Promoting Healthy Adolescent Romantic Relationships: Results of a Multisite, Two-group Parallel Randomized Clinical Trial.

PURPOSE: To examine the impact of About Us, an innovative healthy relationships intervention that promotes positive adolescent romantic relationships and the use of effective contraceptives, on improving behavior, attitudes, and intentions related to sexual intercourse, relationship communication, and conflict resolution at 3- and 9-month follow-up, compared to services as usual. METHODS: This was a multi-site, two-group, parallel, randomized-controlled trial with an intervention/comparison allocation ratio of 3:2 conducted at seven high schools in California between February 2018 and May 2021. RESULTS: Overall, our study did not find statistically significant evidence of improved behavior, attitudes, and intentions related to sexual intercourse, relationship communication, and conflict resolution among participants (14-18 years old) randomized to the intervention group (n = 316) compared to services as usual (n = 217) during follow-up (group x time; p > .05). Exploratory within group analyses showed that, compared to baseline, at the 3-month follow-up, the prevalence of reporting having had sex increased in the control group relative to intervention group (+19% vs. +9%, p < .01). Our sub-group analyses showed that changes in condom use intentions scores differed across school sites (group x time x school; p < .01); mixed (positive and negative) trends were observed for intervention effect, and schools with positive intervention effect trends tended to have greater program participation. DISCUSSION: About Us did not show statistically significant positive impacts on primary or secondary outcomes as anticipated. Our exploratory findings show evidence of some promising trends of intervention effects at the school-level, suggesting a need for better tailored intervention components and/or delivery to address the unique environmental contexts of participants. Overall, the context of study implementation was negatively affected by the COVID-19 pandemic and challenges related to using a non-classroom delivery intervention approach. Combined, these factors may have contributed to the study null findings. Moreover, it is difficult to know (or determine) the intervention's impact under more ideal conditions (i.e., no COVID pandemic).

Client and staff perceptions of acceptability of MyCheck: a direct-to-pathology telehealth and e-testing service for comprehensive bloodborne virus and sexually transmissible infection screening.

Background Sydney Sexual Health Centre (SSHC) is the largest sexual health clinic in New South Wales (NSW), servicing clients at high risk of sexually transmissible infections and bloodborne viruses. SSHC piloted a direct-to-pathology pathway that facilitated bloodborne virus/sexually transmissible infection testing at one of the ~500 participating pathology collection centres located across NSW. This qualitative study sought to understand SSHC client and provider perspectives of acceptability of the MyCheck intervention. Methods Semi-structured in-depth interviews were conducted with 11 clients who underwent testing via the MyCheck pathway and eight staff members involved in implementing MyCheck. The seven components of Sekhon's Theoretical Framework of Acceptability informed this analysis. Results Participants broadly conveyed 'affective attitude' toward the MyCheck pathway. The telehealth intervention reduced client 'burden' and 'opportunity cost' through enabling greater testing convenience at a location suitable to them and provided timely results. Issues of 'ethicality' were raised by clients and staff as pathology centre staff were, on a few occasions, regarded as being judgmental of SSHC clients. 'Intervention coherence' issues were largely attributed to pathology centre personnel being unfamiliar with the intervention, with billing issues being a recurrent concern. Participants perceived MyCheck as an 'effective' testing pathway. SSHC staff were able to offer the intervention with ease through seamless IT integration ('self-efficacy'). Conclusion The MyCheck intervention was perceived by both SSHC clients and staff as an acceptable bloodborne virus/sexually transmissible infection testing pathway. However, further work is required to address stigma experienced by some clients when attending pathology collection centres.

A theory-based assessment of mpox: Findings from a nationally representative survey of U.S. adults.

