not only that an employer who violates its minimum wage and overtime provisions is liable to an employee, but that "[a]n action to recover the liability prescribed ... may be maintained against any employer (including a public agency) in any Federal or State court of competent jurisdiction."
Jim's Concrete removed the case to the United States District Court for the Middle District of Florida under 28 U.S.C. § 1441(a), which reads that "[e]xcept as otherwise expressly provided by Act of Congress, any civil action brought in a State court of which the district courts of the United *694 States have original jurisdiction, may be removed by the defendant or the defendants, to the district court of the United States for the district and division embracing the place where such action is pending." Breuer sought an order remanding the case to state court, arguing that removal was improper owing to the FLSA's provision that an action "may be maintained" in any state court, a provision that Breuer put forward as an express exception to the general authorization of removal under § 1441(a). Though the District Court denied Breuer's motion, it certified the issue for interlocutory appeal under § 1292(b). The Eleventh Circuit affirmed, saying that Congress had expressly barred removal in "direct, unequivocal language" in other statutes, 292 F.3d 1308, 1310 (2002), but was not comparably prohibitory in § 216(b). The Eleventh Circuit thus joined the First, see Cosme Nieves v. Deshler, 786 F.2d 445 (1986), but placed itself at odds with the Eighth, see Johnson v. Butler Bros., 162 F.2d 87 (1947) (denying removability under FLSA). We granted certiorari to resolve the conflict, 537 U.S. 1099 (2003), and now affirm.

II

A
There is no question that Breuer could have begun his action in the District Court. The FLSA provides that an action "may be maintained ... in any Federal or State court of competent jurisdiction," 29 U.S.C. § 216(b), and the district courts would in any event have original jurisdiction over FLSA claims under 28 U.S.C. § 1331, as "arising under the Constitution, laws, or treaties of the United States," and § 1337(a), as "arising under any Act of Congress regulating commerce." Removal of FLSA actions is thus prohibited under § 1441(a) only if Congress expressly provided as much.
Nothing on the face of 29 U.S.C. § 216(b) looks like an express prohibition of removal, there being no mention of removal, let alone of prohibition. While § 216(b) provides *695 that an action "may be maintained ... in any ... State court of competent jurisdiction," the word "maintain" enjoys a breadth of meaning that leaves its bearing on removal ambiguous at best. "To maintain an action" may mean "to continue" to litigate, as opposed to "commence" an action.[1] Black's Law Dictionary 1143 (3d ed. 1933). But "maintain" in reference to a legal action is often read as "bring" or "file"; "[t]o maintain an action or suit may mean to commence or institute it; the term imports the existence of a cause of action." Ibid.; see 1 A J. Moore et al., Moore's Federal Practice ¶ 0.167[5], p. 472 (2d ed. 1996) (calling the "`may be maintained'" language an "ambiguous phrase" and "certainly not an express provision against removal within the meaning of § 1441"); 14C C. Wright, A. Miller, & E. Cooper, Federal Practice and Procedure § 3729, p. 235 (1998) (referring to "use of the ambiguous term `maintain' in the statute"). The most, then, that Breuer can claim simply from the use of the term "maintain" is that any text, even when ambiguous, that might be read as inconsistent with removal is an "express" prohibiting provision under the statute. But if an ambiguous term like "maintain" qualified as an express provision *696 for purposes of 28 U. S. C. § 1441(a), then the requirement of an "expres[s] provi[sion]" would call for nothing more than a "provision," pure and simple, leaving the word "expressly" with no consequence whatever. "[E]xpres[s] provi[sion]" must mean something more than any verbal hook for an argument.
The need to take the express exception requirement seriously is underscored by examples of indisputable prohibitions of removal in a number of other statutes. Section 1445, for example, provides that
"(a) A civil action in any State court against a railroad or its receivers or trustees ... may not be removed to any district court of the United States.
"(b) A civil action in any State court against a carrier or its receivers or trustees to recover damages for delay, loss, or injury of shipments ... may not be removed to any district court of the United States unless the matter in controversy exceeds $10,000, exclusive of interest and costs.
"(c) A civil action in any State court arising under the workmen's compensation laws of such State may not be removed to any district court of the United States.
"(d) A civil action in any State court arising under ... the Violence Against Women Act of 1994 may not be removed to any district court of the United States."
See also 15 U. S. C. § 77v(a) ("[N]o case arising under [the Securities Act of 1933] and brought in any State court of competent jurisdiction shall be removed to any court of the United States"); § 1719 ("No case arising under [the Interstate Land Sales Full Disclosure Act] and brought in any State court of competent jurisdiction shall be removed to any court of the United States, except where the United States or any officer or employee of the United States in his official capacity is a party"); § 3612 ("No case arising under [the Condominium and Cooperative Abuse Relief Act of 1980] and *697 brought in any State court of competent jurisdiction shall be removed to any court of the United States, except where any officer or employee of the United States in his official capacity is a party"). When Congress has "wished to give plaintiffs an absolute choice of forum, it has shown itself capable of doing so in unmistakable terms." Cosme Nieves, 786 F. 2d, at 451. It has not done so here.

