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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_3246"
                     title="Few Conn. Physicians Treat Chronic Lyme Disease"
                     score="0.014"
                     href="http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/tb/22000?impressionId=1283457907990"
                     
      &lt;p&gt;Only a very small number of physicians in Connecticut  --  the epicenter of Lyme disease  --  diagnose and treat patients with the controversial chronic form of this tick-borne infection, a survey found.&lt;/p&gt;
&lt;p&gt;Among 285 primary care physicians surveyed, only about 2% treat chronic Lyme disease, and almost 50% don&apos;t believe that chronic infection with the spirochete &lt;em&gt;Borrelia burgdorferi&lt;/em&gt; exists, Michael Johnson, MD, and Henry M. Feder, Jr., MD, of the University of Connecticut in Farmington, reported online in the&lt;em&gt; Journal of Pediatrics&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The remaining 48% were uncertain as to whether chronic Lyme disease is a valid condition.&lt;/p&gt;
&lt;p&gt;Advocates of chronic Lyme disease believe that the infection can persist for months and even years, requiring long-term treatment with oral or intravenous antibiotics  --  a stance counter to the recommendations of the American College of Rheumatology, the American Academy of Pediatrics, the American College of Neurology, and the Infectious Diseases Society of America (IDSA).&lt;/p&gt;
&lt;p&gt;They have formed their own society, the International Lyme and Associated Diseases Society (ILADS), publishing their own guidelines, and refer to themselves as &quot;Lyme literate.&quot;&lt;/p&gt;
&lt;p&gt;Unlike the more broadly accepted definition of Lyme disease, which includes erythema migrans as well as cardiac, neurologic, and arthritic findings, chronic Lyme disease has been defined by ILADS as being a debilitating illness with subjective symptoms such as fatigue, myalgias, arthralgias, poor concentration, and headaches.&lt;/p&gt;
&lt;p&gt;To see how widespread acceptance of chronic Lyme disease is among clinicians in Connecticut, which has the highest incidence of &lt;em&gt;B. burgdorferi&lt;/em&gt; infection in the country, Johnson and Feder sent a survey to a random sample of more than 1,000 physicians. The survey had a 39.1% response rate.&lt;/p&gt;
&lt;p&gt;Responders estimated that within the past three years they had diagnosed 11,970 cases of Lyme disease, or 14 cases per physician each year.&lt;/p&gt;
&lt;p&gt;The six responders who said they treat chronic Lyme disease reported having diagnosed a total of 84 chronic cases, or 4.7 per physician per year.&lt;/p&gt;
&lt;p&gt;These six also each diagnosed an average of 11.5 cases of nonchronic Lyme disease per year (when an outlier who diagnosed 100 or more cases each year was excluded).&lt;/p&gt;
&lt;p&gt;All physicians reported treating Lyme disease with antibiotics for two to four weeks, and the six who treated chronic Lyme disease used oral antibiotics for an average of 20 weeks.&lt;/p&gt;
&lt;p&gt;Responders who diagnose and treat chronic Lyme disease in this survey were not representative of the &quot;Lyme literate&quot; community, however, in that none used intravenous antibiotics, and only one treated for as long as a year.&lt;/p&gt;
&lt;p&gt;But the Lyme literate community did have an impact on the survey responders, the authors noted, because many said their patients had previously been diagnosed by other physicians as having the chronic condition and had received intravenous or extended-course antibiotics.&lt;/p&gt;
&lt;p&gt;Most of the responders also said that they did not believe patients had been helped by the lengthy and costly treatment, and that underlying conditions such as depression  --  and in one case, leukemia  --  had been overlooked.&lt;/p&gt;
&lt;p&gt;In discussing their findings, Johnson and Feder noted that the number of Lyme literate physicians in Connecticut and elsewhere in the northeast is small but influential.&lt;/p&gt;
&lt;p&gt;&quot;The &apos;Lyme literate&apos; network has been pivotal in advocating legislation in multiple states requiring insurance companies to cover the costs of intravenous therapy for presumed chronic Lyme disease,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;In fact, after the IDSA published an update of its guidelines on treatment in 2006, in which they argued against the long-term use of antibiotics, the attorney general of Connecticut initiated action against IDSA, claiming that the guideline authors had conflicts of interest.&lt;/p&gt;
&lt;p&gt;Finally, in April 2010, an independent review panel convened by the attorney general and IDSA voted that no changes need be made to the 2006 guidelines.&lt;/p&gt;
