Regulatory T Cells in Skin Facilitate Epithelial Stem Cell Differentiation.

The maintenance of tissue homeostasis is critically dependent on the function of tissue-resident immune cells and the differentiation capacity of tissue-resident stem cells (SCs). How immune cells influence the function of SCs is largely unknown. Regulatory T cells (Tregs) in skin preferentially localize to hair follicles (HFs), which house a major subset of skin SCs (HFSCs). Here, we mechanistically dissect the role of Tregs in HF and HFSC biology. Lineage-specific cell depletion revealed that Tregs promote HF regeneration by augmenting HFSC proliferation and differentiation. Transcriptional and phenotypic profiling of Tregs and HFSCs revealed that skin-resident Tregs preferentially express high levels of the Notch ligand family member, Jagged 1 (Jag1). Expression of Jag1 on Tregs facilitated HFSC function and efficient HF regeneration. Taken together, our work demonstrates that Tregs in skin play a major role in HF biology by promoting the function of HFSCs.

A Wave of Regulatory T Cells into Neonatal Skin Mediates Tolerance to Commensal Microbes.

The skin is a site of constant dialog between the immune system and commensal bacteria. However, the molecular mechanisms that allow us to tolerate the presence of skin commensals without eliciting destructive inflammation are unknown. Using a model system to study the antigen-specific response to S. epidermidis, we demonstrated that skin colonization during a defined period of neonatal life was required for establishing immune tolerance to commensal microbes. This crucial window was characterized by an abrupt influx of highly activated regulatory T (Treg) cells into neonatal skin. Selective inhibition of this Treg cell wave completely abrogated tolerance. Thus, the host-commensal relationship in the skin relied on a unique Treg cell population that mediated tolerance to bacterial antigens during a defined developmental window. This suggests that the cutaneous microbiome composition in neonatal life is crucial in shaping adaptive immune responses to commensals, and disrupting these interactions might have enduring health implications.

"Something Like That": Awareness and Acceptability of HIV PrEP and PEP Among Kenyan Adolescents.

BACKGROUND: Adolescents account for 15% of new HIV cases in Kenya. HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly effective prevention tools, but uptake is low among adolescents, particularly in resource-limited settings. We assessed awareness and acceptability of PrEP and PEP among Kenyan adolescents. METHOD: Focus group discussions were conducted with 120 adolescent boys and girls ages 15 to 19 in Kisumu. Data were analyzed using the Framework Approach. RESULTS: Adolescent participants often had not heard of or could not differentiate between PrEP and PEP. They also confused these HIV prevention tools with emergency contraceptives. Taking a daily pill to prevent HIV was perceived as analogous to taking a pill to treat HIV. Boys were aware of and willing to consider using PrEP and PEP due to their dislike for using condoms. Adolescents identified insufficient information, cost, and uncomfortableness speaking with healthcare workers about their HIV prevention needs due to sexuality stigma as barriers to using PrEP and PEP. CONCLUSION: Low awareness and poor understanding of PrEP and PEP among adolescents reveal the need for increased education and sensitization about these HIV prevention options. Expanding access to sexual and reproductive health services that are tailored to the needs of adolescents and staffed with non-judgmental providers could help reduce sexuality stigma as a barrier to accessing care. New HIV prevention approaches such as long-acting injectables or implants, on-demand regimens, and multipurpose prevention technologies may encourage increased uptake of PrEP and PEP by adolescents.

Clinicopathological risk factors associated with tumor relapse of upper tract urothelial carcinoma after radical nephroureterectomy: A single institution 20-year experience.

Upper tract urothelial carcinoma (UTUC) is a relatively rare yet aggressive malignancy. While radical nephroureterectomy (RNU) remains the cornerstone treatment, UTUC has high local and metastatic relapse rates, leading to a dismal prognosis. To identify the clinicopathological factors associated with an increased risk of local and metastatic relapse in UTUC, we conducted a retrospective analysis of 133 consecutive UTUC patients who underwent RNU from 1998 to 2018. Patients lost to follow-up or with a history of bladder cancer were excluded from the study. The remaining 87 patients were categorized into two subgroups: those with tumor recurrence/relapse (40 cases) and those without recurrence/relapse (47 cases). Clinical and pathological characteristics were compared across the two groups. Multiple factors are associated with UTUC recurrence/relapse including larger tumor size, histology divergent differentiations/subtypes, high tumor grade, advanced pathologic T stage, positive margin, lymphovascular invasion (LVI), positive lymph node status, and preoperative hydronephrosis. Multivariate Cox regression analysis revealed that squamous differentiation predicted recurrence/relapse (p = 0.012), independent of tumor stage. Moreover, compared to the conventional histology type, UTUC with squamous differentiation had a significantly higher relapse rate (p = 0.0001) and poorer survival (p = 0.0039). This observation was further validated in invasive high-grade UTUC cases. Our findings suggest that many pathological factors contribute to UTUC recurrence/relapse, particularly, squamous differentiation may serve as an independent risk predictor for relapse and a potent prognosticator for adverse cancer-specific survival in UTUC patients. Recognizing and thoroughly assessing the pathological factors is essential for better oncologic management of UTUC.

