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During the 2022 multicountry mpox outbreak, the United Kingdom identified cases beginning in May. UK cases increased in June, peaked in July, then rapidly declined after September 2022. Public health responses included community-supported messaging and targeted mpox vaccination among eligible gay, bisexual, and other men who have sex with men (GBMSM). Using data from an online survey of GBMSM during November–December 2022, we examined self-reported mpox diagnoses, behavioral risk modification, and mpox vaccination offer and uptake. Among 1,333 participants, only 35 (2.6%) ever tested mpox-positive, but 707 (53%) reported behavior modification to avoid mpox. Among vaccine-eligible GBMSM, uptake was 69% (95% CI 65%–72%; 601/875) and was 92% (95% CI 89%–94%; 601/655) among those offered vaccine. GBMSM self-identifying as bisexual, reporting lower educational qualifications, or identifying as unemployed were less likely to be vaccinated. Equitable offer and provision of mpox vaccine are needed to minimize the risk for future outbreaks and mpox-related health inequalities.

Background Sexually transmitted infections disproportionately affect young people and men who have sex with men. Chlamydia is Britain’s most common sexually transmitted infection. Partner notification is a key intervention to reduce transmission of sexually transmitted infections and human immunodeficiency virus but is hard to implement. Accelerated partner therapy is a promising new approach. Objectives determine the effectiveness, costs and acceptability of accelerated partner therapy for chlamydia in heterosexual people model the cost effectiveness of accelerated partner therapy and impact on chlamydia transmission develop and cost partner notification interventions for men who have sex with men. Design Mixed-methods study to develop a new sex partner classification and optimise accelerated partner therapy; cluster crossover randomised controlled trial of accelerated partner therapy, with process and cost-consequence evaluation; dynamic modelling and health economic evaluation; systematic review of economic studies of partner notification for sexually transmitted infections in men who have sex with men; qualitative research to co-design a novel partner notification intervention for men who have sex with men with bacterial sexually transmitted infections. Settings Sexual health clinics and community services in England and Scotland. Participants Women and men, including men who have sex with men and people with mild learning disabilities. Interventions Accelerated partner therapy offered as an additional partner notification method. Main outcome measures Proportion of index patients with positive repeat chlamydia test (primary outcome); proportion of sex partners treated; costs per major outcome averted and quality-adjusted life-year; predicted chlamydia prevalence; experiences of accelerated partner therapy. Data sources Randomised controlled trial: partnership type, resource use, outcomes, qualitative data: economic analysis, modelling and systematic review: resource use and unit costs from the randomised controlled trial, secondary sources. Results The sex partner classification defined five types. Accelerated partner therapy modifications included simplified self-sampling packs and creation of training films. We created a clinical management and partner notification data collection system. In the randomised controlled trial, all 17 enrolled clinics completed both periods; 1536 patients were enrolled in the intervention phase and 1724 were enrolled in the control phase. Six hundred and sixty-six (43%) of 1536 index patients in the intervention phase and 800 (46%) of 1724 in the control phase were tested for Chlamydia trachomatis at 12–24 weeks after contact tracing consultation; 31 (4.7%) in the intervention phase and 53 (6.6%) in the control phase had a positive Chlamydia trachomatis test result [adjusted odds ratio 0.66 (95% confidence interval 0.41 to 1.04); p = 0.071]. The proportion of index patients with ≥ 1 sex partner treated was 88.0% (775/881) in intervention and 84.6% (760/898) in control phase, adjusted odds ratio 1.27 (95% confidence interval 0.96 to 1.68; p = 0.10). Overall, 293/1536 (19.1%) index patients chose accelerated partner therapy for 305 partners, of which partner types were: committed/established, 166/305 (54.4%); new, 85/305 (27.9%); occasional, 45/305 (14.8%); and one-off, 9/305 (3.0%). Two hundred and forty-eight accepted accelerated partner therapy and 241 partners were sent accelerated partner therapy packs, 120/241 (49.8%) returned chlamydia/gonorrhoea samples (78/119, 65.5%, positive for chlamydia, no result in one), but only 60/241 (24.9%) human immunodeficiency virus and syphilis samples (all negative). The primary outcomes of the randomised trial were not statistically significantly different at the 5% level. However, the economic evaluation found that accelerated partner therapy could be less costly compared with routine care, and mathematical modelling of effects and costs extrapolated beyond the trial end points suggested that accelerated partner therapy could be more effective and less costly than routine care in terms of major outcome averted and quality-adjusted life-years’. Healthcare professionals did not always offer accelerated partner therapy but felt that a clinical management and partner notification data collection system enhanced data recording. Key elements of a multilevel intervention supporting men who have sex with men in partner notification included: modifying the cultural and social context of men who have sex with men communities; improving skills and changing services to facilitate partner notification for one-off partners; and working with dating app providers to explore digital partner notification options. The systematic review found no evaluations of partner notification for men who have sex with men. Modelling of gonorrhoea and human immunodeficiency virus co-infection in men who have sex with men was technically challenging. Limitations In the randomised controlled trial, enrolment, follow-up and