Assessment of the Potential Impact and Cost-effectiveness of Self-Testing for HIV in Low-Income Countries.

Studies have demonstrated that self-testing for human immunodeficiency virus (HIV) is highly acceptable among individuals and could allow cost savings, compared with provider-delivered HIV testing and counseling (PHTC), although the longer-term population-level effects are uncertain. We evaluated the cost-effectiveness of introducing self-testing in 2015 over a 20-year time frame in a country such as Zimbabwe

Pathological changes within the cerebral vasculature in Alzheimer's disease:New perspectives

Cerebrovascular disease underpins vascular dementia (VaD), but structural and functional changes to the cerebral vasculature contribute to disease pathology and cognitive decline in Alzheimer's disease (AD). In this review, we discuss the contribution of cerebral amyloid angiopathy and non‐amyloid small vessel disease in AD, and the accompanying changes to the density, maintenance and remodelling of vessels (including alterations to the composition and function of the cerebrovascular basement membrane). We consider how abnormalities of the constituent cells of the neurovascular unit – particularly of endothelial cells and pericytes – and impairment of the blood‐brain barrier (BBB) impact on the pathogenesis of AD. We also discuss how changes to the cerebral vasculature are likely to impair Aβ clearance – both intra‐periarteriolar drainage (IPAD) and transport of Aβ peptides across the BBB, and how impaired neurovascular coupling and reduced blood flow in relation to metabolic demand increase amyloidogenic processing of APP and the production of Aβ. We review the vasoactive properties of Aβ peptides themselves, and the probable bi‐directional relationship between vascular dysfunction and Aβ accumulation in AD. Lastly, we discuss recent methodological advances in transcriptomics and imaging that have provided novel insights into vascular changes in AD, and recent advances in assessment of the retina that allow in vivo detection of vascular changes in the early stages of AD

Chemical reactions inside carbon nanotubes

The work presented in this thesis describes the development and application of strategies to evaluate the influence of extreme confinement within narrow single-walled carbon nanotubes (SWNT) on the pathways of preparative chemical reactions. Methodologies to reduce carbon nanotube length were critically assessed in order to aid the access and egress of reactants and products to and from the SWNT internal channel during confined reactions. A reliable procedure for the encapsulation of organic molecules within carbon nanotubes was developed utilising a novel fractional distillation procedure which exploits the effect of nanoscale confinement on the phase behaviour of liquids. Confinement of the halogenation of N-phenylacetamide within SWNT demonstrated, for the first time, that narrow SWNT are effective hosts for chemical reactions on a preparative scale in the absence of metallic catalysts. The selective formation of the para-brominated regioisomer improved from 68 to 97% as a direct result of confinement. Furthermore, the confinement of a range of azide-alkyne 1,3-dipolar cycloaddition reactions within SWNT showed a consistent increase in selectivity for the 1,4-triazole (up to a 55% increase). The magnitude of this effect can be tuned by varying the SWNT diameter or the steric bulk of the reactant substituents. In addition to the dominant steric factors, the results herein suggest that the electronic properties of carbon nanotubes induce an additional, more subtle influence on selectivity. Investigating the autocatalytic Soai reaction in the presence of carbon nanotubes demonstrated, on a fundamental level, that the helicity of SWNT induces an effect on the formation of chiral molecules. Since carbon nanotubes exist as a racemic mixture of P and M enantiomers, their presence has a symmetrising effect whereby an enantioselective Soai reaction affording 90% ee becomes racemic upon the addition of (6,5)-SWNT. These results clearly demonstrate the ability of carbon nanotubes to influence the properties of preparative chemical reactions

Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment.

BACKGROUND: In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare. METHODS AND FINDINGS: Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world. CONCLUSIONS: Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free

Cost-effectiveness analysis of tranexamic acid for the treatment of traumatic brain injury, based on the results of the CRASH-3 randomised trial: a decision modelling approach

Introduction An estimated 69 million traumatic brain injuries (TBI) occur each year worldwide, with most in low-income and middle-income countries. The CRASH-3 randomised trial found that intravenous administration of tranexamic acid within 3 hours of injury reduces head injury deaths in patients sustaining a mild or moderate TBI. We examined the cost-effectiveness of tranexamic acid treatment for TBI. Methods A Markov decision model was developed to assess the cost-effectiveness of treatment with and without tranexamic acid, in addition to current practice. We modelled the decision in the UK and Pakistan from a health service perspective, over a lifetime time horizon. We used data from the CRASH-3 trial for the risk of death during the trial period (28 days) and patient quality of life, and data from the literature to estimate costs and long-term outcomes post-TBI. We present outcomes as quality-adjusted life years (QALYs) and 2018 costs in pounds for the UK, and US dollars for Pakistan. Incremental cost-effectiveness ratios (ICER) per QALY gained were estimated, and compared with country specific cost-effective thresholds. Deterministic and probabilistic sensitivity analyses were also performed. Results Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI, at £4288 per QALY in the UK, and US$24 per QALY in Pakistan. Tranexamic acid was 99% and 98% cost-effective at the cost-effectiveness thresholds for the UK and Pakistan, respectively, and remained cost-effective across all deterministic sensitivity analyses. Tranexamic acid was even more cost-effective with earlier treatment administration. The cost-effectiveness for those with severe TBI was uncertain. Conclusion Early administration of tranexamic acid is highly cost-effective for patients with mild or moderate TBI in the UK and Pakistan, relative to the cost-effectiveness thresholds used. The estimated ICERs suggest treatment is likely to be cost-effective across all income settings globally

Steric and electronic control of 1,3-dipolar cycloaddition reactions in carbon nanotube nanoreactors

The use of single-walled carbon nanotubes as effective nanoreactors for preparative bimolecular reactions has been demonstrated for the first time. We show that the extreme spatial confinement of guest reactant molecules inside host carbon nanotubes increases the regioselectivity for 1,4-triazole in thermally initiated azide–alkyne cycloaddition reactions. Through comparison of the internal dimensions of the nanotube and the steric bulk of the reactants, we demonstrate that the formation of the more linear 1,4-regioisomer can be enhanced by up to 55% depending on the extent of spatial restrictions imposed within the nanoreactors. Furthermore, through systematic variation of the substituents in the para-position of the alkyne reactants, we reveal the unexpected influence of the reactants’ electronic properties on the regioselectivity of reactions within nanoreactors, which act to either oppose or promote the preferential formation of the 1,4-regioisomer induced by steric effects, reflecting the unique ability of carbon nanotubes to stabilize the dipole moment of confined reactants. Thus, we show that the observed regioselectivity of azide–alkyne cycloaddition reactions confined within carbon nanotube nanoreactors reflects a subtle interplay between both steric and electronic factors