Dementia care practices among community healthcare workers in Vietnam: a qualitative descriptive study.

BACKGROUND: Vietnam is one of the most rapidly aging countries in the world and the likelihood that someone may have dementia rises dramatically as the population ages. Although caring for persons living with dementia is important, little is known about the circumstances under which community healthcare professionals in Vietnam provide dementia care. This study aimed to describe the practice of caring for persons with dementia among community healthcare professionals in Vietnam. METHODS: This qualitative descriptive study was conducted with 23 community healthcare professionals recruited from 10 primary healthcare centers, representing 10 of 24 districts in Ho Chi Minh City, Vietnam. Participants were physicians (n = 11), physician's assistants (n = 8) and community nurses (n = 4). Data were collected through in-depth face-to-face semi-structured interviews. Interview data were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: The mean age of the 23 participants was 44.6 ± 8.8 years; most were female (n = 16, 69.6%); and the mean time of working in the field of dementia care was 15.9 ± 8.4 years. Analysis of the interview data revealed five categories, which informed how care was provided: 1) Knowledge about dementia and its prevalence among older adults; 2) Identification of dementia in Vietnam; 3) Lack of attention to early diagnosis of dementia and difficulty in providing continuous care; 4) Dependence on family members for prompt and continuous care; and 5) challenges to providing dementia care. Despite having knowledge about dementia, some healthcare professionals incorrectly viewed dementia as an inevitable part of the ageing process. Participants reported that their limited training and practical experience in caring for persons with dementia caused a lack of confidence in dementia care. CONCLUSIONS: The quality of care provided to persons living with dementia was negatively impacted by the limited training of healthcare personnel. The diagnosis, treatment, and provision of supportive services to persons living with dementia and their families are substantial challenges for the Vietnamese healthcare system. It is crucial to initiate and cultivate dementia care education programs aimed at expanding curricula for physicians, physicians' assistants, and nurses.

Flight Path Setting and Data Quality Assessments for Unmanned-Aerial-Vehicle-Based Photogrammetric Bridge Deck Documentation.

Imagery from Unmanned Aerial Vehicles can be used to generate three-dimensional (3D) point cloud models. However, final data quality is impacted by the flight altitude, camera angle, overlap rate, and data processing strategies. Typically, both overview images and redundant close-range images are collected, which significantly increases the data collection and processing time. To investigate the relationship between input resources and output quality, a suite of seven metrics is proposed including total points, average point density, uniformity, yield rate, coverage, geometry accuracy, and time efficiency. When applied in the field to a full-scale structure, the UAV altitude and camera angle most strongly affected data density and uniformity. A 66% overlapping was needed for successful 3D reconstruction. Conducting multiple flight paths improved local geometric accuracy better than increasing the overlapping rate. The highest coverage was achieved at 77% due to the formation of semi-irregular gridded gaps between point groups as an artefact of the Structure from Motion process. No single set of flight parameters was optimal for every data collection goal. Hence, understanding flight path parameter impacts is crucial to optimal UAV data collection.

Efficacy of Kinesio Taping Compared to Other Treatment Modalities in Musculoskeletal Disorders: A Systematic Review and Meta-Analysis.