repeat infections were lower than expected, so statistical power was lower than anticipated. We were unable to determine whether accelerated partner therapy sped up partner treatment. Mathematical modelling of gonorrhoea/human immunodeficiency virus co-infection in men who have sex with men remained at an experimental stage. It was not feasible to include healthcare professionals in the men who have sex with men intervention development due to the COVID-19 pandemic. Conclusions Although the evidence that the intervention reduces repeat infection was not conclusive, the trial results suggest that accelerated partner therapy can be safely offered as a contact tracing option and is also likely to be cost saving, but is best suited to sex partners with emotional connection to the index patient. The Programme’s findings about classification of sexual partner types can be implemented in sexual health care with auditable outcomes. Future work Further research is needed on how to increase uptake of accelerated partner therapy and increase sexually transmitted infections self-sampling by partners; understand how services can use partnership-type information to improve partner notification, especially for those currently underserved; overcome challenges in modelling sexually transmitted infections and human immunodeficiency virus co-infection in men who have sex with men; develop and evaluate an intervention to optimise partner notification among men who have sex with men, focusing on one-off partnerships. Trial registration This trial is registered as ISRCTN15996256. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0614-20009) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information. Plain language summary We aimed to improve the sexual health of people most impacted by sexually transmitted infections and human immunodeficiency virus (young people and men who have sex with men), by preventing transmission and reducing undiagnosed infection. We focused on partner notification (contact tracing and management), particularly accelerated partner therapy. Our research included: a clinical trial interview/focus group studies literature reviews mathematical modelling and health economic evaluations. Firstly, we improved accelerated partner therapy by finding out what people did/didn’t like about it and which types of sex partners might use it. We included some people with mild learning difficulties to see if they could help us improve accelerated partner therapy for people who might find self-managed care tricky. Then, we measured accelerated partner therapy’s value for money in a large clinical trial in people with chlamydia, Britain’s commonest sexually transmitted infection. Finally, we worked with men who have sex with men, sexual healthcare professionals, public health and health planners to make recommendations for new partner notification methods to suit their needs. We found accelerated partner therapy could be less costly than current practices and likely reduce transmission of chlamydia in the population. Our new classification of partnership types showed that accelerated partner therapy suited ‘emotionally connected’, rather than one-off, partners. These partners are important for controlling onward transmission but are traditionally harder to reach. Findings from our stakeholder event suggest that partner notification approaches for men who have sex with men are likely to work best by involving communities as well as clinics, but we were only able to focus on sexually transmitted infections other than human immunodeficiency virus due to COVID-19 impacts. Future research should aim to improve partner notification for one-off partners, simplify the sexually transmitted infection and human immunodeficiency virus self-testing kits used in accelerated partner therapy, explore the pros and cons of immediate antibiotics, and develop and evaluate a system-wide partner notification approach for men who have sex with men, guided by health economics evaluation. Scientific summary Background Sexually transmitted infection (STI) diagnoses have increased since 2010. Young people and men who have sex with men (MSM) are disproportionately affected. Chlamydia is the most commonly reported STI in Britain. Two-thirds of chlamydia infections are diagnosed in heterosexual people under 25 years, while gonorrhoea, syphilis and human immunodeficiency virus (HIV) infections are more common in MSM. Preventing onward transmission is essential to STI and HIV control. Partner notification (PN), also known as contact tracing and management, is a key intervention in which sex partners (SPs) of people with diagnosed infections are identified, tested and treated. PN also provides opportunities to engage people at high risk of infection who might not present for care. Better PN for MSM with infections such as gonorrhoea could enable earlier HIV diagnosis in partners because co-infection is common in this group. However, PN is challenging, and monitoring of performance is limited by the lack of standardised outcome measures and blunt classifications of sex partnership types. Accelerated partner therapy (APT) is a promising new PN method, but its role in preventing transmission is unknown. Aims and objectives The Limiting Undetected Sexually Transmitted infections to RedUce Morbidity (LUSTRUM) Programme aimed to improve the sexual health of people at high risk of STIs and HIV by improving PN outcomes. The Programme had three interconnecting streams: STREAM A: Accelerated partner therapy trial preparation and implementation Specific objectives: Develop a clinically useful SP classification. Optimise the acceptability of the APT intervention. Determine the effectiveness and costs of APT and understand how APT worked in practice. STREAM B: Mathematical modelling and health economic analysis Specific objectives: Quantify the effects of APT on chlamydia transmission and re-infection. Estimate the cost effectiveness of APT, compared with standard PN. STREAM C: Development of partner notification interventions for men who have sex with men Specific objectives: Explore costs and outcomes of PN and testing for