The purpose of this research was to examine individual differences related to fear of, perceived susceptibility to, and perceived severity of mpox as well as mpox knowledge, fear, perceived susceptibility, and perceived severity as predictors of vaccine intention in a national survey of U.S. adults (aged ≥18 years). Address-based sampling (ABS) methods were used to ensure full coverage of all households in the nation, reflecting the 2021 March Supplement of the Current Population Survey. Internet-based surveys were self-administered by Ipsos between September 16-26, 2022. N = 1018 participants completed the survey. The survey included items, based partially on the Health Belief Model, assessing vaccine intention (1 item; responses from 1 [Definitely not] to 5 [Definitely]), fear of mpox (7-item scale; α = .89; theoretical mean = 7-35), perceived susceptibility to mpox (3-item scale; α = .85; theoretical mean = 3-15), and perceived severity of mpox (4-item scale; α = .65; theoretical mean = 4-20). Higher scores indicate greater fear, susceptibility, and severity. One-way ANOVAs were run to examine mean score differences by demographic groups (e.g., gender, race/ethnicity, sexual orientation), and multiple regression analyses assessed the relationship between predictors (mpox knowledge, susceptibility/severity, fear) and a single outcome (vaccination intention), while controlling for demographic covariates. Sampling weights were applied to all analyses. Only 1.8% (n = 18) of respondents reported having received the mpox vaccine. While mpox vaccine intention was low (M = 2.09, SD = 0.99), overall differences between racial/ethnic, sexual orientation, education, and household income groups were statistically significant. Fear of mpox was very low (M = 13.13, SD = 5.33), and there were overall statistically significant differences in both fear and perceived severity among gender, race/ethnicity, sexual orientation, education, and household income groups. While respondents reported not feeling very susceptible to mpox (M = 5.77, SD = 2.50), they generally rated mpox as just above the theoretical mean in terms of severity (M = 11.01, SD = 2.85). Mpox knowledge, fear, severity, and susceptibility, as well as race/ethnicity, were all statistically significant predictors of intention to vaccinate, with susceptibility representing the strongest predictor. Overall, Americans' vaccination for mpox/vaccine intent was low. Gay/lesbian and racial/ethnic minority respondents felt more susceptible to and viewed mpox more severely, compared with heterosexual and White respondents, respectively. These data may be used to tailor risk and prevention (e.g., vaccination) interventions, as cases continue to surge in the current global mpox outbreak. Greater perceptions of susceptibility, severity, and fear about mpox exist largely among minority populations. While public health messaging to promote mpox vaccination can focus on improving knowledge, as well as addressing fear and perceived severity of, and susceptibility to, mpox, such messages should be carefully crafted to prevent disproportionate negative effects on marginalized communities.

Mpox knowledge in the U.S.: Results from a nationally representative survey.

Development and testing of a scale assessing mpox knowledge in a national survey of U.S. adults (aged ≥18 years) was conducted. Address-based sampling methods ensured full coverage of all households. Between September 16-22, 2022, N = 1018 participants self-administered the Internet-based survey that included a 15-item knowledge scale. Responses "yes," "no," and "I do not know," were scored as correct= 1, incorrect= -1, and "I do not know"= 0. Knowledge was dichotomized into good/poor based on modified Bloom's cutoff points (i.e. correctly answering at least 9 of the 15 total questions=good knowledge). We assessed psychometric characteristics and chi-square/one-way ANOVAs examining differences by demographic groups, applying sampling weights to analyses. Score reliability was strong (α = .82). All items but one ("Diarrhea is one of the symptoms of monkeypox") had statistically significant point biserial correlations, indicating a correlation between a correctly answered item and higher knowledge score. Only 35% of respondents were categorized as having good knowledge. Differences in knowledge by racial/ethnic, education, household income, sexual orientation, and MSA status groups were statistically significant. Mpox knowledge was lowest among heterosexually identified, rural, and low education/income respondents. Findings may be used in mpox prevention interventions, as the scale shows promise for assessing mpox knowledge in other groups/settings.

Reverse-Transcription Loop-Mediated Isothermal Amplification Has High Accuracy for Detecting Severe Acute Respiratory Syndrome Coronavirus 2 in Saliva and Nasopharyngeal/Oropharyngeal Swabs from Asymptomatic and Symptomatic Individuals.