Kinesio taping is widely used in musculoskeletal conditions. We performed a systematic review and meta-analysis on the efficacy of kinesio taping in musculoskeletal disorders compared to other interventions. Twelve electronic databases were used for systemic search and data relevant to pain and disability were extracted. The protocol was registered in PROSPERO (CRD42018087606). Meta-analysis was performed to compare the efficacy of kinesio taping to other modalities of musculoskeletal disorders. As a result, 36 studies were included in the quantitative analysis. Kinesio taping was found to provide an improvement of both pain and disability when applied to any region of the body. In the first five days of application, kinesio taping significantly reduced the pain in all body regions (SMD = -0.63, 95%CI: -0.87, -0.39). This was also noted after four-to-six weeks of application (SMD = -0.76, 95%CI: -1.07, -0.45). When kinesio taping was used for disability in low back pain patients, it significantly reduced the disability within five days of application (SMD = -0.70, 95%CI: -1.29, -0.11). Finally, kinesio taping has shown an improvement of the disability in all body regions after four-to-six weeks of application (SMD = -0.59, 95%CI: -0.96, -0.22). Our findings support kinesio taping as an adjuvant to other treatments for musculoskeletal disorders. Abbreviations KT = Kinesio taping; MSK = musculoskeletal; SD = standard deviation; CR = conventional rehabilitation; NDI = Neck Disability Index; NPS = Numerical Pain Scale; CTM = Cervical Thrust Manipulation; PIR = Post-isometric muscle relaxation; NPRS Numerical Pain Rating Scale; OA = osteoarthritis; ROM = Range of motion; VAS = visual analogue scale; VAS-W = visual analogue scale-worst pain; VAS-U = visual analogue scale-usual pain; VAS-R = visual analogue scale-resting pain; VAS-A = visual analogue scale-activity pain; VAS-N = visual analogue scale-night pain; NPDS = Neck Pain Disability Scale; QA = Quality assessment.

HIV drug resistance in persons initiating or reinitiating first-line antiretroviral therapy in Paraguay: Results of a National Patient Survey.

Human immunodeficiency virus (HIV) drug resistance increases mortality and morbidity and antiretroviral therapy (ART) costs. We describe Paraguay's first nationally representative survey on pretreatment drug resistance (PDR) conducted among persons who initiated or reinitiated ART in 2019. ​​​​We conducted a cross-sectional survey of antiretroviral (ARV) drug resistance in Paraguay in 2019. Participants were sampled at four comprehensive care clinics where 90% of patients with HIV in Paraguay initiate ART. Patients included were adults ≥18 years old who initiated first-line ART or reinitiated the same first-line ART regimen after ≥3 months of discontinuation. Of 208 patients, 93.8% had no prior ART exposure, 3.8% reinitiated the same regimen, 2.4% had unknown prior ART exposure; and 31.3% had a CD4 count <200 cells/µl. Mutations associated with resistance were present in 15.4% of patients. Mutations associated with resistance to nonnucleoside reverse transcriptase inhibitors (NNRTI) were present in 13.0% of patients, nucleoside reverse transcriptase inhibitors in 4.3%, and integrase inhibitors in 3.4%. Mutations associated with resistance to tenofovir were present in 1.0% of patients and emtricitabine/lamivudine in 1.4%. ​​Nearly one in six patients had PDR in Paraguay's first nationally representative sample. High NNRTI PDR prevalence underscores the need to accelerate the transition to dolutegravir-based first-line ART. The low PDR prevalence of tenofovir and emtricitabine is reassuring as these ARVs are part of the World Health Organization (WHO)-recommended oral pre-exposure prophylaxis regimen. The high proportion of individuals initiating ART at a late disease stage highlights the need to improve treatment linkage strategies and implement WHO rapid ART initiation recommendations.

Community-Based HIV Testing for Urban Youth in Western Kenya.

Youth aged 15-24 years comprise 48% of new HIV infections and 15% of persons living with HIV in Kisumu County, Kenya. We assessed factors associated with HIV infection among youth participating in the Community Health Initiative (CHI) implemented in an urban informal settlement in 2018. Predictors of HIV infection were assessed by multivariable logistic regression. CHI engaged 4,441 youth through community health campaigns and home-based HIV testing. HIV prevalence was 3.5% overall and 7.1% among young women aged 20-24. There were 24 youth newly identified as HIV-positive out of 157 total HIV-positive youth. HIV-positive status was positively associated with being female (aOR = 2.46; 95% CI 1.57, 3.84) and aged 20-24 (aOR = 2.40; 95% CI 1.52, 3.79), and inversely associated with secondary school education or higher (aOR = 0.27; 95% CI 0.16, 0.44). Our findings highlight the need for HIV prevention programs specially tailored for youth to further reduce new HIV infections in this priority population.

Quality of Service Aware Orchestration for Cloud-Edge Continuum Applications.