HIV. Investigate PN for gonorrhoea in MSM to identify undiagnosed HIV infection using mathematical modelling. Explore barriers and facilitators to PN for bacterial STIs and develop a PN intervention. Methods A1. Development of a clinically usable sex partner classification We synthesised evidence about partnership types from: the third British National Survey of Sexual Attitudes and Lifestyles, 259 dating applications and published literature. Then, we conducted qualitative interviews with members of the public and patients (n = 57), and health professionals (n = 27). We developed definitions for partnership types through external multidisciplinary expert consultation. A2. Optimisation of the accelerated partner therapy intervention We analysed videos of APT role-play consultations and synthesised published evidence about relevant behaviours; explored barriers and facilitators to receiving or delivering APT, including focused work with 25 people with mild learning disabilities, 56 members of the public and patients and 30 healthcare professionals (HCPs); modified and specified key components of APT, wrote a manual and training package, and created online videos. A3. Randomised controlled trial of accelerated partner therapy We conducted a cluster crossover randomised controlled trial with a process and cost-consequence evaluation. Dynamic modelling is described in Stream B. Clusters were 17 sexual health clinics in diverse areas of England and Scotland. Participants [index patients (IPs)] were heterosexual women and men, aged ≥ 16 years with a positive test for Chlamydia trachomatis and/or a clinical diagnosis of pelvic inflammatory disease or cervicitis (women) or non-gonococcal urethritis or epididymo-orchitis (men) and reporting at least one contactable sexual partner in the past 6 months. Intervention: APT was offered as an additional partner notification method for IPs. A HCP assessed their SP(s) by telephone, then sent or gave the IP antibiotics and STI and HIV self-sampling kits for their partner(s). The control arm received standard PN alone. The intervention was implemented at the level of the sexual health clinic, with clinics randomised to intervention or control arm in the first phase by random permutation. The primary outcome was the proportion of IPs testing positive for C. trachomatis 12–24 weeks after the PN consultation. Secondary outcomes included: the proportion of SPs treated; the proportion of partners notified; costs; cost effectiveness; model-predicted chlamydia prevalence. The primary outcome analysis was by intention to treat, fitting random-effects logistic regression models that account for clustering of IPs within clinics and trial periods. Process evaluation: We collected qualitative data through six focus groups and individual interviews (n = 10) with purposively sampled HCPs (n = 34 from 14 sites), IPs (n = 15) and SPs who received APT (n = 17). Quantitative data were collected within a clinical management and PN data collection system (RELAY). Cost-consequence analysis (CCA): We collected data on costs and resource use during the trial and used unit costs from the trial and the Personal Social Services Research Unit. B1 and B2. Modelling the effects of accelerated partner therapy on Chlamydia trachomatis transmission We developed a new deterministic transmission model with a dedicated PN module, which allowed us to identify the effects of different index-partner combinations on chlamydia prevalence. We considered a population aged 16–34 years and calibrated the model to data from the third British National Survey of Sexual Attitudes and Lifestyles. We then extended a previous modelling framework, informed by data from the C. trachomatis transmission model and the trial, to quantify expected rates of chlamydia reinfection (Estcourt CS, Stirrup O, Copas A, Low N, Mapp F, Saunders J, et al. Accelerated partner therapy contact tracing for people with chlamydia (LUSTRUM): a crossover cluster-randomised controlled trial. Lancet Public Health 2022;7(10):e853–65. https://doi.org/10.1016/S2468-2667(22)00204-3). B3. Cost-effectiveness analysis of accelerated partner therapy compared with standard partner notification We developed a spreadsheet-based model using output from the C. trachomatis transmission model to estimate the impact of APT on healthcare costs, major outcomes averted (MOA) and quality-adjusted life-years (QALYs) in a simulated population of 100,000 adults aged 16–34 years. We calculated incremental cost-effectiveness ratios (ICERs) for APT, compared with standard PN and undertook sensitivity and scenario analyses. C1. Systematic review of economic studies of interventions related to partner notification for sexually transmitted infections in men who have sex with men We searched six electronic databases up to June 2020. We included economic evaluation and cost analysis studies if participants were MSM with any STI and/or HIV and the intervention was related to PN, testing or treatment and summarised evidence using a narrative synthesis. C2. Partner notification for bacterial sexually transmitted infections in men who have sex with men as a way to detect undiagnosed human immunodeficiency virus infection in partners We reviewed modelling studies of PN and pre-exposure prophylaxis interventions in MSM and attempted to model PN with co-infections with gonorrhoea HIV. C3. Barriers and facilitators of accelerated partner therapy and development of a novel partner notification intervention for men who have sex with men First, we conducted a stakeholder event with 45 participants from across Britain [MSM, public health experts, service commissioners, multidisciplinary sexual HCPs, non-governmental organisations (NGOs), academics and dating app providers]. We explored the diverse and multilevelled social, cultural and healthcare system-level context shaping poor PN outcomes for one-off partners. We conducted qualitative in-depth interview studies with men who had experienced PN (n = 14, Stream A) and focus groups with MSM (n = 28), clinical and other stakeholders (n = 11) to explore barriers and facilitators to PN. We used the behaviour change wheel within