&lt;p&gt;In the meantime, however, the Connecticut House of Representatives passed legislation protecting physicians who diagnose and treat chronic Lyme disease from disciplinary actions.&lt;/p&gt;
&lt;p&gt;The survey authors noted that their study could have been limited by sampling and recall bias, and that there was significant geographic variation in case numbers throughout the state.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Both authors declared no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3230"
                     title="Hospital-Acquired Infections Trend Downward"
                     score="0.014"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/InfectionControl/tb/21985?impressionId=1283457907990"
                     
      &lt;p&gt;Although healthcare-associated infections (HAIs) remain a large and at least partly avoidable problem in hospitals, it appears to be less of one than it was a few years ago, according to the Agency for Healthcare Research and Quality.&lt;/p&gt;
&lt;p&gt;After peaking in 2004 and 2005 at 2.30 per 1,000 hospital stays, HAI rates among adults declined to 2.03 per 1,000 stays in 2007, according to the most recent data from the Healthcare Cost and Utilization Project, summarized in an AHRQ statistical brief.&lt;/p&gt;
&lt;p&gt;The 2007 figure was identical to the rate seen in 2000 when the project first began collecting data, according to AHRQ researchers led by Claudia Steiner, MD, MPH.&lt;/p&gt;
&lt;p&gt;HAIs were recorded in just 0.2% of hospital stays in 2007.&lt;/p&gt;
&lt;p&gt;All patient subgroups, stratified by age, geographic region, and type of payer, shared in the decline, the researchers also found.&lt;/p&gt;
&lt;p&gt;The findings were seemingly at odds with &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/19568&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/19568&quot; target=&quot;_blank&quot;&gt;another AHRQ report&lt;/a&gt; issued earlier in the year. The agency&apos;s 2009 National Healthcare Quality Report, released in April, struck a pessimistic note by highlighting increases in the 2007 data for certain types of infections  --  postoperative sepsis and urinary tract infections  --  from 2006.&lt;/p&gt;
&lt;p&gt;But the new report indicates that, overall, 2007 was better than the previous year for HAIs, with the rate per 1,000 hospital stays down from 2.19 in 2006.&lt;/p&gt;
&lt;p&gt;No explanation for the downward trend was offered by Steiner and colleagues, but other investigators who have identified declining hospital infection rates have suggested that improved adherence to treatment guidelines and better management of risk factors for HAIs are responsible.&lt;/p&gt;
&lt;p&gt;The new report identified several hospital characteristics that were significantly (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05) associated with increased rates of HAIs: &lt;ul&gt; &lt;li&gt;Hospital size of 500 beds or more&lt;/li&gt; &lt;li&gt;Location in metropolitan area&lt;/li&gt; &lt;li&gt;Teaching hospital&lt;/li&gt; &lt;li&gt;Private for-profit status&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The report also indicated that stays marked by HAIs were distributed almost equally between male and female patients, in contrast with the nearly 2:1 ratio of women to men among hospital patients overall.&lt;/p&gt;
&lt;p&gt;The Healthcare Cost and Utilization Project collects data on all inpatients treated at a rotating nationwide sample of about 1,000 short-term, non-federal hospitals.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_3201"
                     title="Decline in Kids&apos; Pneumonia Linked to Vaccine Use (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Pediatrics/Vaccines/tb/21943?impressionId=1283457907990"
                     
      &lt;p&gt;The use of pneumococcal conjugate vaccine appears to have reduced the incidence of pediatric bacterial pneumonia by 20% in England during the first two years after the vaccine was introduced, investigators reported.&lt;/p&gt;
&lt;p&gt;Hospital admission rates for empyema also declined by 22%, according to Sonia Saxena, MD, of the Imperial College of London, and colleagues.&lt;/p&gt;
&lt;p&gt;The improvement followed a two-year prevaccine period when hospitalization for childhood bacterial pneumonia and empyema increased by 19% and 77%, respectively, they reported in an article published online in the journal &lt;em&gt;Thorax&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The success of any vaccination program depends on vaccinating as many people as possible,&quot; Saxena said in a statement. &quot;Now that we have clear evidence about the benefits of pneumonia vaccine, we hope more parents will be encouraged to have their children vaccinated in the future.&quot;&lt;/p&gt;
