A previous study has suggested that drug price adjustments allow physicians in Taiwan to gain greater profit by prescribing generic drugs. To better understand the effect of price adjustments on physician choice, this study used renin-angiotensin drugs (including angiotensin-converting enzyme inhibitors [ACEIs] and angiotensin receptor blockers [ARBs]) to examine the impact of price adjustments on utilization of and expenditures on patented and off-patent drugs with the same therapeutic indication.Using the Taiwan’s Longitudinal Health Insurance Database (2005), we identified 147,157 patients received ACEIs and/or ARBs between 1997 and 2008. The annual incident and prevalent users of ACEIs, ARBs and overall renin-angiotensin drugs were examined. Box-Tiao intervention analysis was applied to assess the impact of price adjustments on monthly utilization of and expenditures on these drugs. ACEIs were divided into patented and off-patent drugs, off-patent ACEIs were further divided into original brands and generics, and subgroup analyses were performed.The number of incident renin-angiotensin drug users decreased over the study period. The number of prevalent ARB users increased and exceeded the cumulative number of first-time renin-angiotensin drug users starting on ARBs, implying that some patients switched from ACEIs to ARBs. After price adjustments, long term trend increases in utilization were observed for patented ACEIs and ARBs; a long-term trend decrease was observed for off-patent ACEIs; long-term trend change was not significant for overall renin-angiotensin drugs. Significant long-term trend increases in expenditures were observed for patented ACEIs after price adjustment in 2007  and in ARBs after price adjustments in 2001  and 2007 . A significant long-term trend decrease in expenditures was observed for off-patent ACEIs after 2004 price adjustment . Expenditures on overall renin-angiotensin drugs showed long-term trend increases after price adjustments in 2001  and 2007 .Price adjustments did not achieve long-term cost savings for overall renin-angiotensin drugs. Possible switching from ACEIs to ARBs within individuals is evident. Policy makers should reconsider the appropriateness of the current adjustment strategies applied to patented and off-patent drugs. Taiwan’s National Health Insurance (NHI) system is a government-run, single-payer, compulsory program implemented on March 1, 1995. The Bureau of National Health Insurance (BNHI) is the executive organization of the NHI program. This program has universal coverage, including pharmaceuticals, ambulatory care, inpatient care, traditional Chinese medicine, dental services, child delivery, rehabilitation, home nursing care and chronic psychiatric rehabilitation. Currently, it covers more than 99% of the population (approximately 23 million people) [The three main components of the NHI system are the BNHI, the insured and the BNHI-contracted health care providers. Funding for the BNHI comes from the insured (38%), the employers (36%) and the government (26%). The BNHI issues insurance cards to the insured and pays the health care providers according to the services they provide, including prescriptions listed in the Pharmaceutical Benefit scheme (PBS). When the insured receive medical services from BNHI-contracted health care providers, they only pay the provider a registration fee as well as any co-payment for outpatient services, inpatient services and drugs .The BNHI established the PBS in 1996. It contains the reimbursement principles, and a list of the reimbursed products with a brand-specific reimbursement price for each product. This reimbursement price is paid to physicians, as they are responsible for purchasing, prescribing and dispensing in Taiwan . HoweverThe NHI, like many health insurance programs, faces financial challenges and its expenditures have exceeded its revenue since 1998 . Annual Price adjustments based on the market price and volume survey and generic grouping have, from the BNHI’s perspective, demonstrated cost savings in pharmaceutical expenditures for all PBS listed drugs . Liu et ACEIs (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin receptor blockers) both work through the same renin-angiotensin pathway and have a similar effect in cardiovascular disease and renal protection . BecauseThis retrospective, observational study was based on a cohort of patients treated with ACEIs and/or ARBs within Taiwan’s NHI program. The Longitudinal Health Insurance Database 2005 (LHID2005)  containsPatients with at least one ATC code  for ACEIDefined daily dose (DDD)  was usedSeven drug price adjustments were examined, including one based on the market price and volume survey implemented on April 1, 2000 (PA2000) and six based on the market survey in combination with generic grouping implemented on April 1, 2001 (PA2001), March 1, 2003 (PA2003), November 1, 2004 (PA2004), September 1, 2005 (PA2005), November 1, 2006 (PA2006) and September 1, 2007 (PA2007).Multivariate logistic regression was used to explore the differences between ACEI users, ARB users and both drugs users. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.Box-Tiao intervention analysis ,13 was aTherefore, we considered the following model ,14,yt is the dependent variable , t is the baseline trend, denoting months in numerical order, from 1 to T (T is the sample size), and n is the number of price adjustments in this study. PAit is a level indicator function to indicate whether the level changed as the ith price adjustment occurred. That is, assuming the ith price adjustment occurred on PAit be 0 for TPAit is a trend variable to indicate whether the trend changed as the ith price adjustment occurred, that is, let TPAit be 0 for β0 is the constant term that describes the baseline level of the dependent variable. β1 describes the baseline trend before the first intervention occurred. β2i depicts the level change immediately after the ith price adjustment and β2i+1 depicts the trend change after the ith price adjustment . B is the backshift operator  and off-patent drugs . The off-patent ACEIs were further categorized into original branded and generic versions. Potential