Previous studies have described reverse-transcription loop-mediated isothermal amplification (RT-LAMP) for the rapid detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal/oropharyngeal swab and saliva samples. This multisite clinical evaluation describes the validation of an improved sample preparation method for extraction-free RT-LAMP and reports clinical performance of four RT-LAMP assay formats for SARS-CoV-2 detection. Direct RT-LAMP was performed on 559 swabs and 86,760 saliva samples and RNA RT-LAMP on extracted RNA from 12,619 swabs and 12,521 saliva samples from asymptomatic and symptomatic individuals across health care and community settings. For direct RT-LAMP, overall diagnostic sensitivity (DSe) was 70.35% (95% CI, 63.48%-76.60%) on swabs and 84.62% (95% CI, 79.50%-88.88%) on saliva, with diagnostic specificity of 100% (95% CI, 98.98%-100.00%) on swabs and 100% (95% CI, 99.72%-100.00%) on saliva, compared with quantitative RT-PCR (RT-qPCR); analyzing samples with RT-qPCR ORF1ab CT values of ≤25 and ≤33, DSe values were 100% (95% CI, 96.34%-100%) and 77.78% (95% CI, 70.99%-83.62%) for swabs, and 99.01% (95% CI, 94.61%-99.97%) and 87.61% (95% CI, 82.69%-91.54%) for saliva, respectively. For RNA RT-LAMP, overall DSe and diagnostic specificity were 96.06% (95% CI, 92.88%-98.12%) and 99.99% (95% CI, 99.95%-100%) for swabs, and 80.65% (95% CI, 73.54%-86.54%) and 99.99% (95% CI, 99.95%-100%) for saliva, respectively. These findings demonstrate that RT-LAMP is applicable to a variety of use cases, including frequent, interval-based direct RT-LAMP of saliva from asymptomatic individuals who may otherwise be missed using symptomatic testing alone.

Skin Cancer Narratives on Instagram: Content Analysis.

Background: Skin cancer is among the deadliest forms of cancer in the United States. The American Cancer Society reported that 3 million skin cancer cases could be avoided every year if individuals are more aware of the risk factors related to sun exposure and prevention. Social media platforms may serve as potential intervention modalities that can be used to raise public awareness of several diseases and health conditions, including skin cancer. Social media platforms are efficient, cost-effective tools for health-related content that can reach a broad number of individuals who are already using these spaces in their day-to-day personal lives. Instagram was launched in 2010, and it is now used by 1 billion users, of which 90% are under the age of 35 years. Despite previous research highlighting the potential of image-based platforms in skin cancer prevention and leveraging Instagram's popularity among the priority population to raise awareness, there is still a lack of studies describing skin cancer-related content on Instagram. Objective: This study aims to describe skin cancer-related content on Instagram, including the type of account; the characteristics of the content, such as the kind of media used; and the type of skin cancer discussed. This study also seeks to reveal content themes in terms of skin cancer risks, treatment, and prevention. Methods: Through CrowdTangle, a Facebook-owned tool, we retrieved content from publicly available accounts on Instagram for the 30 days preceding May 14, 2021. Out of 2932 posts, we randomly selected 1000 posts for review. Of the 1000 posts, 592 (59.2%) met the following inclusion criteria: (1) content was focused on human skin cancer, (2) written in English language only, and (3) originated from the United States. Guided by previous research and through an iterative process, 2 undergraduate students independently coded the remaining posts. The 2 coders and a moderator met several times to refine the codebook. Results: Of the 592 posts, profiles representing organizations (n=321, 54.2%) were slightly more common than individual accounts (n=256, 43.2%). The type of media included in the posts varied, with posts containing photos occurring more frequently (n=315, 53.2%) than posts containing infographics (n=233, 39.4%) or videos (n=85, 14.4%). Melanoma was the most mentioned type of skin cancer (n=252, 42.6%). Prevention methods (n=404, 68.2%) were discussed in Instagram posts more often than risk factors (n=271, 45.8%). Only 81 out of 592 (13.7%) posts provided a citation. Conclusions: This study's findings highlight the potential role of Instagram as a platform for improving awareness of skin cancer risks and the benefits of prevention practices. We believe that social media is the most promising venue for researchers and dermatologists to dedicate their efforts and presence that can widely reach the public to educate about skin cancer and empower prevention.

C-reactive protein-guided use of procalcitonin in COVID-19.