&lt;p&gt;Following introduction of a seven-valent pneumococcal conjugate vaccine (PCV7) in the U.S., admission rates for pneumonia in children younger than 2 years decreased by almost 40% between 2000 and 2004 (&lt;em&gt;Lancet&lt;/em&gt; 2007; 369: 1179-1186).&lt;/p&gt;
&lt;p&gt;The PCV7 protects against the serotypes that account for a majority of bacterial pneumonia in children but not against &lt;em&gt;Streptococcus pneumoniae&lt;/em&gt; serotype 1, which causes as many as half of empyema cases in the U.S. and England, Saxena and co-authors noted in the introduction to their results.&lt;/p&gt;
&lt;p&gt;The PCV7 vaccine was introduced in England in 2006 in a childhood immunization program that called for immunization at 2, 3, and 13 months and catch-up immunization for children up to 2 years. During 2007 to 2008, uptake of the PCV7 was estimated as 84% of children by their first birthday.&lt;/p&gt;
&lt;p&gt;Within one year, a marked decrease had occurred in the incidence of childhood invasive pneumococcal disease caused by the serotypes in the vaccine, the authors continued. By the end of 2009, however, the incidence of pneumonia caused by non-PCV7 strains rose to levels reported before introduction of the vaccine.&lt;/p&gt;
&lt;p&gt;The British Department of Health switched from the PCV7 to a PCV13 vaccine before the impact of the former had been evaluated. Saxena and co-authors performed a national time-trends analysis to assess the impact of the PCV7 vaccine on admissions for childhood bacterial pneumonia and empyema.&lt;/p&gt;
&lt;p&gt;Investigators queried the Hospital Episode Statistics (HES) database that contains information on all episodes of care at public hospitals in England. They calculated emergency hospital admission rates coded for viral respiratory tract infections (RTIs), bacterial pneumonia, and empyema involving children younger than 15 years during 1997 through 2008.&lt;/p&gt;
&lt;p&gt;&quot;Studying viral respiratory tract infection trends enabled us to determine whether trends in childhood bacterial pneumonia and empyema were independent or secondary to changes in admissions for all pediatric respiratory infections,&quot; the authors noted.&lt;/p&gt;
&lt;p&gt;From 1997 to 2005, admission rates for childhood bacterial pneumonia increased by 31%. The relative risk for bacterial pneumonia admission was 1.19 in 2006 compared with 2004, then declined to 0.81 for 2008 compared with 2006 (95% CI 0.79 to 0.83). Admissions for empyema increased by 77% (95% CI 1.38 to 2.28) between 2004 and 2006, then declined by 22% from 2006 to 2008 (95% CI 0.62 to 0.98).&lt;/p&gt;
&lt;p&gt;&quot;We observed a 19% decline in pneumonia rates following the introduction of PCV7, which is half the reduction of 39% reported in the U.S.,&quot; the authors wrote in the discussion of their findings.&lt;/p&gt;
&lt;p&gt;&quot;However, this U.S. study looked at rates four years after PCV7 whereas our study shows rates two years after PCV7, so further falls may have occurred given the longer lead time,&quot; Saxena and colleagues wrote.&lt;/p&gt;
&lt;p&gt;While noting that their study was based on a large nationally-representative population sample, the authors cited several limitations. For one thing, they wrote, &quot;the accuracy of HES depends on clinical diagnoses recorded in patients&apos; medical records.&quot; Since &quot;coding is based on clinical and microbiological information recorded by clinicians upon discharge, the distinction between viral and bacterial RTI diagnoses is potentially subject to misclassification bias,&quot; they added.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Saxena and co-authors reported that they had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3116"
                     title="More Evidence of Viral Link to Chronic Fatigue (CME/CE)"
                     score="0.009"
                     href="http://www.medpagetoday.com/Neurology/GeneralNeurology/tb/21835?impressionId=1283457907990"
                     
      Blood samples from more&lt;strong&gt; &lt;/strong&gt;than 80% of patients with chronic fatigue syndrome were found to have viral gene sequences similar to those of murine leukemia virus (MLV), according to investigators in a small clinical study.&lt;br&gt;
&lt;br&gt;In a continuation of a study begun in the mid-1990s among 81 patients and healthy volunteers, fewer than 7% of the healthy volunteers tested positive for MLV sequences, Shyh-Ching Lo, MD, of the FDA, and colleagues reported. However, seven of the eight positive patients remained positive when retested 15 years later.&lt;br&gt;