B
None of Breuer's refinements on his basic argument from the term "maintain" puts him in a stronger position. He goes on to say, for example, that interpretation does not stop at the dictionary, and he argues that the statutory phrase "may be maintained" shows up as sufficiently prohibitory once it is coupled with a federal policy of construing removal jurisdiction narrowly. Breuer relies heavily on our statement in Shamrock Oil & Gas Corp. v. Sheets, 313 U. S. 100 (1941), that "the policy of the successive acts of Congress regulating the jurisdiction of federal courts is one calling for the strict construction of [removal legislation].... `Due regard for the rightful independence of state governments, which should actuate federal courts, requires that they scrupulously confine their own jurisdiction to the precise limits ... the statute has defined.'" Id., at 108-109 (quoting Healy v. Ratta, 292 U. S. 263, 270 (1934)). But whatever apparent force this argument might have claimed when Shamrock was handed down has been qualified by later statutory development. At the time that case was decided, § 1441 provided simply that any action within original federal subject-matter jurisdiction could be removed. Fourteen years later, however, it was amended into its present form, requiring any exception to the general removability rule to be express. See Act of June 25, 1948, § 1441(a), 62 Stat. 937 (authorizing removal over civil suits within the district courts' original jurisdiction "[e]xcept as otherwise expressly provided by Act of Congress"); see also 28 U. S. C. § 1441 (historical and revision *698 notes). Since 1948, therefore, there has been no question that whenever the subject matter of an action qualifies it for removal, the burden is on a plaintiff to find an express exception. As Shamrock itself said, "the language of the Act ... evidence[s] the Congressional purpose," 313 U. S., at 108, and congressional insistence on express exception is hardly satisfied by the malleability of the term "maintain" in the text Breuer relies upon.
Nor does it do Breuer any good to emphasize a sense of "maintain" as implying continuation of an action to final judgment, so as to give a plaintiff who began an action the statutory right under 29 U. S. C. § 216(b) to see it through. We may concede that it does, and the concession leaves the term "maintain" just as ambiguous as ever on the issue before us.[2] The right to maintain an action may indeed be a right to fight to the finish, but removal does nothing to defeat that right; far from concluding a case before final judgment, removal just transfers it from one forum to another. As between a state and a federal forum, the statute seems to betray an indifference, with its provision merely for maintaining action "in any Federal or State Court," ibid.
But even if the text of § 216(b) were not itself reason enough to doubt that the provision conveys any right to remain in the original forum, the implication of Breuer's position would certainly raise misgivings about his point. For if the phrase "[a]n action ... may be maintained" meant that a plaintiff could insist on keeping an FLSA case wherever he filed it in the first place, it would seem that an FLSA case brought in a federal district court could never be transferred to a different one over the plaintiff's objection, a result that would plainly clash with the provision for change of venue, 28 U. S. C. § 1404(a) ("For the convenience of parties and witnesses, in the interest of justice, a district court may transfer *699 any civil action to any other district or division where it might have been brought").
It is, finally, a like concern about consequences that leaves us with fatal reservations about Breuer's pragmatic appeal that many claims under the FLSA are for such small amounts that removal to a sometimes distant federal court may make it less convenient and more expensive for employees to vindicate their rights effectively. This may often be true, but even if its truth somehow justified winking at the ambiguity of the term "maintain," the implications would keep us from going Breuer's way. A number of other statutes incorporate or use the same language as § 216(b), see 29 U.S.C. § 626(b) (providing that the Age Discrimination in Employment Act of 1967 "shall be enforced in accordance with the powers, remedies, and procedures provided in" § 216(b) and other sections of the FLSA); § 2005(c)(2) ("An action to recover the liability prescribed [under the Employee Polygraph Protection Act of 1988] in paragraph (1) may be maintained against the employer in any Federal or State court of competent jurisdiction"); § 2617(a)(2) ("An action to recover the damages or equitable relief [under the Family and Medical Leave Act of 1993] prescribed in paragraph (1) may be maintained against any employer (including a public agency) in any Federal or State court of competent jurisdiction by any one or more employees"). Breuer, then, cannot have a removal exception for the FLSA without entailing exceptions for other statutory actions, to the point that it becomes just too hard to believe that a right to "maintain" an action was ever meant to displace the right to remove.[3]