independent variables included a constant (baseline level); a baseline trend; two indicator variables for each price adjustment, namely level change (the immediate effect) and trend change (the long-term effect or changes over time) ; and thrOf the 147 157 patients who met the inclusion criteria, 64 710, 22 317and 60 130 were identified as ACEI users, ARB users and both drugs users, respectively  per month from January 1997. There was an immediate decrease of 48 286 DDD  when PA2000 was implemented, but an immediate increase of 28 987 DDD  following PA2004. ACEIs long-term increasing trend decreased to 671 DDD per month after the implementation of PA2004  and turned to a long-term decreasing trend of 2 858 DDD per month after the implementation of PA2006 , diminishing to 691 742 DDD in December 2008  per month from February 1998. Following PA2003, the long-term increasing trend of the use of ARBs further increased to 10 058 DDD per month . When PA2007 was implemented, ARBs long-term increasing trend further increased to 18 041 DDD per month , reaching 1 157 724 DDD in December 2008. The baseline level of the utilization of overall renin-angiotensin drugs was 135 289 DDD, and utilization showed a long-term increasing trend of 12 027 DDD (p < 0.0001) per month from January 1997. When PA2000 was implemented, overall usage experienced an immediate decrease of 73 794 DDD . However, throughout the study period, the long-term increasing trend in the utilization of overall renin-angiotensin drugs was not influenced by any price adjustment, reaching 1 817 084 DDD in December 2008 , ARBs and overall renin-angiotensin drugs Table .p < 0.0001) per month from January 1997. The expenditures on ACEIs experienced an immediate decrease of 592 252 NT$  and 1 255 287 NT$ , respectively, following PA2000 and PA2003. The long-term increasing trend in ACEI expenditures turned to a downward trend of 30 014 NT$ per month after the implementation of PA2004 . When PA2006 was implemented, ACEI expenditures showed an immediate decrease of 1 545 767 NT$ . After PA2006, it maintained the long-term downward trend of 30 014 NT$ per month, decreasing to 5 527 281 NT$ in December 2008  per month from February 1998. Following PA2001, the long-term increasing trend of expenditures on ARBs increased to 253 009 NT$ per month . When PA2004 was implemented, the long-term increasing trend decreased to 132 671 NT$ per month , but following PA2007, the long-term upward trend further increased to 326 714 NT$ , reaching 24 228 254 NT$ in December 2008. The baseline level of expenditures on overall renin-angiotensin drugs was 3 753 898 NT$ and increased with a trend of 152 800 NT$ (p < 0.0001) per month from January 1997. When PA2001 was implemented, the long-term increasing trend increased to 263 059 NT$ per month , but following PA2004, the long-term increasing trend decreased to 129 734 NT$ per month . When PA2006 was implemented, the expenditures on overall renin-angiotensin drugs showed an immediate decrease of 2 224 884 . Expenditures still maintained a long-term increasing trend of 129 734 NT$ per month until the implementation of PA2007; this upward trend further increased to 302 790 NT$ per month , reaching 30 201 508 NT$ in December 2008 , ARBs and overall renin-angiotensin drugs Table .There are two major findings in our study. One is that the increase in prevalent ARB users is associated with switching from being an ACEI user. This result is consistent with the long-term trend increases in utilization of ARBs, but a long-term trend decrease in utilization of ACEIs. The other is that the increase in expenditures on renin-angiotensin drugs throughout this study primarily resulted from increases in the number of incident ARB users and potential switching from ACEIs to ARBs, but not from changes in the use of overall renin-angiotensin drugs. Ultimately, cost savings have not been achieved in overall use of renin-angiotensin drugs. Our findings differ from those of previous studies that showed cost savings in pharmaceutical expenditures for all PBS listed drugs  and geneAs mentioned, a feature of Taiwan’s health care system is that physicians both prescribe and dispense drugs because they are permitted by Taiwan’s Department of Health to hire pharmacists to work at their on-site pharmacies . PhysiciAnother study conducted by Lee et al.  addresseExploring increases in expenditures on overall renin-angiotensin drugs, we found that annual incident renin-angiotensin drug users declined over time, and no significant trend increases were found in the utilization of renin-angiotensin drugs over the study period. We also found that annual incident ARB users and annual prevalent ARB users increased over time. In particular, the annual prevalent ARB users always exceeded the number of cumulative incident ARB users, indicating that annual prevalent ARB users were not only from the category of cumulative incident ARB users, but also patients who were ever treated with ACEIs. These findings suggest that the increase in expenditures on renin-angiotensin drugs throughout this study primarily resulted from increases in the number of incident ARB users and potential switching from ACEIs to ARBs, but not from changes in the use of overall renin-angiotensin drugs.Although the health care systems in Canada and European countries are different from that in Taiwan, and the reference pricing (RP) scheme  adopted Previous studies have reported that the use of cheaper, generic drugs may lead to cost savings, but clinical concerns regarding patient safety and therapeutic effectiveness related to treatment discontinuation have also been raised -25. Our This study had several limitations. First, the baseline disease severity which led to initiation of treatment with ACEIs or ARBs was not compared, and we were unable to distinguish the clinical appropriateness of stopping or switching drugs for individual patients. The assessment of clinical conditions using ICD9-CM codes is likely to minimize most, but not all, of the potential bias. Second, there was no control group in this study, because price adjustments were implemented nationwide concurrently. However, the time points in the pre-intervention