The fast growth in the amount of connected devices with computing capabilities in the past years has enabled the emergence of a new computing layer at the Edge. Despite being resource-constrained if compared with cloud servers, they offer lower latencies than those achievable by Cloud computing. The combination of both Cloud and Edge computing paradigms can provide a suitable infrastructure for complex applications' quality of service requirements that cannot easily be achieved with either of these paradigms alone. These requirements can be very different for each application, from achieving time sensitivity or assuring data privacy to storing and processing large amounts of data. Therefore, orchestrating these applications in the Cloud-Edge computing raises new challenges that need to be solved in order to fully take advantage of this layered infrastructure. This paper proposes an architecture that enables the dynamic orchestration of applications in the Cloud-Edge continuum. It focuses on the application's quality of service by providing the scheduler with input that is commonly used by modern scheduling algorithms. The architecture uses a distributed scheduling approach that can be customized in a per-application basis, which ensures that it can scale properly even in setups with high number of nodes and complex scheduling algorithms. This architecture has been implemented on top of Kubernetes and evaluated in order to asses its viability to enable more complex scheduling algorithms that take into account the quality of service of applications.

The association between dengue viremia kinetics and dengue severity: A systemic review and meta-analysis.

In this study, we aim to assess the association of dengue viremia with dengue severity. The study protocol was developed and registered in PROSPERO (CRD42016039864). We searched nine databases to find potential papers. Studies meeting the inclusion criteria were included. We, based our analysis on three outcomes which are disease severity, dengue serotype and disease infection type. Thirty studies with 3316 patients were included. Our analysis revealed that viremia is significantly higher in dengue hemorrhagic fever patients than dengue fever in days 5 to 6. Regarding the serotype of dengue, the maximum viremia titre of serotype 1 was significantly higher than serotype 3 and the viremia in dengue serotype 2 was significantly higher than serotype 4 in days 2 to 4. However, comparison of the daily viremia level between the primary and secondary dengue infection revealed that secondary infection was significantly higher than the primary infection on seventh day and on the eighth day. Viremia is strongly associated with disease severity and type of infection which gave viremia a high indicative power to be used as a clinical predictor. Dengue serotype is also associated with viral load with higher viremia in DENV-2/1.

CD27 Promotes CD4+ Effector T Cell Survival in Response to Tissue Self-Antigen.

Signaling through CD27 plays a role in T cell activation and memory. However, it is currently unknown how this costimulatory receptor influences CD4+ effector T (Teff) cells in inflamed tissues. In the current study, we used a murine model of inducible self-antigen expression in the epidermis to elucidate the functional role of CD27 on autoreactive Teff cells. Expression of CD27 on Ag-specific Teff cells resulted in enhanced skin inflammation when compared with CD27-deficient Teff cells. CD27 signaling promoted the accumulation of IFN-γ and IL-2-producing T cells in skin draining lymph nodes in a cell-intrinsic fashion. Surprisingly, this costimulatory pathway had minimal effect on early T cell activation and proliferation. Instead, signaling through CD27 resulted in the progressive survival of Teff cells during the autoimmune response. Using BH3 profiling to assess mitochondrial cell priming, we found that CD27-deficient cells were equally as sensitive as CD27-sufficient cells to mitochondrial outer membrane polarization upon exposure to either BH3 activator or sensitizer peptides. In contrast, CD27-deficient Teff cells expressed higher levels of active caspase 8. Taken together, these results suggest that CD27 does not promote Teff cell survival by increasing expression of antiapoptotic BCL2 family members but instead acts by preferentially suppressing the cell-extrinsic apoptosis pathway, highlighting a previously unidentified role for CD27 in augmenting autoreactive Teff cell responses.

"We Don't Fear HIV. We Just Fear Walking around Pregnant.": A Qualitative Analysis of Adolescent Sexuality and Pregnancy Stigma in Informal Settlements in Kisumu, Kenya.