BACKGROUND: A low procalcitonin (PCT) concentration facilitates exclusion of bacterial co-infections in COVID-19, but high costs associated with PCT measurements preclude universal adoption. Changes in inflammatory markers, including C-reactive protein (CRP), can be concordant, and predicting low PCT concentrations may avoid costs of redundant tests and support more cost-effective deployment of this diagnostic biomarker. OBJECTIVES: To explore whether, in COVID-19, low PCT values could be predicted by the presence of low CRP concentrations. METHODS: Unselected cohort of 224 COVID-19 patients admitted to hospital that underwent daily PCT and CRP measurements as standard care. Both 0.25 ng/mL and 0.5 ng/mL were used as cut-offs for positive PCT test results. Geometric mean was used to define high and low CRP values at each timepoint assessed. RESULTS: Admission PCT was <0.25 ng/mL in 160/224 (71.4%), 0.25-0.5 ng/mL in 27 (12.0%) and >0.5 ng/mL in 37 (16.5%). Elevated PCT was associated with increased risk of death (P = 0.0004) and was more commonly associated with microbiological evidence of bacterial co-infection (P < 0.0001). For high CRP values, significant heterogeneity in PCT measurements was observed, with maximal positive predictive value of 50% even for a PCT cut-off of 0.25 ng/mL. In contrast, low CRP was strongly predictive of low PCT concentrations, particularly <0.5 ng/mL, with a negative predictive value of 97.6% at time of hospital admission and 100% 48 hours into hospital stay. CONCLUSIONS: CRP-guided PCT testing algorithms can reduce unnecessary PCT measurement and costs, supporting antimicrobial stewardship strategies in COVID-19.

Infection prevention and surgery in the pandemic era.

The COVID-19 pandemic has had a significant impact on surgical specialties. COVID-19 carries a significant risk to the surgical patient and the healthcare workers looking after them, with an increased incidence of pulmonary complications and mortality in patients who test positive perioperatively. Appropriate infection prevention and control measures are critical to ensure appropriate care is given and to reduce the risk of onward transmission. This article will discuss the measures that have been instigated and contributed to infection control in surgery, such as testing, patient isolation, personal protective equipment and ventilation. The COVID-19 pandemic has led to healthcare workers across many specialities working together to provide essential clinical care. This collaborative approach is critical to maintain excellent infection prevention and control practices required during this pandemic, which protect patients and preserve surgical services.

Promoting Adolescent Healthy Relationships (The About Us Program): Protocol for a Randomized Clinical Trial.

BACKGROUND: Romantic relationships play a critical role in adolescent development, and by middle adolescence, most young people have been involved in at least one romantic relationship, a context in which most sexual interactions occur. Research suggests adolescents lack positive models and skills related to building healthy relationships. OBJECTIVE: This project aims to test the impact of an innovative healthy relationships intervention, called About Us, implemented in school-based health centers (SBHCs) in California in a randomized controlled trial. METHODS: About Us is being tested using a 7-site, 2-group, parallel randomized controlled trial with a treatment versus control allocation ratio of 3:2 to assess the impact of the intervention relative to the standard of care among adolescents aged 14 to 18 years. Adolescents with active parental consent provide study assent at each of the 3 survey time points: baseline, 3 months postintervention, and 9 months postintervention. A stratified randomization procedure was used to ensure balance in key covariates and screening criteria across intervention groups. Through benchmark intent-to-treat analyses, we will examine the primary outcome of this study-the impact of About Us relative to the standard of care 9 months following the end of the intervention on the prevalence of vaginal or anal sex without condoms in the past 3 months. The secondary outcomes are four-fold: what is the impact of About Us relative to the standard of care 3 and 9 months following the end of the intervention, on (1) the prevalence of abstinence from vaginal or anal sex in the past 3 months, (2) composite scores of relationship communication and positive conflict resolution among participants involved in a relationship at baseline, (3) the prevalence of SBHC service use or information receipt in the past 3 months, and (4) composite scores of condom use intentions and attitudes regarding condoms and other birth control? Additionally, as part of our sensitivity analyses, two additional analyses will be implemented: modified intent-to-treat and complete case analysis. RESULTS: This project (ClinicalTrials.gov #NCT03736876) was funded in 2016 through the Family Youth Services Bureau as part of the Personal Responsibility Education Innovative Strategies program. Baseline data collection took place between February 2018 and March 2020, yielding a total of 5 cohorts and 533 study participants: 316 assigned to treatment and 217 assigned to control. Ongoing follow-up data collection continued through May 2021. CONCLUSIONS: About Us draws on developmental science to create a contextually and developmentally relevant program that addresses motivation and emotional influences in sexual decision-making. The intervention was designed for implementation within SBHCs, an understudied venue for relationship and sexual health promotion interventions. Unfortunately, COVID-19 pandemic restrictions led to school closures, interrupting ongoing programming, and in-person follow-up data collection, which has affected study attrition. TRIAL REGISTRATION: ClinicalTrials.gov NCT03736876; https://clinicaltrials.gov/ct2/show/NCT03736876. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30499.