co-design of a potential new PN intervention. Results A1. We created usable definitions for five SP types (committed/established, new, occasional, one-off, sex work), broadly predicated on duration of the relationship, likelihood of future sex and degree of emotional connection. A2. Modifications to the APT intervention included simplification of the patient packs, creation of ‘how to’ training films for participants and HCPs. People with mild learning disabilities found APT acceptable but described feeling overwhelmed by the packs. They recommended using photographs instead of diagrams of anatomical sites for self-sampling, and an ‘easy read’ format. The new partner types and APT processes were built into a new clinical management and PN data collection system called RELAY. A3. In the trial, all 17 clinics completed both periods. One thousand five hundred and thirty-six and 1724 IPs provided data in intervention and control phases. In intervention and control phases, 666 (43.4%) and 800 (46.4%) IPs were tested for C. trachomatis; 31 (4.7%) and 53 (6.6%) were positive, adjusted odds ratio (aOR) 0.66 [95% confidence interval (CI) 0.41 to 1.04; p = 0.07]. The proportion with ≥ 1 SP treated was 775/881 (88.0%) in intervention and 760/898 (84.6%) in the control phase, aOR 1.27 (95% CI 0.96 to 1.68; p = 0.10) (Estcourt C, Mapp F, Stirrup O, Copas A, Howarth A, Owusu M, et al. O18.2 Does Accelerated partner therapy improve partner notification outcomes for people with chlamydia? The LUSTRUM cluster cross-over randomised control trial. Sex Transm Infect 2021;97:A57–8. http://doi.org/10.1136/sextrans-2021-sti.153). In total, 4807 SPs were reported, of whom 1636 (34%) were committed/established partners. Overall, 293/1536 (19.1%) of IPs in intervention phase chose APT for a total of 305 partners, of whom 248 accepted. Partner types were committed/established, 166/305 (54.4%); new, 85/305 (27.9%); occasional, 45/305 (14.8%); and one-off, 9/305 (3.0%). Common reasons for IPs to decline APT included: preferred face-to-face conversation 400/1832 (21.8%), partner already in clinic 388/1832 (21.2%), unwilling to engage with partner 206/1832 (11.2%), preferred partner to attend clinic 202/1832 (11.0%) and partner overseas 150/1832 (8.2%). Of 241 partners sent APT packs, 120/241 (49.8%) returned chlamydia and gonorrhoea testing samples, of which 78/119 (65.5%) were positive for chlamydia (no result in one), but only 60/241 (24.9%) HIV and syphilis samples (all negative). In an unplanned analysis, 2/106 (2.0%) IPs, who were offered APT and accepted it for one or more partners, tested positive for chlamydia at 12–24 weeks. Of IPs not selecting APT or whose partners refused, 29/560 (5.2%) had a positive result on repeat testing. The process evaluation showed that overall intervention fidelity was good and APT was well liked by those who delivered and received it. Overall, we found a mixed picture of an intuitive, coherent intervention struggling to gain purchase within already pressured services. HCPs preferred RELAY to their clinic systems because it helped them standardise PN. However, many sites struggled to scale up the trial processes owing to continual external pressures to adapt services to achieve efficiencies. In some services, APT was perceived as time-consuming and without palpable impact. This observation was related to the absence of a reduction in patient numbers in clinic waiting rooms. In this way, the ‘invisibility’ of the effectiveness of APT curtailed the establishment of positive feedback loops driving normalisation within services. In the CCA, APT cost more than standard PN (£91.23 vs. £75.21). Where accepted, it was more effective than standard PN with an absolute effect difference of 5.26%. B1 and B2. In the model, chlamydia positivity was highest for symptomatic index cases of low sexual activity, with infected partners who were typically asymptomatic and highly sexually active. Partner notification for this index–partner combination would prevent the most transmission. Increasing the number of treated partners from current levels in Britain (0.51, 95% credible interval, CI 0.21 to 0.80) by 25% would reduce chlamydia prevalence by 18% (95% CI 5% to 44%) in both women and men within 5 years. Reducing the time to partner treatment alone had a minor effect on reducing prevalence. Together, these results suggest that PN typically identifies sexual partners who are likely to further transmit chlamydia and that APT could further reduce prevalence if PN uptake increases. B3. In the cost-effectiveness analysis, the base-case results showed APT cost less and was more effective than standard PN in terms of MOA and QALYs, and therefore cost-saving. The results were supported by deterministic sensitivity analysis and scenario analysis for most scenarios, with ICERs very low and well within accepted thresholds. C1. There was very little published evidence on health economic aspects of PN in MSM. This supports the need for new interventions with parallel economic evaluation. C2. Published models have not examined the impact on HIV diagnosis of PN for bacterial STIs, and interventions cannot be extrapolated between countries. There were challenges in fitting the model of gonorrhoea/HIV co-infection to data, including issues with parameter identifiability. C3. We considered APT for MSM (and their more emotionally connected partners) and developed recommendations for a multilevel, multistakeholder intervention targeting MSM with other types of partners for whom PN is known to be more challenging. Key intervention elements included: a co-ordinated and coproduced mass and social media intervention to change norms and beliefs to challenge stigma and other barriers to PN; NGO peer-led work reducing STI-related stigma and persuading MSM to participate actively in PN to protect others and their communities; working with MSM to enable them to prepare for PN interactions and encourage HCP action, monitoring systems to directly address one-off PN outcomes; dating app providers promoting appropriate PN messaging. Conclusions The Programme provides findings about APT, which show promise for future PN. RELAY