In Kenya, adolescent pregnancy rates are high, contraception utilization is low, and adolescent sexuality is stigmatized. We describe how perceptions of sexuality and pregnancy stigma influence decision-making among adolescents in the informal settlements of Kisumu. We used purposive sampling to recruit 120 adolescent boys and girls aged 15-19 for focus group discussions. A semistructured interview guide was used to elicit social norms and community attitudes about sexual and reproductive health. We analyzed the data using the Framework Approach. The social stigma of adolescent sexuality and the related fear of pregnancy as an unambiguous marker of sexual activity emerged as main themes. This stigma led adolescents to fear social retribution but did not lead to more frequent contraception use due to additional stigma. The intensity of this fear was most acutely expressed by girls, leading some to seek unsafe, sometimes fatal, abortions, and to contemplate suicide. Fear of pregnancy outweighed fear of contracting HIV that was viewed as both treatable and less stigmatized. Our findings illustrate how fear of pregnancy among these adolescents is driven primarily by fears that their community will discover that they are sexually active. Interventions are urgently needed to address adolescent sexual stigma and to prevent negative outcomes.

The role of drug resistance in poor viral suppression in rural South Africa: findings from a population-based study.

BACKGROUND: Understanding factors driving virological failure, including the contribution of HIV drug resistance mutations (DRM), is critical to ensuring HIV treatment remains effective. We examine the contribution of drug resistance mutations for low viral suppression in HIV-positive participants in a population-based sero-prevalence survey in rural South Africa. METHODS: We conducted HIV drug resistance genotyping and ART analyte testing on dried blood spots (DBS) from HIV-positive adults participating in a 2014 survey in North West Province. Among those with virologic failure (> 5000 copies/mL), we describe frequency of DRM to protease inhibitors (PI), nucleoside reverse transcriptase inhibitors (NRTI), and non-nucleoside reverse transcriptase inhibitors (NNRTI), report association of resistance with antiretroviral therapy (ART) status, and assess resistance to first and second line therapy. Analyses are weighted to account for sampling design. RESULTS: Overall 170 DBS samples were assayed for viral load and ART analytes; 78.4% of men and 50.0% of women had evidence of virologic failure and were assessed for drug resistance, with successful sequencing of 76/107 samples. We found ≥1 DRM in 22% of participants; 47% were from samples with detectable analyte (efavirenz, nevirapine or lopinavir). Of those with DRM and detectable analyte, 60% showed high-level resistance and reduced predicted virologic response to ≥1 NRTI/NNRTI typically used in first and second-line regimens. CONCLUSIONS: DRM and predicted reduced susceptibility to first and second-line regimens were common among adults with ART exposure in a rural South African population-based sample. Results underscore the importance of ongoing virologic monitoring, regimen optimization and adherence counseling to optimize durable virologic suppression.

Skin-Resident T Cells Drive Dermal Dendritic Cell Migration in Response to Tissue Self-Antigen.

Migratory dendritic cell (DC) subsets deliver tissue Ags to draining lymph nodes (DLNs) to either initiate or inhibit T cell-mediated immune responses. The signals mediating DC migration in response to tissue self-antigen are largely unknown. Using a mouse model of inducible skin-specific self-antigen expression, we demonstrate that CD103+ dermal DCs (DDCs) rapidly migrate from skin to skin DLN (SDLNs) within the first 48 h after Ag expression. This window of time was characterized by the preferential activation of tissue-resident Ag-specific effector T cells (Teffs), with no concurrent activation of Ag-specific Teffs in SDLNs. Using genetic deletion and adoptive transfer approaches, we show that activation of skin-resident Teffs is required to drive CD103+ DDC migration in response to tissue self-antigen and this Batf3-dependent DC population is necessary to mount a fulminant autoimmune response in skin. Conversely, activation of Ag-specific Teffs in SDLNs played no role in DDC migration. Our studies reveal a crucial role for skin-resident T cell-derived signals, originating at the site of self-antigen expression, to drive DDC migration during the elicitation phase of an autoimmune response.

Promoting 'Equitable Access' to PrEP in Australia: Taking Account of Stakeholder Perspectives.

As evidence of the safety and effectiveness of HIV pre-exposure prophylaxis (PrEP) has grown, so has attention to the views of prospective users and providers. However, far less attention has been paid to understanding the perspectives of other stakeholders in the rollout of PrEP access programs. We conducted 21 semi-structured qualitative interviews in 2017 with key stakeholders working across the policy, advocacy, research and/or clinical dimensions of the Australian HIV response, before federal support for a subsidised access scheme was achieved. Our analysis explored three areas of shared concern: who is a suitable candidate for PrEP; why are disparities in PrEP access important; and how can disparities be addressed? In examining how this diverse group of professionals grappled with the challenges of promoting 'equitable access' to PrEP in an increasingly resource rationed health system, we can see how the principles believed to underpin the Australian response to HIV were both reaffirmed and challenged through this period of significant change.