&lt;br&gt;In contrast to a previous study showing genetic homogeneity, the MLV-like viruses exhibited substantial genetic diversity, the researchers wrote a report published online in the &lt;em&gt;Proceedings of the National Academy of Sciences&lt;/em&gt;.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Nonetheless, the findings provide additional evidence of an association between MLVs and chronic fatigue syndrome, they added.&lt;/p&gt;
&lt;p&gt;&quot;Our results clearly support the central argument ... that MLV-related viruses are associated with chronic fatigue syndrome and are present in some blood donors,&quot; they wrote in the discussion of their findings.&lt;/p&gt;
&lt;p&gt;The authors acknowledged that several other recent studies failed to show an association between MLV-like viruses and the syndrome.&lt;/p&gt;
&lt;p&gt;&quot;It remains to be shown that the association that we have found ... can be generalized to a larger group of patients with chronic fatigue syndrome,&quot; they wrote. &quot;Indeed, we suspect that the association will be lower in chronic fatigue syndrome cases identified through community-based surveys, as contrasted to cases seen at academic medical centers.&quot;&lt;/p&gt;
&lt;p&gt;Several immunologic and neurologic abnormalities occur more often in patients with chronic fatigue syndrome than in the general population, prompting speculation about a microbial or viral infection as the cause of the condition. To date no single infectious agent has been linked to a substantial proportion of patients with the syndrome, the authors noted.&lt;/p&gt;
&lt;p&gt;One recent study showed a 67% prevalence of infection with a mouse leukemia retrovirus in patients with chronic fatigue syndrome as compared with 3.7% of a health control group (&lt;em&gt;Science&lt;/em&gt; 2009; 326: 585-589). Called xenotropic murine leukemia virus-related virus (XMRV), the organism was first identified in prostate cancer specimens (&lt;em&gt;PLoS Pathog&lt;/em&gt; 2006; 2: e25).&lt;/p&gt;
&lt;p&gt;Subsequent studies failed to demonstrate the presence of XMRV in prostate cancer tissue, and four recent studies of patients with chronic fatigue syndrome showed no evidence of XMRV or MLV-related viral gene sequences in peripheral blood, the authors noted.&lt;/p&gt;
&lt;p&gt;Continuing the investigation of XMRV, MLV, and chronic fatigue, researchers examined peripheral blood mononuclear cells and whole-blood samples obtained in the mid-1990s from patients who met the accepted clinical definition of chronic fatigue syndrome. Samples were obtained about 15 years afterward from eight of the original 37 patients.&lt;/p&gt;
&lt;p&gt;The authors used polymerase chain reaction assays to target the MLV-related virus &lt;em&gt;gag&lt;/em&gt; gene in the original specimens from the 37 patients and in blood and serum samples obtained from 44 healthy volunteer blood donors.&lt;/p&gt;
&lt;p&gt;The results showed that 32 of 37 (86.5%) of patients with chronic fatigue syndrome had positive tests for MLV-like virus &lt;em&gt;gag&lt;/em&gt; gene sequences compared with three of the 44 (6.8%) blood donors. The eight patients who provided specimens on two occasions 15 years apart were &lt;em&gt;gag&lt;/em&gt; positive on initial testing. Analysis of the more recent specimens showed that seven of the eight remained positive for &lt;em&gt;gag&lt;/em&gt; gene sequences.&lt;/p&gt;
&lt;p&gt;The investigators discussed extensively why their results differed from other studies. They stated that contamination of their specimens seemed unlikely since they tested for and did not find mouse DNA contamination.&lt;/p&gt;
&lt;p&gt;They noted, however, that it is possible that differing groups of patients could show different results since chronic fatigue syndrome is a clinical diagnosis.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;The earlier study showing a 67% prevalence of XMRV in patients with chronic fatigue syndrome also showed near-genetic identity among all of the viruses. In contrast, Lo and co-authors reported finding three distinct types of MLV-related virus &lt;em&gt;gag&lt;/em&gt; sequences all of which were more closely related to sequences of polytropic mouse endogenous retroviruses than to XMRV.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors reported that they had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_3107"
                     title="Hepatitis E Vaccine Candidate Completely Blocked Disease (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/InfectiousDisease/Hepatitis/tb/21823?impressionId=1283457907990"
                     
      &lt;p&gt;An investigational vaccine against hepatitis E was shown to be completely effective in a large randomized trial in China, researchers reported.&lt;/p&gt;
&lt;p&gt;The trial, involving more than 100,000 patients, found that none of the patients who received the full three doses of the vaccine (HEV 239 or Hecolin) developed hepatitis E over a 12-month follow-up, according to Ning-Shao Xia, MD, of Xiamen University in Xiamen, China, and colleagues.&lt;/p&gt;
