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The COVID-19 pandemic interrupted health care delivery and exacerbated disparities. Many sexual health clinics transitioned to telemedicine, including for pre-exposure prophylaxis (PrEP). We conducted a retrospective cohort study of patients at an urban sexual health clinic to assess the likelihood and predictors of PrEP persistence in the year following PrEP initiation. We compared patients starting PrEP in the four months preceding the first COVID surge to those starting PrEP one year prior. We found lower PrEP persistence in the COVID cohort compared to the pre-COVID cohort (50.8% vs. 68.9%, respectively). In both cohorts, most care was provided through in-person visits and telemedicine was rare. In the pre-COVID cohort, older patients and those identifying as non-Hispanic White were more likely to persist on PrEP. In the COVID cohort, these disparities in PrEP persistence were not observed. Flexible models of care may facilitate equitable care engagement and re-engagement.

Sexual health clinic patients with no identified risk for HIV transmission are the second most numerous group with indications for preexposure prophylaxis but are the least likely to receive a prescription., Background New diagnoses of HIV increasingly occur among people who fall outside traditional transmission risk categories. This group remains poorly defined, and HIV prevention efforts for this group lag behind efforts for patients in other risk groups. Methods We conducted a retrospective review of patient visits at sexual health clinics in Boston, MA, over a 14-month period. Patients were classified into Centers for Disease Control and Prevention–defined HIV transmission risk categories. We compared frequencies of sexually transmitted infections (STIs), HIV, preexposure prophylaxis (PrEP) indications, and PrEP prescriptions. Predictors of HIV or STI among patients in the undetermined risk category were assessed with logistic regression. Results There were 4723 clinic visits during the study period. Patients in the undetermined risk group constituted the largest proportion (55.8%), followed by men who have sex with men (MSM; 42.7%). The proportion of visits by patients in the undetermined risk group with an indication for PrEP was low (28.0%) compared with MSM (91.3%) and MSM who also inject drugs (93.8%); however, the absolute number was high (737). Among patients with an indication for PrEP, those in the undetermined risk group were least likely to receive a prescription. Behavioral risk factors were poorly predictive of STI or HIV among patients in the undetermined risk group. Conclusions Patients with undetermined risk for HIV constituted a large proportion of clinic visits and had a large volume of sexual health needs but rarely received PrEP when indicated. To end the HIV epidemic in the United States, prevention efforts must include people who fall outside traditional risk categories.

BackgroundPredicting long-term care trajectories at the time of HIV diagnosis may allow targeted interventions. Our objective was to uncover distinct CD4-based trajectories and determine baseline demographic, clinical, and contextual factors associated with trajectory membership.MethodsWe used data from the Sizanani trial (NCT01188941), in which adults were enrolled prior to HIV testing in Durban, South Africa from August 2010-January 2013. We ascertained CD4 counts from the National Health Laboratory Service over 5y follow-up. We used group-based statistical modeling to identify groups with similar CD4 count trajectories and Bayesian information criteria to determine distinct CD4 trajectories. We evaluated baseline factors that predict membership in specific trajectories using multinomial logistic regression. We examined calendar year of participant enrollment, age, gender, cohabitation, TB positivity, self-identified barriers to care, and ART initiation within 3 months of diagnosis.Results688 participants had longitudinal data available. Group-based trajectory modeling identified four distinct trajectories: one with consistently low CD4 counts (21%), one with low CD4 counts that increased over time (22%), one with moderate CD4 counts that remained stable (41%), and one with high CD4 counts that increased over time (16%). Those with higher CD4 counts at diagnosis were younger, less likely to have TB, and less likely to identify barriers to care. Those in the least favorable trajectory (consistently low CD4 count) were least likely to start ART within 3 months.ConclusionsOne-fifth of people newly-diagnosed with HIV presented with low CD4 counts that failed to rise over time. Less than 40% were in a trajectory characterized by increasing CD4 counts. Patients in more favorable trajectories were younger, less likely to have TB, and less likely to report barriers to healthcare. Better understanding barriers to early care engagement and ART initiation will be necessary to improve long-term clinical outcomes.

A 22-year-old man presented to the emergency department on Christmas Day with a 5-day history of myalgias, cough, dyspnea, nonbilious emesis, and nonbloody diarrhea. Although he had been ill for several days, he ultimately sought treatment because of intractable vomiting. He reported feeling feverish, although he had not measured his temperature, and noted one episode of hemoptysis.

Background: The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.Objective: Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.Design: Toolkit development included cognitive interviewing and test–retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.Participants: A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.Interventions: The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)—a tool that allows patients to create a personalized accommodations report for their PCP—and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.Main Measures: Satisfaction with patient–provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit’s usability and utility; responses to open-ended questions.Key Results: Preliminary testing of the AHAT demonstrated strong content validity and adequate test–retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p p = 0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p = 0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).Conclusions: The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient–provider communication.