period served as a control group for the post-intervention period in the intervention analysis. Thus, issues regarding internal validity (such as history and maturation) were taken into consideration . FinallyThe implementation of Taiwan’s stepwise price adjustments, with different adjustment strategies applied to patented and off-patent drugs, has achieved cost savings for off-patent ACEIs, but not for patented ACEI, ARBs and overall renin-angiotensin drugs in the long term. Increases in incident ARB users and possible switching from ACEIs to ARBs have emerged. These results indicate that policy makers in Taiwan should reconsider the appropriateness of the current adjustment strategies applied to patented and off-patent products, since they result in a difference in the profit margin that physicians obtain from these two classes of drugs and affect physicians’ prescribing decisions.The authors declare that they have no competing interests.SHH conceived of the study, participated in its design, conducted data management and statistical analysis, interpreted the results and drafted the manuscript. CNH participated in the study design, statistical analysis, interpretation of the results, and drafting of the manuscript. SHY participated in the statistical analysis, interpretation of the results, and drafting of the manuscript. TMC conceived of the study, and participated in its design and coordination, interpretation of the results, as well as drafting of the manuscript. All authors read and approved the final manuscript.The principles of Taiwan’s price adjustments based on the market price and volume surveys, as well as generic grouping. This file describes the background of Taiwan’s pharmaceutical benefit scheme (PBS) and delineates in detail the process of stepwise price adjustment. It also provides an example to show how lowering the reimbursement price decreases the profit for physicians.Click here for file


Eosinophil degranulation has been described around degenerating onchocercal microfilariae in patients treated with diethylcarbamazine (DEC). In bancroftian filariasis, traditional histopathologic studies have shown remarkable numbers of eosinophils in granulomatous lesions associated with both DEC-induced and spontaneous death of adult Wuchereria bancrofti parasites. No immunohistochemical study targeting eosinophil degranulation has been previously performed in these granulomas, which are found mainly within intrascrotal lymphatic vessels. This investigation was undertaken in 22 (12 DEC-treated and 10 untreated) male patients in order to determine the immunohistochemical expressions of MBP, EPO and ECP in bancofitian granulomas, using the indirect method. Stained intact esosinophils, as well as granular, extra-cellular material positive for all three proteins, were found in all granulomas. The immunohistochemical patterns were similar in both DEC-treated and untreated cases, irrespective of microfilaremia, blood eosinophilia, and granuloma age. Positive intact cells were observed mostly at the periphery of the granulomas, whereas granular material predominated in central areas around dead or degenerating parasites. These results indicate that eosinophils accumulate in the granulomas and degranulate preferentially in close proximity to degenerating or dead adult parasites. In bancroftian granulomas, influx and degranulation of eosinophils are considered a consequence of parasite death, rather than its cause.It has been suggested, mostly using  For instance, in vitro investigations have shown that eosinophils operate via ADCC (antibody-dependent cytotoxicity) directed against schistosomula  treatment and naturally  and the Laboratory of Immunopathology Keizo Asami-LIKA, both at Federal University of Pernambuco in Recife, Brazil. Tissue specimens for this study were randomly selected from the filariasis histopathology tissue bank. The material consisted of excised nodules that had been detected by physical examination of the intrascrotal contents; they were obtained during previous trials described elsewhere , 23-26 aThe microfilaria (Mf) density was obtained from venous blood collected between 23:00 and 01:00 o’clock and filtered through a 3μm polycarbonate membrane, stained, and examined by microscopy. Amicrofilaremia was defined as having no Mf detected in 11 mL of blood  . In treaThe peripheral eosinophil concentration was measured by Neubauer counting chamber. All patients receiving DEC blood eosinophilia was avaluated before and between 7 and 14 days after the first dose of DEC intake as described elsewhere . In patiThe surgical specimens, fixed in buffered 10% formalin, were elastic, white-grayish, and either chord-like (varying from 2.5 × 0.5 cm to 4.5 × 0.4 cm) or ovoid (0.5 to 2.5 cm in its largest diameter). Several transverse slices from each specimen were routinely processed, and 5 μm-thick sections were stained with hematoxylin-eosin and Masson’s trichrome, as previously described . Images Immunohistochemical staining was conducted using the standard indirect method. A set of six de-paraffinized 5 μm-thick sections of the same material used for the histopathological study was subjected to microwave for 20 minutes at maximum power as an antigen retrieval method. The endogenous peroxidases were blocked with a methanol solution containing 0.03% hydrogen peroxide and 1% sodium azide for 20 minutes. Tissue sections were then incubated overnight at 4°C with either normal swine serum  as a negative control, or with primary high-affinity chromatrography-purified rabbit IgG antibodies to MBP, EPO, and ECP. Goat high-affinity anti-Fc-rabbit IgG conjugated to peroxidase  was applied to the tissues for 60 minutes at 37°C. The slides were developed using diaminobenzidine and counterstained with 10% Harris hematoxylin. After each treatment stage and incubation, the slides were washed in phosphate buffered saline. Brown staining was considered as an expression of immunoreactivity to MBP, EPO, and ECP. Interpretation of immunohistochemical results included both the location of the positive reaction and the staining pattern: intact, well-defined cells versus extra-cellular granular staining. The presence of