could be added to clinic systems for recording PN outcomes and processes. The Programme identified gaps in research about PN for one-off, and other partnerships with poor outcomes and high potential for onward sexual transmission. Data from the trial also suggested that APT uptake might be lower for people belonging to ethnic minority groups, although it was not powered to formally evaluate any such differences. The process evaluation and the work in Stream C identify a need for interventions that reach beyond sexual health services. Future work Future work should identify PN approaches for one-off partners; determine how to provide real-time or fast feedback for practitioners on the impact of interventions whose value is not obvious; further research is needed on how to increase uptake of APT, explore the pros and cons of immediate antibiotics, and optimise the uptake of self-sampling in partners, particularly people with mild learning disabilities; understand how services can use sex partnership-type information to improve PN methods, especially for hard-to-reach groups; develop and evaluate a system intervention to increase readiness in MSM for and engagement with PN for bacterial STIs, focusing on one-off partnerships and addressing economic factors and partnership type. Trial registration This trial is registered as ISRCTN15996256. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0614-20009) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Abstract Background Men and gender-diverse people who have sex with men are disproportionately affected by health conditions associated with increased risk of severe illness due to COVID-19 infection. Methods An online cross-sectional survey of men and gender-diverse people who have sex with men in the UK recruited via social networking and dating applications from 22 November-12 December 2021. Eligible participants included self-identifying men, transgender women, or gender-diverse individuals assigned male at birth (AMAB), aged ≥ 16, who were UK residents, and self-reported having had sex with an individual AMAB in the last year. We calculated self-reported COVID-19 test-positivity, proportion reporting long COVID, and COVID-19 vaccination uptake anytime from pandemic start to survey completion (November/December 2021). Logistic regression was used to assess sociodemographic, clinical, and behavioural characteristics associated with SARS-CoV-2 (COVID-19) test positivity and complete vaccination (≥ 2 vaccine doses). Results Among 1,039 participants (88.1% white, median age 41 years [interquartile range: 31-51]), 18.6% (95% CI: 16.3%-21.1%) reported COVID-19 test positivity, 8.3% (95% CI: 6.7%-10.1%) long COVID, and 94.5% (95% CI: 93.3%-96.1%) complete COVID-19 vaccination through late 2021. In multivariable models, COVID-19 test positivity was associated with UK country of residence (aOR: 2.22 [95% CI: 1.26-3.92], England vs outside England) and employment (aOR: 1.55 [95% CI: 1.01-2.38], current employment vs not employed). Complete COVID-19 vaccination was associated with age (aOR: 1.04 [95% CI: 1.01-1.06], per increasing year), gender (aOR: 0.26 [95% CI: 0.09-0.72], gender minority vs cisgender), education (aOR: 2.11 [95% CI: 1.12-3.98], degree-level or higher vs below degree-level), employment (aOR: 2.07 [95% CI: 1.08-3.94], current employment vs not employed), relationship status (aOR: 0.50 [95% CI: 0.25-1.00], single vs in a relationship), COVID-19 infection history (aOR: 0.47 [95% CI: 0.25-0.88], test positivity or self-perceived infection vs no history), known HPV vaccination (aOR: 3.32 [95% CI: 1.43-7.75]), and low self-worth (aOR: 0.29 [95% CI: 0.15-0.54]). Conclusions In this community sample, COVID-19 vaccine uptake was high overall, though lower among younger age-groups, gender minorities, and those with poorer well-being. Efforts are needed to limit COVID-19 related exacerbation of health inequalities in groups who already experience a greater burden of poor health relative to other men who have sex with men.

Establishing intervention effectiveness is an important component of a broader knowledge translation (KT) process. However, mobilizing the implementation of these interventions into practice is perhaps the most important aspect of the KT cycle. The purpose of the current study was to conduct an umbrella review to (a) identify promising interventions for SI&L in older adults, (b) interpret (translate) the findings to inform clinical knowledge and practice interventions in different settings and contexts, and (c) highlight research gaps that may hinder the uptake of these interventions in practice. The broader purpose of this study was to inform evidence-based clinical practice guidelines on SI&L for HCSSPs. In line with other reviews, our study noted variations in methods and intervention designs that prohibit definitive statements about intervention effectiveness. Perhaps, the most significant contribution of the current review was in identifying knowledge-to-practice gaps that inhibit the implementation of interventions into practice-based realities.

Abstract Ethylene-Vinyl Acetate (EVA) is the most popular material for manufacturing mouthguards. However, EVA mouthguards are problematic, for example inconsistent thicknesses across the mouthguard. Additive manufacturing provides a promising solution to this problem, as it can manufacture mouthguards with a greater precision. This paper compares the energy dissipation of EVA, the current material used for mouthguards, to various designs of a 3D printed material, some of which contain air cells. Impact testing was carried out at three different strain rates. The Split-Hopkinson bar was used for medium and high strain rate tests, and an Instron test rig was used for low strain rate testing. The best performing design dissipated 25% more energy than EVA in the medium and high strain rate testing respectively while the low strain rate testing was inconclusive. This research has shown that additive manufacturing provides a viable method of manufacturing mouthguards. This opens up the opportunity for embedding electronics/sensors into additive manufactured mouthguards.