*700 III
Breuer's case was properly removed under 28 U. S. C. § 1441, and the judgment of the Eleventh Circuit is affirmed.
It is so ordered.
NOTES
[*]   Briefs of amici curiae urging affirmance were filed for the Academy of Florida Management Attorneys, Inc., by Peter W. Zinober; and for the Human Resource Association of Palm Beach County, Florida, et al. by Christine D. Hanley, Sally Still, and Betty L. Dunkum.
[1]  Actually, there is reason to think that this sense of "maintain" was intended. Under the FLSA, the Secretary of Labor may file a suit on behalf of an employee to recover unpaid wages or overtime compensation, and when the Secretary files such a suit, an employee's right to bring a comparable action terminates, see, e.g., 29 U.S.C. § 216(c). Congressional reports suggest that although an employee may no longer initiate a new action once the Secretary has sued, an employee may continue to litigate, i.e., "maintain," an action already pending. See H. R. Conf. Rep. No. 327, 87th Cong., 1st Sess., 20 (1961) (filing of the Secretary's complaint would "not, however, operate to terminate any employee's right to maintain such a private suit to which he had become a party plaintiff before the Secretary's action"); S. Rep. No. 145, 87th Cong., 1st Sess., 39 (1961) (Secretary's filing of complaint "terminates the rights of individuals to later file suit"); cf. Smallwood v. Gallardo, 275 U. S. 56, 61 (1927) ("To maintain a suit is to uphold, continue on foot and keep from collapse a suit already begun"). Seen in this light, Congress's use of the term "maintain" is easy to understand, carrying no implication for removal.
[2]  As to individual cases brought before the institution of any suit by the Government, see n. 1, supra.
[3]  Breuer points to two nonjudicial authorities that do nothing to assuage our skepticism. He calls our attention to the position taken by the Administrator of the Wage and Hour Division, United States Department of Labor, in an amicus brief filed before the Eighth Circuit in Johnson v. Butler Bros., 162 F. 2d 87 (1947), arguing that the text of the FLSA and the policies motivating its passage demonstrate that FLSA actions may not be removed to federal court. But this brief is not persuasive authority. The Secretary has no responsibility for applying the removal statute and no particular authority to interpret it; the Secretary's opinion cannot make up for the absence of express statutory language. Breuer also points to a Senate Report accompanying the 1958 enactment of 28 U. S. C. § 1445, a provision barring removal of workers' compensation actions under state law. Referring to actions brought under the FLSA, the report states "[i]f filed in the State courts the law prohibits removal to the Federal court." S. Rep. No. 1830, 85th Cong., 2d Sess., 9 (1958). But a stray comment in a congressional report stands a long way from an express statutory provision.


