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We developed an agent-based model using a trial emulation approach to quantify effect measure modification of spillover effects of pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM) in the Atlanta-Sandy Springs-Roswell metropolitan area, Georgia. PrEP may impact not only the individual prescribed, but also their partners and beyond, known as spillover. We simulated a two-stage randomised trial with eligible components (≥3 agents with ≥1 HIV+ agent) first randomised to intervention or control (no PrEP). Within intervention components, agents were randomised to PrEP with coverage of 70%, providing insight into a high PrEP coverage strategy. We evaluated effect modification by component-level characteristics and estimated spillover effects on HIV incidence using an extension of randomisation-based estimators. We observed an attenuation of the spillover effect when agents were in components with a higher prevalence of either drug use or bridging potential (if an agent acts as a mediator between ≥2 connected groups of agents). The estimated spillover effects were larger in magnitude among components with either higher HIV prevalence or greater density (number of existing partnerships compared to all possible partnerships). Consideration of effect modification is important when evaluating the spillover of PrEP among MSM.
Natalizumab is an efficacious disease modifying therapy (DMT) for relapsing remitting multiple sclerosis (RRMS), often limited by risk of progressive multifocal leukoencephalopathy. We describe the clinical course of RRMS patients switched from natalizumab to another DMT. We identified all RRMS patients treated with natalizumab ≥3 months with JC virus antibody positivity who switched to another DMT. Overall, 84 individuals switched DMT with 57 (68%) beginning fingolimod. On fingolimod, survival without a relapse was 74% (55.8–85.6%) at 36 months and survival without disease progression was 78% (62.6–87.6%) at 36 months. In conclusion, fingolimod is an effective therapy post-natalizumab.
Introduction: Patients from all population groups visit the emergency department (ED), with increasing visits by elderly patients. Patient falls in the ED are a significant safety concern, and they can lead to serious injuries and worse outcomes. Toronto Western Hospital’s ED Quality Improvement (QI) team identified as a problem our assessment and management of patients at risk for falls. The aim of this project was to develop a comprehensive and standardized approach to patients at risk of falls in the ED, including implementing timely interventions for fall prevention. Methods: A literature review of existing tools was completed to develop our own reliable and valid fall risk screening tool for ED patients. QI methods were used to devise a comprehensive strategy starting with detection at triage and implementation of action-driven steps at the bedside, through multiple PDSA cycles, randomized audits, surveys, and education. Repeated measurements were undergone throughout the project, as were staff satisfaction surveys. Results: The chart audits showed a five-fold increase in the completion rate of the fall risk screening tool in the ED by the end of the QI initiative (from 10% to 50%). Constructive feedback by an engaged team of nurses was used to iteratively improve the tool, and there was mostly positive feedback on it after various PDSA cycles were completed. The various component of this novel and useful ED-based falls screening tool and bundle will be presented in tables and figures for other leaders to replicate in their EDs. Conclusion: We developed a completely new ED-specific fall risk screening tool through literature review, front-line provider feedback, and iterative PDSA cycles. It was used for the identification, prevention, and management of ED patients with fall risk. We also contributed to a positive change in the culture of a busy ED environment towards the promotion of patient safety. Education and feedback continue to be provided to the ED nurses for reflective practice, and we hope to continue to improve our tool and to share it with other EDs.
A study was undertaken to investigate the views of professional staff and paid and informal carers' views of a new integrated mental health service for people with learning disabilities.
Twenty semi-structured interviews were conducted and transcribed. Most staff and carers were generally satisfied with the in-patient facility. However, information exchange, ward rounds and the ward environment were identified as areas requiring improvement.
Many of the participants had no previous experience of supporting a person with learning disabilities and mental health problems in an in-patient setting. However, over time they became supportive of the mental health service and provided valuable input in improving the service provision for people with learning disabilities.
Experiments have been performed on the cationic bilayer and liposome-forming surfactant DODAB, a successful DNA transfection agent. The surface forces apparatus (SFA) was utilized to measure the long-range colloidal and short-range adhesion forces between Langmuir-Blodgett bilayers exposing DODAB in the outer monolayers. Forces were measured in aqueous solutions of varying salt concentrations between 1 and 10 mM, with and without single-stranded DNA added to the solution. These represent the first measurements of the forces between surfactant/DNA assemblies. At low salt concentrations without DNA, the interbilayer forces are repulsive due to their electrostatic interaction, in agreement with DLVO theory. In contrast, in the presence of DNA which adsorbs to the bilayer surfaces, the forces between the bilayers changed to an enhanced and longer ranged repulsive steric-electrostatic interaction. At shorter range. the DNA can be excluded from the gap leading to an enhanced adhesion at contact accompanied by lipid rearrangement.
The migration kinetics of antiphase boundaries (APBs) in long-range ordered Fe-Al alloys are analyzed using in-situ hot-stage transmission electron microscopy, making it possible to observe the interfacial migration directly as it occurs. The observed domain structures are essentially two dimensional due to the thin foil configuration of the specimen, facilitating analytical interpretation of the data. By measuring the local curvatures and migration distances from a series of micrographs taken at a constant temperature, the proportionality constant relating velocity to curvature can be determined. This proportionality constant, called the mobility for APB migration, is found to be independent of the curvature for <100> APBs in Fe-27 atomic percent Al at 745K, having the value of 4.8×10−19 m2/s.