Cooling electrons into the microkelvin temperature range is of interest both for practical purposes and fundamental studies, but current demonstrations are limited to small, specific devices. Here, the authors achieve sub-millikelvin temperatures in a large-area, two-dimensional electron gas.

IntroductionHIV pre-exposure prophylaxis (PrEP), in which people take HIV medication to prevent HIV acquisition, underpins global HIV transmission elimination strategies. Effective prevention needs people to adhere to PrEP and remain in care during periods of risk, but this is difficult to achieve. We undertook a process evaluation of Scotland's PrEP programme to explore barriers and facilitators to PrEP adherence and retention in care and to systematically develop evidence-based, theoretically-informed recommendations to address them.MethodsWe conducted semi-structured interviews and focus groups (09/2018-07/2019) with patients who identified as gay or bisexual men and were either using PrEP, had declined the offer of PrEP, had stopped PrEP, or had been assessed as ineligible for PrEP (n = 39 of whom n = 5 (13%) identified as trans, median age 31 years and interquartile range 14 years), healthcare professionals involved in PrEP provision (n = 54 including specialist sexual health doctors and nurses of various grades, PrEP prescribing general practitioners, health promotion officers, midwifes, and a PrEP clinical secretary), and clients (n = 9) and staff (n = 15) of non-governmental organisations with an HIV prevention remit across Scotland. We used thematic analysis to map key barriers and facilitators to priority areas that could enhance adherence and retention in care. We used implementation science analytic tools (Theoretical Domains Framework, Intervention Functions, Behaviour Change Technique Taxonomy, APEASE criteria) and expert opinion to systematically generate recommendations.ResultsBarriers included perceived complexity of on-demand dosing, tendency for users to stop PrEP before seeking professional support, troublesome side-effects, limited flexibility in the settings/timings/nature of review appointments, PrEP-related stigma and emerging stigmas around not using PrEP. Facilitators included flexible appointment scheduling, reminders, and processes to follow up non-attenders. Examples of the 25 recommendations include: emphasising benefits of PrEP reviews and providing appointments flexibly within individualised PrEP care; using clinic systems to remind/recall PrEP users; supporting PrEP conversations among sexual partners; clear on-demand dosing guidance; encouraging good PrEP citizenship; detailed discussion on managing side-effects and care/coping planning activities.ConclusionsPrEP adherence and retention in care is challenging, reducing the effectiveness of PrEP at individual and population levels. We identify and provide solutions to where and how collaborative interventions across public health, clinical, and community practice could address these challenges.

Objective: To investigate feasibility of the SUCCESS app; a cross-platform e-health innovation to improve health literacy, self-management and shared decision-making among culturally-diverse Australian haemodialysis patients. Methods: Multi-site, pre-post, mixed-methods study. Haemodialysis patients ≥18 years used the app for 12 weeks. Qualitative data from 18 interviews were thematically analysed to evaluate app acceptability. Quantitative analysis using paired sampled t-tests evaluated feasibility outcomes pertaining to recruitment, retention, data collection and app efficacy (including health literacy; decision self-efficacy; quality of life; behaviour; knowledge; confidence). Results: We successfully recruited diverse participants (N = 116; 45% born overseas; 40% low/moderate health literacy) from four Local Health Districts in Sydney, Australia. However, only 61 participants completed follow-up questionnaires. Qualitative analyses provided insights into acceptability and user engagement. Quantitative analyses showed significant improvements on the health literacy domain ‘Ability to actively engage with healthcare providers’ (Mean Difference [MD] = 0.2 on a 5-point scale; CI95%: 0.0–0.4; p = 0.03) and decision self-efficacy (MD = 4.3 on a 10-point scale; CI95%: 0.6–7.9; p = 0.02) after 12 weeks app use. Conclusions: The SUCCESS app was feasible and acceptable to participants. The app will be adapted to facilitate ongoing use and engagement among diverse haemodialysis patients. Innovation: This is the first health literacy-informed app to promote active participation in haemodialysis self-management and decision-making, tailored toward culturally-diverse and low health literacy groups.