Q:

iOS: Modify server response to AVPlayer or how to provide MIME type

I'm trying to play a video file from a server, the file plays in the simulator, but it doesn't in the actual device. When the item's status changes (failed) the error message is:

Error Domain=AVFoundationErrorDomain Code=-11828 "Cannot Open"
  UserInfo=0x15542db0 {NSLocalizedDescription=Cannot Open,
  NSUnderlyingError=0x156f49f0 "The operation couldn’t be completed.
  (OSStatus error -12847.)", NSLocalizedFailureReason=This media format
  is not supported.}

I've read in this question that the file should have either an extension or the server should reply with the correct mime type, however in this situation neither is possible.
I'd like to know if there's a way to modify the server response or provide the mime type programmatically, either with AVPlayer or MPMoviePlayerController. Thank you in advance.

A:

I implemented a NSURLProtocol with a custom scheme to intercept the call and modify the response:
https://developer.apple.com/library/mac/documentation/cocoa/reference/foundation/classes/NSURLProtocol_Class/Reference/Reference.html


Pharmacokinetics of pidotimod in broiler chickens by UHPLC-MS/MS after oral and intravenous administration.
Pidotimod is widely used in children as an immune promoter but it has not been fully evaluated in animals. The pharmacokinetics of pidotimod and its oral bioavailability have not been described in broiler chickens. We developed a simple and sensitive UHPLC-MS/MS assay for rapid determination of pidotimod levels in chicken blood. Recoveries were nearly 100% and the coefficients of accuracy and precision were minimal. Healthy broiler chickens were given 10 mg/kg pidotimod either orally or intravenously. The oral pidotimod was rapidly absorbed (time to reach maximum concentration, 1.25 h) and rapidly eliminated (the mean residence time was 3.2 h). A noncompartmental analysis of the intravenous route indicated a mean plasma clearance of 2.2 L (h kg)-1 with an estimated mean volume of distribution at steady state of 12.69 L/kg. The bioavailability of pidotimod after oral dosing was 27%.


About

Born and raised in Spain, I left my home country in search of new adventures. After living in Portugal, the United Kingdom and Italy for approximately 6 years my journey took me to Switzerland, where I am now settled.

My photography is clearly influenced by the need to wander, observe and capture unique moments. My love for nature is present in the majority of my work, which strives to inspire other people by sharing my unique perspective and prompting the experience behind.


india

Updated: Nov 18, 2016 16:42 IST

With the demonetisation decision playing out as a political war in Parliament, Prime Minister Narendra Modi, who was widely expected to attend the Global Citizen’s India event in Mumbai on Saturday, is now likely to give it a miss.

Until Friday morning, there had been no communication from the prime minister’s office on Modi participating in the event. The event organisers as well as the chief minister’s office have so far got no confirmation about the PM’s visit.

The event is being partnered by the state government and it was expected that the PM, who was present for the Global Citizen festival in New York in 2014, would lend his brand to this social platform, which amplifies some of his favourite causes — such as sanitation. Riding on this, the state Bharatiya Janata Party (BJP) had also planned to get the PM to lay the foundation stones for two of the proposed metro corridors in the city and, thus, informally launch the poll campaign for the BMC elections due next year.

Read | Coldplay concert: Traffic diversions and restrictions at Bandra Kurla Complex

“With the political slug fest over the demonetisation drive, PM may not want to be seen at the festival that is being headlined by an international pop-rock band and has a host of Bollywood celebrities in attendance even though the event is meant to garner support and funds for social causes,” said a senior BJP leader. “It will only give the Opposition (reason) to criticise the PM as being elitist when many common citizens are still in queue to withdraw cash.”

Last week, Mumbai Metropolitan Region Development Authority (MMRDA) officials were preparing for ‘bhoomi pujan’ for the metro lines, while the party unit was looking at holding a public meeting at Somaiya ground in Ghatkopar. However, on Friday, the MMRDA said the planned event was not taking place on Saturday.

The Global Citizen India event ran into controversy over the issue of the state government waiving entertainment tax for the Cold Play concert here on Saturday. Social activists Anjali Damania and Hemant Gawande moved court through a Public Interest Litigation. The court, however, refused to stay the event.