Pre-exposure Prophylaxis (PrEP) Information on Instagram: Content Analysis.

BACKGROUND: There is still an HIV epidemic in the United States, which is a substantial issue for populations bearing a disproportionate burden of HIV infections. Daily oral pre-exposure prophylaxis (PrEP) has proven to be safe and effective in reducing HIV acquisition risk. However, studies document that PrEP awareness/usage is low. There is also limited understanding of social media platforms, such as Instagram, as PrEP information sources. OBJECTIVE: Given the paucity of research on PrEP-related Instagram posts and popularity of this social media platform, the purpose of this research is to describe the source characteristics, image types, and textual contents of PrEP-related posts on Instagram. METHODS: Using Crowdtangle Search, a public insights tool owned/operated by Facebook, we retrieved publicly accessible and English-language-only Instagram posts for the 12-month period preceding April 22, 2020, using the following terms: Truvada or "pre-exposure prophylaxis" or #truvada or #truvadaprep or #truvadawhore or #truvadaforprep. We employed a qualitative coding methodology to manually extract information from posts. Using a pretested codebook, we performed content analysis on 250 posts, examining message and source characteristics (ie, organization type [eg, government, news] and individual type [eg, physician]), including information about PrEP (eg, how it works, cost), and indicated users. Frequencies and percentages were calculated for all categorical variables. A Chi-square test was conducted to determine differences between source types on a variety of message characteristics. RESULTS: Three-quarters of the posts (193/250, 77.2%) were posted by organizations. Of the 250 posts reviewed, approximately two-thirds (174/250, 69.6%) included a photograph, more than half (142/250, 56.8%) included an infographic, and approximately one-tenth (30/250, 12%) included a video. More than half defined PrEP (137/250, 54.8%), but fewer posts promoted PrEP use, explained how PrEP works, and included information on the effectiveness of PrEP or who can use it. The most commonly hashtagged populations among posts were men who have sex with men (MSM), but not necessarily bisexual men. Few posts contained race-/ethnicity-related hashtags (11/250, 4.4%). Fewer posts contained transgender-associated tags (eg, #transgirl; 5/250, 2%). No posts contained tags related to heterosexuals or injection drug users. We found statistical differences between source types (ie, individual versus organization). Specifically, posts from organizations more frequently contained information about who can use PrEP, whereas posts from individuals more frequently contained information describing adverse effects. CONCLUSIONS: This study is among the first to review Instagram for PrEP-related content, and it answers the National AIDS Strategy's call for a clearer articulation of the science surrounding HIV risk/prevention through better understanding of the current public information environment. This study offers a snapshot of how PrEP is being discussed (and by whom) on one of the most popular social media platforms and provides a foundation for developing and implementing PrEP promotion interventions on Instagram.

Preliminary optimisation of a simplified sample preparation method to permit direct detection of SARS-CoV-2 within saliva samples using reverse-transcription loop-mediated isothermal amplification (RT-LAMP).

We describe the optimisation of a simplified sample preparation method which permits rapid and direct detection of SARS-CoV-2 RNA within saliva, using reverse-transcription loop-mediated isothermal amplification (RT-LAMP). Treatment of saliva samples prior to RT-LAMP by dilution 1:1 in Mucolyse™, followed by dilution in 10 % (w/v) Chelex© 100 Resin and a 98 °C heat step for 2 min enabled detection of SARS-CoV-2 RNA in positive saliva samples. Using RT-LAMP, SARS-CoV-2 RNA was detected in as little as 05:43 min, with no amplification detected in 3097 real-time reverse transcription PCR (rRT-PCR) negative saliva samples from staff tested within a service evaluation study, or for other respiratory pathogens tested (n = 22). Saliva samples can be collected non-invasively, without the need for skilled staff and can be obtained from both healthcare and home settings. Critically, this approach overcomes the requirement for, and validation of, different swabs and the global bottleneck in obtaining access to extraction robots and reagents to enable molecular testing by rRT-PCR. Such testing opens the possibility of public health approaches for effective intervention during the COVID-19 pandemic through regular SARS-CoV-2 testing at a population scale, combined with isolation and contact tracing.