extra-cellular positive granular material was interpreted as evidence of eosinophil degranulation. It was beyond to the scope of the study to assess quantitatively the immunohistochemical reaction for each protein studied.Descriptive statistics were used in the analysis of the data (Excel 2002). Pre and post eosinophil counts were log-transformed. Means of log-transformed counts were compared using the Student t test for paired samples.The clinical, parasitological and antifilarial treatment schedules of the patients are shown in Table W. bancrofti in different stages of degeneration; progressing and healing lesions coexisted in the same tissue section. In all cases but one, a granulomatous response was seen around the damaged worms. The non-granulomatous pattern was observed in a patient seven days after beginning a 12-day course of DEC. In this case, a considerably dilated segment of the lymphatic showed cross-sections of adult worms with early signs of degeneration such as deformity and collapse of internal structures. Eosinophils, macrophages and lymphocytes infiltrated the vessel wall diffusely and were seen also entrapped in a fibrin-like material in the lumen, together with numerous free Mf   . Thus, D30 days) . Fifth, 30 days) , 23, 26,30 days) , 26. Imm sources . Positiv sources . In suchWolbachia endosymbiont bacterium present in most filarid nematodes and its link with neutrophilic infiltrates after parasite death (Wolbachia (Loa loa adult worms cause significant inflammation with initial neutrophil accumulation and suppuration, followed by granulomatous reaction (B. pahangi, indicating that Wolbachia may not play a pivotal role in the development of the lymphatic lesions (Wolbachia-host interactions in the development of W. bancrofti granulomas and their impact on pathogenesis of adult worm-related chronic conditions.A remarkable finding in our material is the virtual absence of neutrophils in the tissue sections, even in earlier cases. This finding is relevant in view of the attention that has been paid to the te death . On the olbachia , dying Lreaction . In addi lesions . It is cper se are not responsible for the initiation of lethal damage to adult worms, as much as intrascrotal filarial granulomas are concerned. Rather, eosinophil influx and degranulation in DEC-related and non DEC-related bancrofitian granulomas likely represent a consequence of parasite death rather than its cause. However, eosinophils may play an important role in postmortem worm degradation as well as in granuloma evolution and modulation (Our current and previous studies in bancroftian filariasis give additional support to the concept that, as far as adult helminths are concerned, tissue eosinophilia appears to be triggered after the sudden release of antigens from parasites dying either spontaneously or following chemotherapy . The predulation .


Childhood obesity is associated with an increased risk for type 2 diabetes. Early identification of adolescents at risk for impaired fasting blood glucose may lead to earlier and more comprehensive evaluation and intervention. Because widespread blood glucose testing of adolescents is not recommended, community-based tools are needed to identify those who could benefit from further testing. One such tool, developed for adults, was the Tool for Assessing Glucose ImpairmenT (TAG-IT). Our objective was to validate whether a similar tool could be useful for community-based screening of glucose impairment risk among adolescents.Our study sample consisted of 3,050 adolescents aged 12 to18 years who had participated in the 1999-2008 National Health and Nutrition Examination Survey (NHANES). Half of participants were female and 40% were nonwhite. NHANES measured fasting blood glucose and height, weight, and resting heart rate. We used Pearson correlations and regression analysis to determine key variables for predicting glucose impairment. From these measurements, we created a composite TAG-IT score for adolescents called TAG-IT-A. We then applied the TAG-IT-A model to 1988-1994 NHANES data, using linear regression analysis and receiver operating characteristic analysis to determine how well the TAG-IT-A score predicted a fasting blood glucose at or above 100 mg/dL.P < .001 vs 0.55, P = .10, respectively). A TAG-IT-A score of 3 or higher correctly identified 50% of adolescents with impaired fasting blood glucose, while a score of 5 or higher correctly identified 76% .We determined that age, sex, body mass index, and resting heart rate were predictors of impaired fasting blood glucose and that TAG-IT-A was a better predictor of impaired fasting blood glucose than body mass index alone (area under the curve, 0.61, The TAG-IT-A score is a simple screening tool that clinicians and public health professionals could use to easily identify adolescents who may have impaired fasting blood glucose and need a more comprehensive evaluation. Obesity rates have tripled in the past 20 years among children and adolescents, leading to an obesity epidemic in this population ,2. ConcuBecause few children have impaired fasting blood glucose, widespread use of glucose screening in this population is not recommended. In addition, many adolescents seek health care infrequently and only for acute problems and thus may go years without contact with a health care provider. New tools are needed for community-based screening to identify those at increased risk of glucose impairment and in need of further evaluation or interventions.In adults, the Tool for Assessing Glucose ImpairmenT (TAG-IT) was developed for use in the community to assess risk of glucose impairment . CompareAlthough both TAG-IT and AGRA-6 are valid community screening tools to assess glucose impairment risk in adults ,6, to ouOur objective was to develop and validate a community-based screening tool specifically for adolescents. The tool is based on TAG-IT, the adult screening tool, and is called Tool for Assessing Glucose ImpairmenT among Adolescents (TAG-IT-A). We hypothesized that the TAG-IT-A tool would effectively predict risk of impaired fasting blood glucose levels in adolescents.The Centers for Disease Control and Prevention (CDC) conducts the National