Background & aimsThe American Consortium of Early Liver Transplantation for Alcoholic Hepatitis comprises 12 centers from 8 United Network for Organ Sharing regions studying early liver transplantation (LT) (without mandated period of sobriety) for patients with severe alcoholic hepatitis (AH). We analyzed the outcomes of these patients.MethodsWe performed a retrospective study of consecutive patients with a diagnosis of severe AH and no prior diagnosis of liver disease or episodes of AH, who underwent LT before 6 months of abstinence from 2006 through 2017 at 12 centers. We collected data on baseline characteristics, psychosocial profiles, level of alcohol consumption before LT, disease course and treatment, and outcomes of LT. The interval of alcohol abstinence was defined as the time between last drink and the date of LT. The primary outcomes were survival and alcohol use after LT, defined as slip or sustained.ResultsAmong 147 patients with AH who received liver transplants, the median duration of abstinence before LT was 55 days; 54% received corticosteroids for AH and the patients had a median Lille score of 0.82 and a median Sodium Model for End-Stage Liver Disease score of 39. Cumulative patient survival percentages after LT were 94% at 1 year (95% confidence interval [CI], 89%-97%) and 84% at 3 years (95% CI, 75%-90%). Following hospital discharge after LT, 72% were abstinent, 18% had slips, and 11% had sustained alcohol use. The cumulative incidence of any alcohol use was 25% at 1 year (95% CI, 18%-34%) and 34% at 3 years (95% CI, 25%-44%) after LT. The cumulative incidence of sustained alcohol use was 10% at 1 year (95% CI, 6%-18%) and 17% at 3 years (95% CI, 10%-27%) after LT. In multivariable analysis, only younger age was associated with alcohol following LT (P= .01). Sustained alcohol use after LT was associated with increased risk of death (hazard ratio, 4.59; P= .01).ConclusionsIn a retrospective analysis of 147 patients who underwent early LT (before 6 months of abstinence) for severe AH, we found that most patients survive for 1year (94%) and 3 years (84%), similar to patients receiving livertransplants for other indications. Sustained alcohol use after LT was infrequent but associated with increased mortality. Our findings support the selective use of LT as a treatment for severe AH. Prospective studies are needed to optimize selection criteria, management of patients after LT, and long-term outcomes.

Core-shell particles have been prepared by surfactant-free emulsion polymerisations of butyl methacrylate in the presence of either linear or highly branched poly(acrylamidomethylpropane sulphonate)s (L-PAMPS or HB-PAMPS) with dithioate end groups: using a "shell-first" approach. In this method the water soluble PAMPS shells were anchored to the cores by polymerisation of BMA from the chain ends. The linear PAMPS produced non-crosslinked poly(AMPS-BMA) particles but the multiple chain ends of the highly branched PAMPS led to crosslinked particles. The particles were loaded with vascular endothelial growth factor or platelet derived growth factor, both of which are cytokines that are known to be important in the production of new blood vessels. The release of the growth factors was shown to be controlled by the architecture of the shell and we propose a mechanism that involves both ionic interaction of the PAMPS with the heparin-binding domains of the growth factors and size exclusion mediated diffusion.

Violence against people with developmental disabilities is a highly prevalent yet understudied phenomenon. In particular, there is a paucity of literature surrounding the role of gender and the experiences of men. Using a cross-sectional study design, we surveyed 350 people with diverse developmental disabilities about experiences of abuse, perpetrators of abuse, and their physical and mental health status. These data were analyzed to determine whether gender influenced these domains. Statistical methods included chi-square, independent t tests, logistic regression, and hierarchical multiple regressions. Male and female participants reported abuse at high rates, with 61.9% of men and 58.2% of women reporting abuse as children and 63.7% of men and 68.2% of women reporting abuse as adults. More women than men reported adult sexual abuse, but there was no gender difference in the prevalence of any other form of abuse. Women were more likely than men to identify an intimate partner as their abuser, although intimate partners represented the minority of abusers for both men and women. Violence was associated with worse health status regardless of participant gender. These findings confirm that violence is an important issue for both men and women with developmental disabilities. Although some expected gender differences arose, such as higher rates of adult sexual abuse and intimate partner violence against women, these differences were less pronounced than they are in the general population, and the overall picture of abuse was one of gender similarities rather than differences.

In a world in which fossil fuel energy is becoming ever more scarce and expensive and countries are struggling to meet their carbon reduction obligations, hydrogen solutions have finally reached the top of energy agendas. The only industrially applicable zero carbon method to produce hydrogen is via electrolysis utilizing renewable sources of electricity. ITM Power is at the very heart of the initiatives and programmes to adopt hydrogen technology that will reduce both carbon footprints and energy costs. Using its technology and knowhow, ITM is aiming to be the world leading supplier of both infrastructure for the production of green hydrogen transport fuel, and products for the generation and storage of hydrogen fuel from internittent renewable energy sources. Despite having a number of electrolyser products on the market, ITM Power have an active PEM electrolyser research and development programme aimed at the next generation of electrolysers. Some of the electrochemical and materials challenges faced by both ITM and the industry will be presented along with recent results, examples given below. PEM electrolysers have a lifetime of 5-10 years; as such there is difficulty in getting new materials to market. ITM along with the National Physical Laboratory have used a novel in-situ reference electrode to help understand catalyst degradation within the cell. This approach enables separation of the relative contributions of anode and cathode to the overall reaction. During shut down periods it was observed for the first time that the cathode contributes more to changes in the open circuit voltage. This knowledge has been used to show that the majority of the degradation is occurring on the cathode catalyst, which is in contrast to the perceived thought which assumes the anode degrades faster. Changes in the electrochemically active surface area of the platinum cathode as a result of potential cycling were determined in-situ via hydrogen underpotential cyclic voltammetry. Scanning electron microscopy and X-ray tomography were used to correlate changes in catalyst morphology with performance degradation of both carbon-supported and unsupported platinum catalysts. These experiments have led to the development of accelerated stress tests, based on cycling of the electrode potential, for PEM electrolyser catalysts. In addition ITM have made progress in the development of new membranes for PEM electrolysis. ITM’s approach to membrane development is the UV polymerisation of low cost hydrocarbon monomers. A new highly conductive membrane has been developed and tested to 3 A∙cm-2. This membrane is 125 um thick to minimise hydrogen crossover, has a conductivity of 260 mS∙cm-1 and is extremely low cost. When made into a MEA, this membrane allows a voltage of below 1.6 V at 1 A∙cm-2 at only 55°C. This has been benchmarked against Nafion(R)115.