A highly effective reverse-transcription loop-mediated isothermal amplification (RT-LAMP) assay for the rapid detection of SARS-CoV-2 infection.

The COVID-19 pandemic has illustrated the importance of simple, rapid and accurate diagnostic testing. This study describes the validation of a new rapid SARS-CoV-2 RT-LAMP assay for use on extracted RNA or directly from swab offering an alternative diagnostic pathway that does not rely on traditional reagents that are often in short supply during a pandemic. Analytical specificity (ASp) of this new RT-LAMP assay was 100% and analytical sensitivity (ASe) was between 1 × 101 and 1 × 102 copies per reaction when using a synthetic DNA target. The overall diagnostic sensitivity (DSe) and specificity (DSp) of RNA RT-LAMP was 97% and 99% respectively, relative to the standard of care rRT-PCR. When a CT cut-off of 33 was employed, above which increasingly evidence suggests there is a low risk of patients shedding infectious virus, the diagnostic sensitivity was 100%. The DSe and DSp of Direct RT-LAMP (that does not require RNA extraction) was 67% and 97%, respectively. When setting CT cut-offs of ≤33 and ≤25, the DSe increased to 75% and 100%, respectively, time from swab-to-result, CT < 25, was < 15 min. We propose that RNA RT-LAMP could replace rRT-PCR where there is a need for increased sample throughput and Direct RT-LAMP as a near-patient screening tool to rapidly identify highly contagious individuals within emergency departments and care homes during times of increased disease prevalence ensuring negative results still get laboratory confirmation.

Evaluating Smart Assistant Responses for Accuracy and Misinformation Regarding Human Papillomavirus Vaccination: Content Analysis Study.

BACKGROUND: Almost half (46%) of Americans have used a smart assistant of some kind (eg, Apple Siri), and 25% have used a stand-alone smart assistant (eg, Amazon Echo). This positions smart assistants as potentially useful modalities for retrieving health-related information; however, the accuracy of smart assistant responses lacks rigorous evaluation. OBJECTIVE: This study aimed to evaluate the levels of accuracy, misinformation, and sentiment in smart assistant responses to human papillomavirus (HPV) vaccination-related questions. METHODS: We systematically examined responses to questions about the HPV vaccine from the following four most popular smart assistants: Apple Siri, Google Assistant, Amazon Alexa, and Microsoft Cortana. One team member posed 10 questions to each smart assistant and recorded all queries and responses. Two raters independently coded all responses (κ=0.85). We then assessed differences among the smart assistants in terms of response accuracy, presence of misinformation, and sentiment regarding the HPV vaccine. RESULTS: A total of 103 responses were obtained from the 10 questions posed across the smart assistants. Google Assistant data were excluded owing to nonresponse. Over half (n=63, 61%) of the responses of the remaining three smart assistants were accurate. We found statistically significant differences across the smart assistants (N=103, χ22=7.807, P=.02), with Cortana yielding the greatest proportion of misinformation. Siri yielded the greatest proportion of accurate responses (n=26, 72%), whereas Cortana yielded the lowest proportion of accurate responses (n=33, 54%). Most response sentiments across smart assistants were positive (n=65, 64%) or neutral (n=18, 18%), but Cortana's responses yielded the largest proportion of negative sentiment (n=7, 12%). CONCLUSIONS: Smart assistants appear to be average-quality sources for HPV vaccination information, with Alexa responding most reliably. Cortana returned the largest proportion of inaccurate responses, the most misinformation, and the greatest proportion of results with negative sentiments. More collaboration between technology companies and public health entities is necessary to improve the retrieval of accurate health information via smart assistants.

Characteristics of clients newly diagnosed with HIV in central Sydney in 2016-17: a retrospective audit comparing a community-based testing site and a clinical sexual health service.

In New South Wales (NSW), Australia, innovative community-based testing models have been implemented to increase HIV testing among populations at risk. The characteristics of patients newly diagnosed with HIV at a community-based testing site and at a traditional clinical service in Sydney, NSW, were compared. Compared with the clinical service, clients diagnosed at the community-based site were more likely to be diagnosed at their first visit and report no prior HIV test. A high proportion of clients at both sites had a preferred language other than English. Innovative HIV testing models are reaching under-tested populations, but could be further improved.