Health and Nutrition Examination Survey (NHANES) annually. NHANES uses complex probability sampling with a cluster sample design to assess the health and nutritional status of adults and children in the United States. For our study, we used multiple NHANES data sets. We used the 1999-2008 NHANES data to develop TAG-IT-A because NHANES oversampled adolescents and racial/ethnic minorities during these years to provide more precise population estimates. Furthermore, given the rise in the prevalence of type 2 diabetes, there were more adolescents with elevated glucose levels in later years (1999-2008) compared with earlier NHANES data sets (1988-1994). After using the 1999-2008 NHANES data to develop TAG-IT-A, we used NHANES III (1988-1994) data to validate the TAG-IT-A score in a manner similar to that described by Koopman et al. . The NHATo develop the TAG-IT-A score, we used data from adolescents aged 12 to 18 who participated in the fasting subsample of the NHANES 1999-2008 survey. We excluded participants who did not have a fasting blood sample, were currently taking diabetes medication, or had incomplete data on key variables used in the data analysis.The purpose of the screening tool is to use demographic and noninvasive clinical variables to identify adolescents with a fasting blood glucose at or greater than 100 mg/dL, defined by the American Diabetes Association as impaired . Key varAge, race, and sex were all self-reported, and race was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or other (Asian and American Indian). Age was then divided into 2 groups, 12 to 14 and 15 to 18. BMI was calculated from height and weight, which was measured by trained technicians who used standard NHANES methods . RestingTo validate TAG-IT-A we used data on adolescents who participated in the fasting blood glucose subsample of NHANES III (1988-1994). We excluded adolescents who did not have a fasting blood sample, were currently taking diabetes medication, or had incomplete data on key variables used in the data analysis. The same variables used to develop the TAG-IT-A tool were used in the validation sample. Age, race, sex, and BMI were used as the predictive variables of the population from the NHANES III database, and fasting blood glucose was used as the outcome variable to validate the TAG-IT-A score.In all analyses, we used NHANES weights to accommodate the complex sampling design of NHANES. The weights account for geographic probability sampling methods and oversampling of specific groups, such as minorities and adolescents, and are designed to ensure that the weighted findings are representative of all US adolescents.P value was less than or equal to .05, the variable was associated with an impaired fasting blood glucose level. Once we identified significant variables, we used logistic regression analysis to examine the relationship of these variables to fasting blood glucose levels. We also used the logistic regression model to generate weighted scores for each key factor that the TAG-IT-A score comprised. The method for developing the weighted scores was modeled after the widely used Charlson Comorbidity Index ; 51% were male, 32% were either overweight or obese, and 16% had a fasting blood glucose value of 100 mg/dL or higher . A totalCorrelations among the variables examined for the TAG-IT-A score were low, but we found a positive and significant relationship between fasting blood glucose, age, BMI, and resting heart rate . Age wasThe variables related to impaired fasting blood glucose included being aged 12 to 14, male, obese, and having a resting heart rate of 70 beats per minutes or higher . The oddTwenty-nine percent of the adolescents in NHANES III had a TAG-IT-A score of 3 or higher, and 14% had a TAG-IT-A score of 7 or higher . As scor The area under the curve was 0.61 for the TAG-IT-A tool compared with 0.55 for BMI alone, which suggests that the TAG-IT-A tool is modestly more useful than BMI alone in identifying adolescents who may need additional evaluation for impaired fasting blood glucose .2 increase in BMI in children was associated with a 1.4 mm Hg higher systolic blood pressure. To our knowledge, the positive relationship between fasting blood glucose and resting heart rate has not been examined in the adolescent population. Among adults, elevated resting heart rates are linked to higher all-cause and cardiovascular disease mortality . The area under the curve for the impaired glucose tool in adolescents is less than what has been found in adults (0.61 vs 0.74-0.80). One reason this tool may not be as predictive in adolescents is that other variables, such as lipid aerobic fitness, physical activity levels, or puberty and sexual development, may also be important -23. UnfoA logical question is what TAG-IT-A score public health or medical practitioners should use to determine if an adolescent needs further screening. If a score of 3 is used, then sensitivity is 50%, but sensitivity improves with higher criteria. The economic costs of additional tests need to be considered. Furthermore, health care practitioners need to decide if they want to maximize the number of cases identified correctly (sensitivity); if so, a value of 5 or higher might be used. In contrast, if health care practitioners are more concerned about minimizing the number of false positives, then a lower score with a higher specificity could be used .Few children and adolescents have fasting blood glucose values above 100 mg/dL ,23,24. FThe limitations of this study include the cross-sectional design of NHANES; adolescents who have fasting blood glucose values of 100 mg/dL or higher may not go on to develop type 2 diabetes. Nguyen et al , howeverThe TAG-IT-A tool is a simple measure that uses variables that can be obtained in community settings, and it is modestly better than BMI alone in predicting risk for impaired fasting blood glucose. The usefulness of this screening tool for identifying adolescents who have impaired fasting blood glucose should be further evaluated in community-based settings. Longitudinal studies are also needed to determine if adolescents with a high TAG-IT-A score subsequently develop type 2 diabetes in adulthood.