&lt;p&gt;In contrast, there were 15 cases of hepatitis E among the participants in the placebo arm (who were given a licensed hepatitis B vaccine)  --  for an efficacy rate of 100%, Xia and colleagues reported online in &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The vaccine efficacy was equally high when the analysis was expanded to include participants who only got two doses and reached 95.5% among those who got at least one dose, the researchers reported.&lt;/p&gt;
&lt;p&gt;Although the existence of hepatitis E has been known for years, research into the virus has largely been neglected. (See &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ICAAC/16022&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ICAAC/16022&quot; target=&quot;_blank&quot;&gt;ICAAC: Hepatitis E Virus Finally Gets Some Respect&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;But hepatitis E is widespread  --  estimates suggest that a third of the world&apos;s people are infected  --  and can cause serious disease and death, especially in the developing world, according to background provided by the researchers.&lt;/p&gt;
&lt;p&gt;The double-blind, randomized, placebo-controlled trial was done between August, 2007, and June, 2009 in Jiangsu Province in China, where the virus is endemic. In fact, a preliminary analysis of more than 11,000 of the trial participants showed that 47% already had antibodies against hepatitis E, the researchers reported.&lt;/p&gt;
&lt;p&gt;All told, the investigators randomly assigned 56,302 volunteers to get three doses of the vaccine (delivered intramuscularly at baseline, one, and six months) and 56,302 to get the hepatitis B vaccine on the same schedule.&lt;/p&gt;
&lt;p&gt;The main analysis included those who got all three doses -- 86% in each arm -- and were followed for 12 months starting the 31st day after the last dose.&lt;/p&gt;
&lt;p&gt;In that group, there were no cases in the vaccine arm and 15 in the placebo arm.&lt;/p&gt;
&lt;p&gt;As well, five additional volunteers  --  all in the placebo group  --  developed hepatitis E during the period from 14 days after the second dose and before the third dose, the researchers reported, yielding an efficacy rate of 100% among trial participants who got two doses of vaccine.&lt;/p&gt;
&lt;p&gt;In the entire cohort, there were 23 cases of hepatitis E recorded during the follow-up  --  including a case in one volunteer in the vaccine group who had received only one dose, and 22 cases among participants in the placebo group, producing an efficacy rate of 95.5%.&lt;/p&gt;
&lt;p&gt;The high efficacy rate after two doses suggests that the vaccine can be deployed quickly and would be effective in the context of an outbreak or for travelers to an endemic area, the researchers argued.&lt;/p&gt;
&lt;p&gt;The researchers concluded that the vaccine was well tolerated and effective among a general adult population. &quot;Further studies are needed to assess the safety and to support the benefits of the vaccine for pregnant women and for people younger than 15 years or older than 65 years.&quot; they added.&lt;/p&gt;
&lt;p&gt;Adverse events were mostly mild and local, including pain and swelling at the injection site, Xia and colleagues reported.&lt;/p&gt;
&lt;p&gt;The study is &quot;an important event in the prevention and control of hepatitis E.&quot; according to Scott Holmberg, MD, of the CDC.&lt;/p&gt;
&lt;p&gt;In an accompanying comment, Holmberg said that a safe and effective vaccine  --  if it&apos;s affordable  --  &quot;raises the prospect&quot; of routine vaccination to reduce the impact of chronic hepatitis E, as well as epidemic outbreaks.&lt;/p&gt;
&lt;p&gt;Vaccines, he argued, should not substitute for improvements in sanitation. But, given that sanitary conditions in many places have been slow to improve, &quot;this vaccine might be our best new stopgap in the effort to control the scourge of (hepatitis E) in many parts of the world,&quot; he concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study had support from the Chinese National High-tech R&amp;amp;D Programme, the Chinese National Key Technologies R&amp;amp;D Programme, the Chinese National Science Fund for Distinguished Young Scholars, the Fujian Provincial Department of Sciences and Technology, the Xiamen Science and Technology Bureau, and the Fujian Provincial Science Fund for Distinguished Young Scholars.&lt;/p&gt;&lt;p&gt;Two of the authors are employees of Xiamen Innovax Biotech, which is developing the vaccine. The remaining authors, including Xia, said they had no conflicts.&lt;/p&gt;&lt;p&gt;Holmberg said he had no conflicts.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>