An automated, electronic, client-centred results delivery system saves time and improves workflow.

Background Traditional result notification methods, such as telephone calls, return visits and individualised emails or Short Message Service (SMS) texts, can be time consuming and may not align with client preference. We conducted a cross-sectional survey of our clients that showed that many clients prefer negative results by SMS or email, with the option to call or attend in person for positive results. Methods: We developed an innovative result-robot module in the electronic medical record that reads the electronic result and, using predefined algorithms, determines which SMS or email result template to send to the client. Results and Conclusion: Delivering automated negative results resulted in a 41% decrease in the number of clients calling for their results, demonstrating a significant efficiency gain.

Nurse-led pre-exposure prophylaxis: a non-traditional model to provide HIV prevention in a resource-constrained, pragmatic clinical trial.

There is little evidence and no standardised model for nurse-led HIV pre-exposure prophylaxis (PrEP). In 2016, public sexual health clinics in the state of New South Wales (NSW), Australia, participating in the population-scale PrEP access trial Expanded PrEP Implementation In Communities in New South Wales (EPIC-NSW) were authorised to adopt a nurse-led model of PrEP provision in order to facilitate the rapid expansion of PrEP access to more than 8000 participants in under 2 years without additional resources. The model has been implemented successfully in public clinics in 10 of 14 local health districts, with widespread support and no serious safety events reported. With the increasing importance of PrEP as an HIV prevention tool, non-traditional models of care, including nurse-led PrEP, are needed.

Routine molecular point-of-care testing for respiratory viruses in adults presenting to hospital with acute respiratory illness (ResPOC): a pragmatic, open-label, randomised controlled trial.

BACKGROUND: Respiratory virus infection is a common cause of hospitalisation in adults. Rapid point-of-care testing (POCT) for respiratory viruses might improve clinical care by reducing unnecessary antibiotic use, shortening length of hospital stay, improving influenza detection and treatment, and rationalising isolation facility use; however, insufficient evidence exists to support its use over standard clinical care. We aimed to assess the effect of routine POCT on a broad range of clinical outcomes including antibiotic use. METHODS: In this pragmatic, parallel-group, open-label, randomised controlled trial, we enrolled adults (aged ≥18 years) within 24 h of presenting to the emergency department or acute medical unit of a large UK hospital with acute respiratory illness or fever higher than 37·5°C (≤7 days duration), or both, over two winter seasons. Patients were randomly assigned (1:1), via an internet-based allocation sequence with random permuted blocks, to have a molecular POC test for respiratory viruses or routine clinical care. The primary outcome was the proportion of patients who received antibiotics while hospitalised (up to 30 days). Secondary outcomes included duration of antibiotics, proportion of patients receiving single doses or brief courses of antibiotics, length of stay, antiviral use, isolation facility use, and safety. Analysis was by modified intention to treat, excluding patients who declined intervention or were withdrawn for protocol violations. This study is registered with ISRCTN, number 90211642, and has been completed. FINDINGS: Between Jan 15, 2015, and April 30, 2015, and between Oct 1, 2015, and April 30, 2016, we enrolled 720 patients (362 assigned to POCT and 358 to routine care). Six patients withdrew or had protocol violations. 301 (84%) of 360 patients in the POCT group received antibiotics compared with 294 (83%) of 354 controls (difference 0·6%, 95% CI -4·9 to 6·0; p=0·84). Mean duration of antibiotics did not differ between groups (7·2 days [SD 5·1] in the POCT group vs 7·7 days [4·9] in the control group; difference -0·4, 95% CI -1·2 to 0·4; p=0·32). 50 (17%) of 301 patients treated with antibiotics in the POCT group received single doses or brief courses of antibiotics (<48 h) compared with 26 (9%) of 294 patients in the control group (difference 7·8%, 95% CI 2·5 to 13·1; p=0·0047; number needed to test=13). Mean length of stay was shorter in the POCT group (5·7 days [SD 6·3]) than in the control group (6·8 days [7·7]; difference -1·1, 95% CI -2·2 to -0·3; p=0·0443). Appropriate antiviral treatment of influenza-positive patients was more common in the POCT group (52 [91%] of 57 patients) than in the control group (24 [65%] of 37 patients; difference 26·4%, 95% CI 9·6 to 43·2; p=0·0026; number needed to test=4). We found no differences in adverse outcomes between the groups (77 [21%] of 360 patients in the POCT group vs 88 [25%] of 354 patients in the control group; -3·5%, -9·7 to 2·7; p=0·29). INTERPRETATION: Routine use of molecular POCT for respiratory viruses did not reduce the proportion of patients treated with antibiotics. However, the primary outcome measure failed to capture differences in antibiotic use because many patients were started on antibiotics before the results of POCT could be made available. Although POCT was not associated with a reduction in the duration of antibiotics overall, more patients in the POCT group received single doses or brief courses of antibiotics than did patients in the control group. POCT was also associated with a reduced length of stay and improved influenza detection and antiviral use, and appeared to be safe. FUNDING: University of Southampton.