Read | Coldplay concert: Organisers will have to pay entertainment tax, says HC

The scrapping of Rs 1,000 and 500 notes ahead of the local self government polls in the state is likely to impact the elections, with the unorganised and agrarian sector being hit by the move. The BJP, however, is hoping the drive that is increasingly being seen through a rich-versus-poor prism will end up giving the party dividends in the local elections even if it is at the cost of losing the party’s core trader base.

The Prime Minister is expected to sound the bugle for the high decibel Brihanmumbai Municipal Corporation polls later this month or early in December.


Business travel card scheme aimed at promoting trade, investment in grouping

Commonwealth nations could consider a scheme similar to the Business Travel Card scheme, used across the Asia-Pacific Economic Cooperation (APEC) forum, as a means of promoting intra-Commonwealth trade and investment, the chairman of the Commonwealth Enterprise and Investment Council said.

His comments come ahead of the inaugural Meeting of Commonwealth Trade Ministers in London on March 9-10, convened by the CWEIC, and the Commonwealth Secretariat.

Lord Marland, the chair of the body that represents private sector businesses within the Commonwealth, and a former U.K. trade envoy, said that the issue of immigration policy between Commonwealth countries was one for ministers to discuss, but the travel card scheme could be one of the ideas looked at.

“I think there is certainly a case for allowing entrepreneurs and skilled professionals greater freedom to work across the Commonwealth,” he said in an e-mail interview with this paper. Under the APEC scheme, which includes 19 fully participating countries, including Australia, Hong Kong, Russia and Singapore, business travellers are able to apply for five-year-long, short-term, multiple-entry permits to other member states, freeing them from the need to apply for visas every time they travel.

Exploring opportunities

The inaugural trade ministers meeting was planned before last June’s Brexit referendum, but is being seen as particularly relevant in Britain, which is seeking new alliances outside the union. While Prime Minister Theresa May visited India last year, her government had signaled its eagerness to boost ties with other Commonwealth countries.

“This meeting is not a response to Brexit but is an opportunity for all 52 Members of the Commonwealth to explore the opportunities for trade and prosperity which exist within the Commonwealth and develop their trading relationships with one another,” said Lord Marland.

He added that Brexit provided an opportunity for the U.K. to play a bigger role in developing trade relationships between Commonwealth countries.

“The lack of formal mechanisms to promote trade and investment has been a challenge but the fundamentals and ‘Commonwealth Factor’ remain strong and the trade ministers meeting is a positive step towards unlocking the potential,” Lord Marland said.

He said that the meeting would provide a platform for countries to strengthen the dialogue with each other and ensure private sector representatives were brought into the fold. “The Trade Ministers Meeting will provide a platform for this and help Ministers and business leaders develop an understanding of the diverse nature of Commonwealth economies.”

Lord Marland said that another focus area would be on the ease of doing business and the implementation of the WTO facilitation agreement, which came into force on February 22. “There is lots countries can do to improve the business environment before we discuss potential trade deals.”

“A united Commonwealth which takes advantage of our historic ties can be extremely beneficial. There’s so much cross fertilisation – look at the education system, so many Commonwealth decision makers have attended British universities. It’s so much easier to do business in the same language, and with common rules underpinned by the same legal system.”


World Action

At Buckingham Parish Church, we believe God has a heart for this world, and so we support a host of different organisations and charities who try to share God's love with those who need it.

Current Overseas Mission Partners are:

Chris & Fiona Courtman, Latin Link
Arequipa, Peru

Chris and Fiona, with Edith, Rufus & Teddy, have been on Latin Link’s Stride programme serving God in the city of Arequipa, Peru since September 2016. They are working with Nuevas Fuerzas to establish a social enterprise, which seeks to give employment and skills to differently-abled people. Nuevas Fuerzas, which means renewed strength, is a study centre run by the wife of a local pastor for differently-abled young adults to socialise and gain valuable skills in a safe environment. Peru, like many majority world contexts, has very little formal support for differently-abled people, making them some of the most marginalised and vulnerable members of society.