Abstract Background Syndemic theory highlights the potential for health problems to interact synergistically, compounding impact. Young adults not in education, employment or training (NEET) are more likely to experience disadvantage and poorer general health outcomes. However, there is little research on their sexual health, or the extent to which this clusters with mental and physical health outcomes. Methods Analysis of data from 16 to 24 year olds (1729 men, 2140 women) interviewed 2010–12 for Britain’s third National Survey of Sexual Attitudes and Lifestyles. Natsal-3 is a national probability sample survey using computer-assisted personal interviewing with computer-assisted self-interviewing. Participants were classified as workers, students or NEET. We used multivariable logistic regression to examine associations between being NEET (relative to worker or student) and risk behaviours and outcomes in physical, sexual and mental health domains. We then examined how risk behaviours and poor health outcomes cluster within and across domains. Results 15% men and 20% women were NEET; 36% men and 32% women were workers; and 49% men and 48% women were students. Young people who were NEET were more likely to report smoking and drug use (men) than other young people. There were few differences in sexual health, although NEETs were more likely to report condomless sex, and NEET women, unplanned pregnancy (past year). Risk behaviours clustered more within and across domains for NEET men. Among NEET women, poor health outcomes clustered across mental, physical and sexual health domains. Conclusions Harmful health behaviours (men) and poor health outcomes (women) clustered more in those who are NEET. This points to a possible syndemic effect of NEET status on general ill health, especially for women. Our paper is novel in highlighting that elevated risk pertains to sexual as well as mental and physical health.

Background: Patients receiving warfarin who spend a lower proportion of time in therapeutic international normalized ratio (INR) range (TTR) have a higher risk of both bleeding complications and thromboembolic events. Using warfarin dosing algorithms is one intervention associated with improved INR stability. Objective: To determine the feasibility of an individualized warfarin dosing algorithm (Fearon Algorithm) under anticoagulation management service (AMS) care and compare measures of INR control using the algorithm with standard care. Methods: A pre/post intervention feasibility study consisting of the 12 months prior to patient enrollment (pre-study phase) and 6 months in which patients used the Fearon Algorithm under the supervision of an AMS pharmacist (AMS phase). The primary study outcome was the change in individual TTR. Results: A total of 30 patients were enrolled in the study, 26 (87%) of whom successfully completed the AMS study phase using the Fearon Algorithm. Median corrected individual TTR increased significantly from 53% (IQR: 39%, 64%) during the year prior to enrollment to 63% (IQR: 57%, 73%) during the AMS phase (p

Abstract Background The nucleotide reverse transcriptase inhibitor Tenofovir Alafenamide (TAF) is a novel pro-drug of tenofovir (TFV) and possesses a superior renal safety profile compared with tenofovir disoproxil fumerate (TDF). Due to unique pharmacokinetic characteristics, treatment with TAF is not associated with significant renal proximal tubular accumulation of TFV. TAF is associated with a lower risk of acute kidney injury, chronic kidney disease, proteinuria and renal proximal tubular dysfunction than treatment with TDF. No cases of Fanconi syndrome have been reported in clinical trials of TAF. It is unknown whether treatment with TAF can lead to accumulation of TFV in proximal tubular cells and cause nephrotoxicity under certain clinical circumstances. Case presentation Here we report the case of a patient on stable TAF-based antiretroviral therapy with for HIV-1 infection who developed proximal tubulopathy when treated with gentamicin for febrile neutropenia in the context of relapsed Hodgkin lymphoma. Eighteen days after commencing chemotherapy for relapsed Hodgkin lymphoma the patient presented to hospital with fevers, hypotension and neutropenia. The patient was commenced on piperacillin, tazobactam and gentamicin. Within 24 h the patient developed marked hypokalaemia and hypophosphataemia requiring intravenous replacement therapy. There was proteinuria, glycosuria and evidence of marked urinary electrolyte wasting, consistent with acute proximal tubular dysfunction. Eleven days after the gentamicin was stopped the serum biochemistry normalised. The urinary electrolyte wasting and proteinuria had improved, and the glycosuria had resolved. Conclusion This is the first case report to describe acute renal proximal tubulopathy in an HIV-infected patient treated with TAF and gentamicin. As the number of patients prescribed TAF outside the clinical trial setting increases, so too does the potential for previously unreported drug interactions and adverse events. Clinicians need to be aware of potential unreported adverse drug reactions as the use of TAF becomes increasingly common in clinical practice.

As COVID-19 becomes endemic, identifying vulnerable population groups for severe infection outcomes and defining rapid and effective preventive and therapeutic strategies remains a public health priority. We performed an umbrella review, including comprehensive studies (meta-analyses and systematic reviews) investigating COVID-19 risk for infection, hospitalization, intensive care unit (ICU) admission, and mortality in people with psychiatric disorders, and outlined evidence- and consensus-based recommendations for overcoming potential barriers that psychiatric patients may experience in preventing and managing COVID-19, and defining optimal therapeutic options and current research priorities in psychiatry. We searched Web of Science, PubMed, and Ovid/PsycINFO databases up to 17 January 2022 for the umbrella review. We synthesized evidence, extracting when available pooled odd ratio estimates for the categories “any mental disorder” and “severe mental disorders.” The quality of each study was assessed using the AMSTAR-2 approach and ranking evidence quality. We identified four systematic review/meta-analysis combinations, one meta-analysis, and three systematic reviews, each including up to 28 original studies. Although we rated the quality of studies from moderate to low and the evidence ranged from highly suggestive to non-significant, we found consistent evidence that people with mental illness are at increased risk of COVID-19 infection, hospitalization, and most importantly mortality, but not of ICU admission. The risk and the burden of COVID-19 in people with mental disorders, in particular those with severe mental illness, can no longer be ignored but demands urgent targeted and persistent action. Twenty-two recommendations are proposed to facilitate this process.