A standardized and rapid peptide-based SARS assay is characterized for sensitivity and specificity. A peptide-based enzyme-linked immunosorbent assay (ELISA) can be used for retrospective serosurveillance of severe acute respiratory syndrome (SARS) by helping identify undetected chains of disease transmission. The assay was developed by epitope mapping, using synthetic peptides from the spike, membrane, and nucleocapsid protein sequences of SARS-associated coronavirus. The new peptide ELISA consistently detected seroconversion by week 2 of onset of fever, and seropositivity remained through day 100. Specificity was 100% on normal blood donor samples, on serum samples associated with infection by other pathogens, and on an interference panel. The peptide-based test has advantages of safety, standardization, and automation over previous immunoassays for SARS. The assay was used for a retrospective survey of healthy healthcare workers in Taiwan who treated SARS patients. Asymptomatic seroconversions were detected in two hospitals that had nosocomial disease. Such surveillance may be key to tracking the severe acute respiratory syndrome–associated coronavirus (SARS-CoV) because mild and asymptomatic cases of SARS-CoV infection that do not meet the World Health Organization’s case definition  for detecting viral RNA is the most sensitive method for early identification of SARS. However, viral load rapidly declines beginning 9 or 10 days after disease onset  ratio, and cutoff absorbance was determined from the mean of the two controls plus 6 standard deviations (SD) from the distribution of normal human samples . Serum samples were collected from healthy healthcare workers after interviews to confirm lack of signs and symptoms of SARS including fever, respiratory symptoms, and diarrhea.Additional specificity studies were conducted with serum that had serologic reactivities for bloodborne pathogens  obtained by United Biomedical Inc. before 2000 from various U.S. sources, an interference panel supplied by Boston Biomedica Inc.  of serum samples with interference substances commonly found in processed clinical samples , and serum supplied by National Taiwan University Hospital from patients associated with typical and atypical respiratory pathogens other than SARS-CoV , seroconversion was apparent on day 16 after the onset of fever. On day 116, the A450 remained >3. In five of the other six seroconversion panels, from acute to convalescent phases, seropositivity was observed by days 8 to 12, and by day 16 in patient 6, from whom serum had not been collected from days 6 to 16 . Subsequently, the cutoff value for the peptide-based assay was set as the mean A450 for duplicate nonreactive controls plus 0.279 . The distribution of the S/C ratio for the blood bank samples is plotted in The specificity of the peptide-based SARS ELISA was tested on plasma obtained before 2001 from 1,390 random Florida blood donors . These normal plasma samples with a presumed zero seroprevalence rate gave a mean AThe peptide ELISA was further evaluated for specificity with a pre-2000 collection of serum samples from patients with seropositivities for bloodborne pathogens such as HIV-1, HIV 2, hepatitis C virus, HTLV 1/II, and syphilis (various U.S. sources), and with normal serum samples spiked with interference substances heparin, EDTA, ACD, and CPDA-1 (Boston Biomedica). The 52 samples with seroreactivities for the pathogens all tested negative by the peptide-based SARS ELISA, as did the 41-sera interference panel .Mycoplasma pneumoniae, a bacterial agent for atypical pneumonia, and 6) pre- and postvaccine blood samples from 16 patients given influenza vaccine. All samples were tested in duplicate. The site-specific antigens of the peptide SARS-CoV ELISA were free of cross-reactivities to the other respiratory pathogens . These included samples from 1) 10 patients naturally infected with influenza , 2) 10 patients with rubella, 3) 8 patients with cytomegalovirus infection, 4) 9 patients with Epstein-Barr virus, 5) 5 patients infected with athogens .A prospective study was performed to determine asymptomatic infection among primary healthcare workers in hospitals that treated SARS patients. We collected serum samples from 623 healthcare workers without symptoms, not all of whom were in direct contact with SARS patients, who agreed to be tested for antibody to SARS-CoV at Ho Ping, Yang Ming, En Chu Kong, and Hsin Tai Hospitals, approximately 4 weeks after the outbreaks were recognized. Ho Ping and Yang Ming Hospitals had admitted SARS patients before the recognition of SARS and before healthcare workers had implemented control measures. Subsequently, these facilities experienced transmission to healthcare workers. The En Chu Kong and Hsin Tai facilities admitted patients once control measures had been implemented. Neither of these hospitals recorded transmission of SARS to healthcare workers.ELISA detected three cases out of 383 samples from Ho Ping and one case in 50 blood samples from nursing aides at Yang Ming. These four positive samples, indicative of asymptomatic infection, were confirmed for seropositivity by IFA. None of the 190 serum samples from the two hospitals without nosocomial infection displayed seroconversion.A convenient ELISA to detect IgG to SARS-CoV, based on site-specific synthetic antigens taken from the S, M, and N proteins of the virus, has high specificity. No cross-reactivity was detected in samples associated with common non-coronavirus respiratory pathogens. In addition, the lack of detectable reactivities among the 1,390 U.S. blood donors supports a specificity for the assay to distinguish SARS-CoV infection from infection by other human coronaviruses. The presence of anti-coronavirus antibodies among a U.S. population of this size is strongly anticipated because an incidence as high as 8% for OC43 and 229E respiratory infections has been observed, even among healthy young adults (The new peptide-based ELISA is equivalent in sensitivity to other immunoassays for SARS and can be detected after day 100. The synthetic antigens provide the advantages of high standardization, freedom from biohazard, and ease of scale-up production. Moreover, testing by the ELISA format can be readily automated for large-scale screening. The highly specific peptide-based SARS antibody test is a convenient means to carry out widespread retrospective surveillance, such as that now being proposed for China to trace hotspots of persons carrying antibodies to SARS-CoV and to track the origins of the disease (A preliminary survey with the peptide ELISA detected asymptomatic clusters of seroconversion among exposed healthcare workers in two Taiwan hospitals that also had nosocomial disease. In contrast, no seroconversion was found among the exposed healthcare workers from two hospitals that had no apparent disease transmission to healthcare workers. The finding of asymptomatic seropositive persons indicates that the test will be useful in larger retrospective surveillance studies, which are needed to fully define the epidemiology and spectrum of disease.