Haemagglutinin and neuraminidase sequencing delineate nosocomial influenza outbreaks with accuracy equivalent to whole genome sequencing.

OBJECTIVES: We describe haemagglutinin (HA) and neuraminidase (NA) sequencing in an apparent cross-site influenza A(H1N1) outbreak in renal transplant and haemodialysis patients, confirmed with whole genome sequencing (WGS). METHODS: Isolates were sequenced from influenza positive individuals. Phylogenetic trees were constructed using HA and NA sequencing and subsequently WGS. Sequence data was analysed to determine genetic relatedness of viruses obtained from inpatient and outpatient cohorts and compared with epidemiological outbreak information. RESULTS: There were 6 patient cases of influenza in the inpatient renal ward cohort (associated with 3 deaths) and 9 patient cases in the outpatient haemodialysis unit cohort (no deaths). WGS confirmed clustered transmission of two genetically different influenza A(H1N1)pdm09 strains initially identified by analysis of HA and NA genes. WGS took longer, and in this case was not required to determine whether or not the two seemingly linked outbreaks were related. CONCLUSION: Rapid sequencing of HA and NA genes may be sufficient to aid early influenza outbreak investigation making it appealing for future outbreak investigation. However, as next generation sequencing becomes cheaper and more widely available and bioinformatics software is now freely accessible next generation whole genome analysis may increasingly become a valuable tool for real-time Influenza outbreak investigation.

Painful lymphadenopathy due to silicone breast implant rupture following extensive global air travel.

A 25-year-old Caucasian flight attendant with an extensive travel history presented with night sweats, fevers, weight loss and axillary and supraclavicular lymphadenopathy. Apart from surgical breast augmentation, she had no past medical or surgical history. She was anaemic, leucopenic and lymphopenic, and a broad infection screen was negative. Cross-sectional imaging revealed ipsilateral silicone breast implant rupture, with leaking of implant contents into the surrounding tissue. Histological examination of an axillary lymph node core biopsy confirmed the diagnosis of silicone lymphadenopathy. This case illustrates the broad differential for acute painful lymphadenopathy in the context of global travel, and the use of targeted infection testing, early cross-sectional imaging and biopsy to arrive at an unexpected diagnosis.

Barriers to hand hygiene in ophthalmic outpatients in Uganda: a mixed methods approach.

BACKGROUND: Healthcare-associated infection rates are high in low-income countries and are associated with significant morbidity. There is a paucity of published data on infection control practice, attitudes or resources in these settings, particularly in ophthalmology. The aim of this study is to understand current hand washing practices, barriers to hand washing and facilities available in two Ugandan specialist eye hospitals. This study was undertaken through non-participant observations of healthcare worker hand washing practices, documentation of hand hygiene facilities and semi-strucutured interviews with clinical staff. RESULTS: Eighty percent of the WHO opportunities for hand washing were missed through lack of attempted hand hygiene measures. Facilities for hand hygiene were inadequate with some key clinical areas having no provisions for hand hygiene. Training on effective hand hygiene varied widely with some staff reporting no training at all. The staff did not perceive the lack of facilities to be a barrier to hand washing but reported forgetfulness, lack of time and a belief that they could predict when transmission might occur and therefore did not wash hands as often as recommended. CONCLUSIONS: Hand hygiene at the two observed sites did not comply with WHO-recommended standards. The lack of facilities, variable training and staff perceptions were observable barriers to effective hand hygiene. Simple, low-cost interventions to improve hand hygiene could include increased provision of hand towels and running water and improved staff education to challenge their views and perceived barriers to hand hygiene.