The Use of Social Media in Pediatric Urology-Forging New Paths or Crossing Boundaries?

PURPOSE OF REVIEW: There has been a remarkable change in how people connect, access, and share professional and medical information over social media. This perspective article describes opportunities, potential pitfalls, and guidelines for social media use by pediatric urology providers. RECENT FINDINGS: Pediatric urologists have effectively used social media to connect and share expertise, augment scientific conference participation, promote themselves and their research, disseminate guidelines and best practices, participate in virtual journal clubs, and engage with patients and their families. Information shared over social media is not protected by copyright law, not confidential, not regulated, permanent, and subjected to public domain and scrutiny. Despite these potential pitfalls, social media is a useful tool if best practices are observed and online communication adheres to professional guidelines and organizational policy. Social media use in healthcare is here to stay and pediatric urologists have online visibility whether or not they choose to actively participate. Despite new legal, ethical, and professional considerations that social media introduces, a well-executed social media presence provides pediatric urologists a wealth of new opportunities for networking, research, and disseminating high-quality medical information online.

HIV pre-exposure prophylaxis and the 'problems' of reduced condom use and sexually transmitted infections in Australia: a critical analysis from an evidence-making intervention perspective.

HIV pre-exposure prophylaxis (PrEP) has been embraced in Australia, making PrEP available with public funding to people at risk of HIV. Here, we consider the associated 'problems' of reduced condom use and sexually transmissible infections (STIs), as seen by HIV professionals. Twenty-one interviews were conducted during May-August 2017. All agreed that PrEP was a valuable addition to HIV prevention, but their views about reduced condom use and STIs were variable. Using poststructural policy analysis, three main stances were identified: (1) Concerned/alarmed. PrEP was seen as causing reduced condom use, STIs and antibiotic resistance, posing threats to the general population; (2) Neutral/normalising. Stakeholders emphasised that condom use was declining and STIs increasing independently of PrEP, and that PrEP was simply a new tool to be accommodated; (3) Optimistic/critical. PrEP was seen as diminishing fear of HIV and engaging users in more frequent testing and treatment that could lead to declining STI rates. What linked all three stances was the selective performance of evidence, deploying a mixture of personal experience, clinical observations, behavioural data and epidemiology. Anticipating possible futures through evidence-making suggested practical, political and moral consequences for what PrEP could become. We encourage others to consider these consequences with care.

Therapeutic efficacy and safety of chamomile for state anxiety, generalized anxiety disorder, insomnia, and sleep quality: A systematic review and meta-analysis of randomized trials and quasi-randomized trials.

This systematic review and meta-analysis aimed to study the efficacy and safety of chamomile for the treatment of state anxiety, generalized anxiety disorders (GADs), sleep quality, and insomnia in human. Eleven databases including PubMed, Science Direct, Cochrane Central, and Scopus were searched to retrieve relevant randomized control trials (RCTs), and 12 RCTs were included. Random effect meta-analysis was performed by meta package of R statistical software version 3.4.3 and RevMan version 5.3. Our meta-analysis of three RCTs did not show any difference in case of anxiety (standardized mean difference = -0.15, 95% CI [-0.46, 0.16], P = 0.4214). Moreover, there is only one RCT that evaluated the effect of chamomile on insomnia and it found no significant change in insomnia severity index (P > 0.05). By using HAM-A scale, there was a significant improvement in GAD after 2 and 4 weeks of treatment (mean difference = -1.43, 95% CI [-2.47, -0.39], P = 0.007), (MD = -1.79, 95% CI [-3.14, -0.43], P = 0.0097), respectively. Noteworthy, our meta-analysis showed a significant improvement in sleep quality after chamomile administration (standardized mean difference = -0.73, 95% CI [-1.23, -0.23], P < 0.005). Mild adverse events were only reported by three RCTs. Chamomile appears to be efficacious and safe for sleep quality and GAD. Little evidence is there to show its effect on anxiety and insomnia. Larger RCTs are needed to ascertain these findings.

Hepatitis B Vaccination and Infection Prevalence Among Men Who Have Sex With Men Who Travel Internationally.

Among men who have sex with men traveling internationally, self-reported hepatitis B virus (HBV) vaccination prevalence was 77% and less prevalent among older men and those with HBV infection. The HBV infection prevalence was 25% and was associated with older age and HIV infection. Testing for chronic infection, universal vaccination, and treatment for populations with multiple risks is needed.