Hyaluronic acid (HA) is a naturally occurring glycosaminoglycan that exists in living systems, and it is a major component of the extracellular matrix. The hyaluronic acid receptor CD44 is found at low levels on the surface of epithelial, haematopoietic, and neuronal cells and is overexpressed in many cancer cells particularly in tumour initiating cells. HA has been therefore used as ligand attached to HA-lipid-based nanovectors for the active targeting of small or large active molecules for the treatment of cancer. This paper describes the different approaches employed for the preparation, characterization, and evaluation of these potent delivery systems. It is moreover an acidic molecule with an isoelectric point between 4.2 and 5.8 [CD44  is a nonsulfated glycosaminoglycan polymer. It is ubiquitous, being the main component of extracellular matrix . HA is cic bonds . HA is aunogenic . MoreoveIn adult tissues such as the vitreous, synovial fluid and dermis, hyaluronan plays an extracellular, structural role that depends on its hydrodynamic properties as well as on its interactions with other extracellular matrix components. However, it is also concentrated in regions of high cell division and invasion . Hyaluronic acid is thus also involved in tumorigenesis, and its role is complex and depends on various factors such as, for example its molecular weight. In fact lower molecular weight HA (10–100 kDa) stimulates angiogenesis but high molecular weight hyaluronan  is inhibitory –30. HighIn addition to its principal and previously described receptor, CD44, HA also interacts with other cell surface receptors such as RHAMM , ICAM-1 (intracellular adhesion molecule-1), TLR-4 (toll-like receptor-4), HARE (HA receptor for endocytosis), and LYVE-1 (lymphatic vessel endocytic receptor).The mechanism of HA-CD44 binding is still not fully understood, but it has been reported that the CD44 receptor contains the specific binding domain for HA, which consists of 160 amino acid residues. The binding affinity of CD44 to HA was found to be dependent on the size of HA oligomers. In fact, hexamer and decamer are considered to be the minimum size able to bind to CD44 while larger oligomers (20) have higher binding affinity because of their multiple interactions with more than one CD44 receptor simultaneously , 36, 37.It has also been reported that all the CD44 isoforms have uniform affinity for HA ; therefoDifferent approaches can be used to bind HA to the lipid-based nanocarriers, depending on the molecular weight of the HA as well as on the need to start from preformed nanocarriers or from pure lipids that will be then used to prepare particles.HA binding to preformed nanocarriers was the firstly used method  and offeAlternatively, HA can be previously conjugated to a pure lipid and then added in the lipid mixture during the preparation of the nanoparticles. This procedure permits the introduction of a controlled amount of HA on nanocarriers, but could require a more elaborated synthetic method.High molecular weight (HMW) HA was attached to the surface of preformed liposomes through amidation reaction between the aminoreactive group of a lipid on the liposome surface, generally a phosphatidylethanolamine (PE), and HA glucuronic carboxylate  13, 14,,14, 43. HA conjugation to the lipid before nanocarrier preparation was carried out with both high and low molecular weight (LMW) polymers , 19. In 1HNMR.In these reactions involving LMW-HA, only one PE molecule was linked to the polymer. Both kinds of conjugates were purified by silica column chromatography, and the latter was characterized by MALDI and HMW-HA-dioleoylphosphatidylethanolamine (DOPE) conjugate was prepared by EDC-mediated amidation reaction . In thisA similar synthetic approach was used by Toriyabe et al.  for the Recently Cho et al. described the preparation of an amphiphilic polymer obtained conjugating HA oligomers to a cellular component, ceramide (CE). To obtain HA-CE conjugate, HA was first activated by reaction with tetra-n-butylammoniumhydroxide (HA-TBA), and CE was previously modified by esterification reaction with chloromethylbenzoyl chloride, used as linker. Then linker CE was conjugated to HA-TBA by ether bond formation .First evidence of powerful delivery of chemotherapeutics to cancer cells by HA-modified liposomes was provided by the group of Eliaz and Szoka  Table 1Table 1. in vivo study, HA-modified liposomes resulted in long-circulating species, over a time frame at least equal to those reported for PEG-coated liposomes [in vitro and in two experimental models of lung metastases. The in vitro studies showed that loading into the HA-modified liposomes generates a 100-fold increase in MMC potency in tumor cells that overexpress hyaluronan receptors, but not in cells with poor expression of these receptors. Moreover, when using HA-modified liposomes, MMC accumulated in the tumor 30-fold higher than when the drug was administered in free form and 4-fold higher than when delivered via unmodified liposomes. Interestingly, liver uptake was significantly reduced when the drug was delivered via the HA-modified liposomes that should contribute to reducing the subacute toxicity associated with MMC administered as free drug [The targeting of cancer cells using HMW-HA bound to liposomes was firstly demonstrated by Peer and Margalit , 14. HMWiposomes . Mitomycree drug . It is w In vivo evidence of CD44 targeting by HA-modified lipid-based nanoparticles was also obtained by encapsulating paclitaxel (PXT) into self-assembled lipid nanoparticle-like “clusters” [in vitro cytotoxicity and in vivo antitumoral activity studies showed that HA-PTX-NLCs were more effective than Taxol with fewer side effects. HA-NCL also prolonged the blood circulation time of PTX and increased