***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The time to the first antibiotic dose  ( TFAD ) has been adopted as a measure of quality of care in patients with community-acquired pneumonia ( CAP ) based on two retrospective studies of large Medicare data bases . The mechanism by which a difference of a few hours in receiving antibiotics can be deleterious is difficult to underst and given the historical data regarding how long it takes for antibiotics to influence outcome . We investigated the factors that predict a prolonged TFAD and their association with mortality . DESIGN Prospect i ve cohort study . SETTING A large tertiary hospital . PATIENTS Immunocompetent adults admitted to the hospital with CAP . RESULTS A total of 451 patients with CAP were studied . A TFAD of > 4 h was associated with increased mortality ( p = 0.017 ) . Altered mental state ( p = 0.001 ) , absence of fever ( p = 0.02 ) , absence of hypoxia ( p = 0.025 ) , and increasing age ( p = 0.038 ) were significant predictors of a TFAD of > 4 h. After adjusting for these factors , the association between TFAD and mortality was not statistically significant ( p = 0.131 ) . Similar findings were observed in patients who were > or = 65 years . CONCLUSIONS A delay in administering antibiotics in patients with CAP is more common in patients who present with an altered mental state or minimal signs of sepsis . TFAD is likely to be a marker of comorbidities driving both an atypical presentation and mortality rather than directly contributing to outcome . Using TFAD as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD , comorbidities , and outcome are complex Pneumococcal vaccine effectiveness was assessed in a r and omized trial among 1,686 old people ( mean age : 74 , st and ard deviation : 4 years ) living in 24 geriatric hospitals and 26 homes for the aged in our district ; 937 were vaccinated with  Merck-Sharp and Dohme pneumococcal vaccine ( 14 serotypes ) . The 749 others composed the reference group . This study was performed during 2 years , since December 1980 . Both groups were r and omized after a two- criteria stratification : by clinical risk assessed before the study , and by type of homes for the aged . Forty pneumonias were diagnosed , with 13 proved pneumococcal etiology . The incidence of pneumonia was significantly reduced in the vaccinated group ( p less than 10(-4 ) but the mortality rate was not modified . We concluded in favor of the effectiveness of pneumococcal  vaccine :  etiological fraction 77.1 % ( 51.2%-89.3 % confidence limits , 95 % risk ) in the population we studied . The incidence of pneumococcal-proved pneumonia was not significantly reduced BACKGROUND This study examined the 1-year effects of a minimal-contact smoking cessation intervention for cardiac in patients . METHODS The multicenter study included cardiac in patients who had smoked prior to hospitalization . A pretest-posttest quasi-experimental design was used . Patients ' experimental condition depended on the hospital they were assigned to . The design was partially r and omized : 4 of the 11 hospitals selected the experimental condition themselves ( 2 experimental , 2 control ) , while the remaining 7 hospitals were r and omly assigned . The experimental group consisted of patients of 5 hospitals ( N = 388 ) . Patients of 6 other hospitals served as the control group ( N = 401 ) . The intervention included stop-smoking advice by the cardiologist , brief counseling by the nurse , the provision of self-help material s , and aftercare by the cardiologist . RESULTS Logistic regression analyses controlling for baseline differences and covariates did not show significant intervention effects on point prevalence and continuous abstinence . The study also showed that the outcomes were not significantly related to the way hospitals were assigned to the experimental condition . CONCLUSIONS While short-term effects were found , the minimal-contact intervention did not result in significant effects after 12 months , at least if patients lost to follow-up were treated as posttest smokers . Efforts should be made to improve the intervention , especially the aftercare CONTEXT Data are limited and conflicting regarding the effectiveness of influenza vaccine in health care professionals . OBJECTIVE To determine the effectiveness of trivalent influenza vaccine in reducing infection , illness , and