Fiona’s main focus is on using both her design training and teaching experience to equip the workers at Nuevas Fuerzas with new skills whilst seeking to establish a full-scale social enterprise. Chris is supporting Fiona by looking after their three young children, learning Spanish and providing assistance with the management and administrative elements of the project.

If you would like more information on what the Courtmans are doing please contact them by email or speak to Michael or Zena Greig.

Emma Cottrell – Creativity Ministry - Worldwide

Emma is one of our mission partners serving the Lord through creativity, currently in the Middle East, Eastern Europe and within the UK. Her main focus is on helping to support local teams within churches and organisations by helping to equip and teach them to reach out to their local communities through creativity. The Lord is using creativity in lots of different ways to bring healing and hope to people, often overseas those traumatised by events in recent years. She is also involved in prayer ministry, teach and mentoring and is part of Ellel Ministries team from time to time.
If you would like more information on creativity including how to support please visit the website: createdcreative.co.uk or email Emma at emmacottrell@yahoo.com.

INDIA

Will Pearson-Gee (our Rector) travels to India each year to develop a missionpartnership with St Mary's Church in Pune. The visit programme is here for your prayers.
This link was instigated by the late Angelina Chilver. In 2018 Will is taking Jacob Ash our intern and hsi daughter Jemima. They will be visiting:
The Mukti Mission which is a refuge for over 700 women an dgirls who have been orphaned or simply dumped due to their gender and/or disabilities.
A refuge for street children in Pune
as well as preaching an dteaching at St Mar;s and at the United Bible Seminary in Pune.


import { h, Component } from 'preact';

class Home extends Component {
  state = {
    date: undefined,
  };
  componentDidMount() {
    fetch('/api/date')
      .then(res => res.text())
      .then(date => this.setState({ date }));
  }
  render() {
    const { date } = this.state;
    return (

Preact + Node.js API

          Deployed with{' '}

            Vercel

          !

          This project is a Preact app and
          contains two directories, /src for components, routing
          and content, and /api which contains a serverless{' '}
          Node.js function. See{' '}

            api/date for the Date API with Node.js

          .

The date according to Node.js is:

{date ? date : 'Loading date...'}

    );
  }
}

export default Home;


Sen. Bernie Sanders (I-Vt.)

Sen. Bernie Sanders (I-Vt.) has reportedly hired a twice-arrested illegal alien as his deputy national secretary.

Belen Sisa enters the job with one year left of DACA-protection from deportation, The Washington Examiner reported Thursday:

The hiring of Belen Sisa, an Arizona leftist activist, was announced Wednesday evening. Sisa, who says she was brought to this country illegally from Argentina by her parents at age six, is currently protected from deportation under President Barack Obama's Deferred Action for Childhood Arrivals, or DACA, program.

According the Examiner article, Sisa claims to have organized a prison strike:

She has been arrested at least twice for protests throughout her activist career. As a college senior in 2017, she was jailed for her role in a sit-in outside of Sen. Chuck Schumer's, D-N.Y., office. While in jail, Sisa told reporters that she organized a "prison strike." Just weeks before that, she was arrested for a protest outside the Senate Hart Office Building.

The Examiner report comes the same day that Sen. Sanders’ fellow Democrat, Rep. Alexandria Ocasio-Cortez (D-NY) declared on Twitter that “Tokenism *is* racism” – in reference to Republican Rep. Mark Meadows (R-N.C.) allowing an African-American colleague attest to President Donald Trump’s character, as CNSNews.com reported:


Jonas Lefevere

Jonas Lefevere is currently an assistant professor at the University of Amsterdam, but remains affiliated with the Partirep project and the University of Antwerp, where he completed his PhD. On the first round of the Partirep project he completed his PhD on campaign effects on voting motives during the Belgian regional elections. His research interests include bounded rationality, electoral campaign behavior of political parties and campaign effects on public opinion formation. Among others, he has published in Public Opinion Quarterly, Communication Research, Political Communication.