Worldwide, 1.3 billion people live in Poverty, a socio-economic status that has been identified as a key determinant of a lack of sports participation. Still, numerous athletes around the world have grown up in underprivileged socio-economic conditions. This is the case in Brazil, a country with around 13.5 million impoverished citizens, yet, over decades, many of its best professional footballers have emerged from its favelas. In this article, we explore the role of the socio-cultural-economic constraints in shaping the development of skill and expertise of Brazilian professional football players. The methodological and epistemological assumptions of the “Contextualized Skill Acquisition Research” (CSAR) approach are used as an underpinning framework for organizing and analyzing data. Results suggested that, at the exosystemic level of Brazilian society, Poverty emerges as an influential constraint that can potentially enrich football development experiences of Brazilian players. Poverty, however, is not the direct causation of outstanding football skill development. Rather, from the perspective of ecological dynamics, Poverty creates specific contexts that can lead to the emergence of physical as well as socio-cultural environment constraints (e.g., Pelada, Malandragem) that can shape affordances (opportunities) for skill acquisition. These ideas suggest the need to ensure that environmental constraints can support people to amuse themselves cheaply, gain access to employment opportunities and maintain health and well-being through (unstructured and more structured) sport and physical activities in dense urban environments such as favelas, inner city areas, and banlieues. For this purpose, design of open play areas and even parkour installations can provide affordances landscapes for physical activity and sports participation in urban settings.

This study examined consumer attitudes towards attributes in food and beverages in China, India, Indonesia, Japan and the UK. The attributes included basic attributes such as price and quality, but also extended to food safety and health benefits, as well as environmental and social attributes. The importance of factors affecting key attributes were examined in more detail. The study used a web-based survey with 1,000 middle and upper income consumers in each country. In addition, the potential economic impact of agricultural returns of different levels of premiums for food attributes in the EU and New Zealand were examined using the partial equilibrium Lincoln Trade and Environment Model (LTEM). This study found that consumers from developing countries valued food attributes more than the developed countries. Trade model projections showed an important impact on the agricultural sectors in the EU and New Zealand from the different levels of premiums for food attributes in selected overseas markets.

Introduction HIV pre-exposure prophylaxis (PrEP) is an effective intervention to reduce acquisition of HIV. PrEP provision has increased in recent years, however, it is not known whether PrEP implementation has been equitably implemented across all risk groups, particularly groups experiencing high levels of health inequity. A PrEP care continuum (PCC) has been proposed to evaluate the success of PrEP implementation programmes, but the extent to which health equity characteristics are currently taken into account in the PCC has not been described. The objectives of this proposed systematic review are to (i) identify and collate outcome measure definitions for the main stages of the PCC (awareness, acceptability, uptake, adherence and retention), (ii) describe how equity characteristics are considered in outcome definitions of the PCC and (iii) describe data sources for capturing equity characteristics.Methods and analysis Quantitative studies published between 1 January 2012 and 3 March 2020 will be included. Five databases (MEDLINE, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index and Abstracts) will be searched to identify English language publications that include an outcome measure definition of at least one of the five main stages of the PCC. Risk of bias will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Data on outcome measure definitions and equity characteristics will be extracted. Results will be presented in a narrative synthesis and all findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Ethics and dissemination Ethical approval is not required. The results will be disseminated via submission for publication to a peer-reviewed journal when complete. The review findings will have relevance to healthcare professionals, policymakers and commissioners in informing how to best evaluate PrEP implementation programmes and inform new implementation strategies for vulnerable and less advantaged populations.PROSPERO registration number CRD42020169779.

Copyright © 2020 Harris. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The discovery of superconductivity in the quantum critical Kondo-lattice system YbRh _2 Si _2 at an extremely low temperature of 2 mK has inspired efforts to perform high-resolution electrical resistivity measurements down to this temperature range in highly conductive materials. Here we show that control over the sample geometry by microstructuring using focused-ion-beam techniques allows to reach ultra-low temperatures and increase signal-to-noise ratios (SNRs) tenfold, without adverse effects to sample quality. In five experiments we show four-terminal sensing resistance and magnetoresistance measurements which exhibit sharp phase transitions at the Néel temperature, and Shubnikov–de-Haas (SdH) oscillations between 13 T and 18 T where we identified a new SdH frequency of 0.39 kT. The increased SNR allowed resistance fluctuation (noise) spectroscopy that would not be possible for bulk crystals, and confirmed intrinsic $1/f$ -type fluctuations. Under controlled strain, two thin microstructured samples exhibited a large increase of $T_\mathrm{N}$ from 67 mK up to 188 mK while still showing clear signatures of the phase transition and SdH oscillations. Superconducting quantum interference device-based thermal noise spectroscopy measurements in a nuclear demagnetization refrigerator down to 0.95 mK, show a sharp superconducting transition at $T_\mathrm{c} = 1.2$ mK. These experiments demonstrate microstructuring as a powerful tool to investigate the resistance and the noise spectrum of highly conductive correlated metals over wide temperature ranges.