absence from work in young , healthy health care professionals . DESIGN R and omized , prospect i ve , double-blind , controlled trial over 3 consecutive years , from 1992 - 1993 to 1994 - 1995 . SETTING Two large teaching hospitals in Baltimore , Md. PARTICIPANTS Two hundred sixty-four hospital-based health care professionals without chronic medical problems were recruited ; 49 participated for 2 seasons ; 24 participated for 3 seasons . The mean age was 28.4 years , 75 % were resident physicians , and 57 % were women . INTERVENTION Participants were r and omly assigned to receive either an influenza vaccine or a control ( meningococcal vaccine , pneumococcal vaccine , or placebo ) . Serum sample s for antibody assays were collected at the time of vaccination , 1 month after vaccination , and at the end of the influenza season . Active weekly surveillance for illness was conducted during each influenza epidemic period . MAIN OUTCOME MEASURES Serologically defined influenza infection ( 4-fold increase in hemagglutination-inhibiting antibodies ) , days of febrile respiratory illness , and days absent from work . RESULTS We conducted 359 person-winters of serologic surveillance ( 99.4 % follow-up ) and 4746 person-weeks of illness surveillance ( 100 % follow-up ) . Twenty-four(13.4 % ) of 179 control subjects and 3 ( 1.7 % ) of 180 influenza vaccine recipients had serologic evidence of influenza type A or B infection during the study period . Vaccine efficacy against serologically defined infection was 88 % for influenza A ( 95 % confidence interval [ CI ] , 47%-97 % ; P=.001 ) and 89 % for influenza B ( 95 % CI , 14%-99 % ; P=.03 ) . Among influenza vaccinees , cumulative days of reported febrile respiratory illness were 28.7 per 100 subjects compared with 40.6 per 100 subjects in controls ( P=.57 ) and days of absence were 9.9 per 100 subjects vs 21.1 per 100 subjects in controls ( P=.41 ) . CONCLUSIONS Influenza vaccine is effective in preventing infection by influenza A and B in health care professionals and may reduce reported days of work absence and febrile respiratory illness . These data support a policy of annual influenza vaccination of health care professionals Background : Guidelines recommend that smoking cessation interventions are offered in all clinical setting s to all smokers willing to make a quit attempt . Since the effectiveness of routine provision of behavioural counselling and nicotine replacement therapy ( NRT ) to smokers admitted to hospital has not been established , a r and omised controlled trial of these interventions given together compared with counselling alone or minimal intervention was performed in hospital in patients . Methods : Medical and surgical in patients who were current smokers at the time of admission were r and omised to receive either usual care ( no additional advice at admission ) , counselling alone ( 20 minute intervention with written material s ) , or NRT plus counselling ( counselling intervention with a 6 week course of NRT ) .  Continuous and point prevalence abstinence from smoking ( vali date d by exhaled carbon monoxide < 10 ppm ) was measured at discharge from hospital and at 3 and 12 months , and self-reported reduction in cigarette consumption in smokers was assessed at 3 and 12 months . Results : 274 inpatient smokers were enrolled .  Abstinence was higher in the NRT plus counselling group ( n=91 ) than in the counselling alone ( n=91 ) or usual care ( n=92 ) groups . The difference between the groups was significant for vali date d point prevalence abstinence at discharge ( 55 % , 43 % , 37 % respectively , p=0.045 ) and at 12 months ( 17 % , 6 % , 8 % , p=0.03 ) . The respective differences in continuous vali date d abstinence at 12 months were 11 % , 4 % , 8 % ( p=0.25 ) . There was no significant difference between counselling alone and usual care , or in reduction in cigarette consumption between the treatment groups . Conclusions : NRT given with brief counselling to hospital in patients is an effective routine smoking cessation intervention OBJECTIVES To measure quality -of-care variables relevant to the treatment of community-acquired pneumonia and to determine their relative contribution to variation in length of hospital stay ( LOS ) . METHODS One hundred cases of pneumonia requiring hospitalization from each of 7 institutions ( 2 community and 5 university teaching hospitals ) were r and omly selected ( total sample , 700 cases ) . Demographic and clinical variables were abstract ed using a st and ardized data instrument . Three quality -of-care measures were analyzed : ( 1 ) site of  initial antibiotic treatment  ( emergency department vs floor ) , ( 2 ) door-to-needle time  , and ( 3 )  appropriateness of antibiotic selection  . Appropriate antibiotic selection was defined by the 1998 Infectious Disease Society of America guidelines for the treatment of hospitalized pneumonia cases . Regression modeling was used to determine associations between LOS and our quality -of-care ( process ) variables . RESULTS The mean + /- SD LOS for this sample was 7.0 + /- 4.1 days . Prolonged LOS , defined as greater than or equal to the 75th percentile of the LOS distribution , was the dependent variable in our regression analysis and was greater than or equal to 9.0 days . After clinical and demographic variables were adjusted for , logistic regression modeling revealed that all 3 quality -of-care measures were associated with prolonged LOS : ( 1 ) initial antibiotic treatment in the emergency department ( odds ratio [ OR ] , 0.31 ; 95 % confidence interval [ CI ] , 0.19 - 0.48 ) ; ( 2 ) appropriate antibiotic selection ( OR , 0.55 ; 95 % CI , 0.35 - 0.88 ) ; and ( 3 ) door-to-needle time ( OR , 1.75 per 8 hours ; 95 % CI , 1.34 - 2.29 ) . In a secondary analysis , we examined the clinical and demographic characteristics of the patients who were treated more rapidly in the emergency department compared with those who were treated on the inpatient floor . No clinical ly meaningful differences were observed between these groups . CONCLUSIONS Unlike clinical and demographic variables , process-of-care variables are modifiable and amenable to quality improvement . We observed that rapid antibiotic initiation and appropriate antibiotic selection in the emergency department have a statistically significant association with shorter LOS . These findings suggest quality improvement targeted at these processes of care may improve re source utilization and reduce LOS for patients with community-acquired pneumonia BACKGROUND Approximately 10 % of the general population worldwide acquires influenza infection every year . Airline crews run a particularly high risk of contracting influenza and influenza-like viruses because they come in contact with hundreds of potentially infected individuals every day . Respiratory diseases are the most frequent cause of absenteeism among flight crews in airline companies . Several studies have shown the efficacy of influenza vaccination in the workplace of healthy , working adults leading to increased productivity and lower absenteeism . We conducted a double blind , r and omized , placebo-controlled study on flight crews of an airline company in order to determine the safety and efficacy of a trivalent inactivated influenza vaccine in reducing illness and absences from work . METHODS The 813 healthy members of a Brazilian airline company were r and omly assigned to receive injections of either an influenza vaccine or a placebo , with a follow-up period of 7 mo after vaccination . Primary outcomes included influenza-like illness episodes and absenteeism from work due to such episodes . RESULTS Demographic characteristics were similar in the two groups . No significant side-effects occurred in either group . Compared to the placebo group , individuals receiving the vaccine showed 39.5 % fewer episodes of flu-like illness ( p < 0.001 ) and 26 % fewer days of work lost ( p = 0.03 ) . The vaccinated group developed 33 % fewer episodes of any severe flu-like illness ( p < 0.01 ) . CONCLUSION The data indicates that influenza vaccination is safe in airline flight crews and may produce health-related benefits including reduced absenteeism A live , attenuated influenza B virus vaccine was evaluated in a group of students . The virus , cold-recombinant ( CR ) 7 , was produced by recombining the attenuated cold-adapted parent , B/Ann Arbor/1/66 , with a wild strain , B/Hong Kong/8/73 . In ferrets , the wild strain produced histopathologic lesions in the lungs , whereas the CR strain and the attenuated parent did not . A total of 306 individuals was inoculated intranasally with either the CR 
    Output:
    
However , among these performance measures , only influenza vaccination was supported by high- quality evidence .