its accumulation in tumors.HA-modified lipid-based nanoparticles encapsulating paclitaxel (PXT) were also proposed. PXT is a chemotherapeutic agent largely used in the treatment of solid tumors. However, its poor water solubility as well as the lack of selective delivery approach represents important clinical limitations.lusters” . Thus, Hlusters” . Moreovelusters” . Recentllusters” . In thisin vitro cellular uptake studies showed that nanoparticles enhanced intracellular DCT uptake in the CD44-overexpressing cell lines MCF-7. MDR-overcoming effects of DCT nanoparticles were observed in cytotoxicity test in CD44-positive MCF-7 breast cancer cells resistant to doxorubicin. The in vivo tumor targetability was evaluated using a noninvasive fluorescence imaging system in the same cells xenografted in a mouse model. To assess the uptake mechanism by a competitive inhibition assay, CD44 receptors were blocked with preinjection of high doses of HA. The fluorescence signal in the HA preinjected animal group was lower than that in no preinjection group for 24 h, indicating a probable reduction in nanoparticle uptake due to the blocking of CD44. The real-time imaging data showed that the fluorescent signal increased for the first 6 h and was maintained for 1 day. Then the tumors were dissected 24 h following injection, and the observed fluorescence intensity of HA pre-injection group was only 43.9% of the no preinjection group.HA-modified nanoparticles have been proposed to overcome clinical limits of chemotherapeutics, such as Docetaxel (DCT). DTC is a semisynthetic taxane derivative very effective against different tumors, but its clinical use causes several side effects and other limitations regarding the appearance of multidrug resistance (MDR) and its insolubility. Recently Cho et al. described the preparation of HA-ceramide (CE) self-assembled nanoparticles for DCT and DOX active targeting , 49. TheIn vitro tests were performed on two different cell lines with different CD44 expression: NIH3T3  and SCC7 . The cytotoxicity studies showed that HA-CE-based nanoparticles can be used as vehicle without important toxicity. The cellular uptake efficacy of DOX from nanoparticles via HA and CD44 interaction was demonstrated by confocal microscopy analysis. In vivo studies on SCC7 tumor xenograft mouse model showed improved retention time in the bloodstream and nanoparticle accumulation at the tumor site. The pharmacokinetics evaluation confirmed that PEGylation resulted in prolonged nanoparticle circulation and reduced DOX clearance rate. Improved half-life of DOX, when formulated as HA-CE-PEG nanoparticles, led to higher in vivo antitumor efficacy in the tumor xenograft mouse model in comparison to non-PEGylated nanoparticles and DOX alone.The same research team described the preparation of DOX-loaded, self-assembled, HA-CE-PEG-based nanoparticles . In vitrin vitro cytotoxicity, on the MDA-MB-231 and MCF-7 breast cancer cell lines, characterized by high and low expressions of CD44, respectively. On the contrary, the use of HA strongly reduced the cytotoxic profile of DOTAP/DOPE liposomes in combination with siRNA on A549 CD44-expressing cells [HA was also used to increase transfection efficiency of cationic liposomes. Plasmid DNA and siRNA were successfully delivered to CD44-expressing cancer cells with this approach , 21. Theng cells , 20.HA-coated cationic liposomes were also prepared using an HA-stearylamine (SA) conjugate, and their ability to reach liver endothelial cells was evaluated . The phaRecently, the complement activation capacity of HA nanoparticles has been investigated , 50. Comin vitro studies  and stated that cellular targeting efficiency of HA liposomes depends on HA molecular weight, grafting density, and cell surface CD44 receptor density. In particular, the HA liposomes binding and internalization increased with increasing polymer molecular weight and/or the grafting density [The impact of HA size and density of HA-grafted nanoparticles on affinity toward CD44 was evaluated in a systematic manner , 52. Qha density . The aut density .HA represents a promising opportunity to develop new cancer therapies. A growing number of scientific works explored the possibility to target cancer cells overexpressing CD44 receptor by using HA-modified vectors. HA is biocompatible, biodegradable, nontoxic and noninflammatory. Moreover, it can easily undergo chemical modifications and conjugates with drugs or other ligands. HA targeting of cancer cells overexpressing CD44 receptor has been largely demonstrated. In addition, HA coating has been recently proposed as a safer alternative to PEG grafting in order to increase the particles' half-life. The success of this strategy is demonstrated by an HA conjugate at the moment in clinical trials. A phase III clinical trial based on a hyaluronic acid-Irinotecan conjugate is in the recruitment state, and the final data collection is scheduled for January 2014. The possibility to conjugate HA to lipid-based nanocarriers, such liposomes that are on long time in the clinical practice, should open new opportunities to target cancer cells also with drug that cannot be easily conjugated to HA. Further studies are certainly needed to understand the relations between the molecular weight and “biological” properties of HA, especially in the interaction of HA-modified nanoparticles with the target.in vivo distribution of HA conjugated nanocarries as well as their tumor localization should be useful to design new anticancer therapies based on CD44 targeting. Moreover, further information on the


Many strategies have been designed and evaluated to address poor hand hygiene (HH) compliance. Unfortunately, well-designed economic evaluations of HH improvement strategies are lacking.We compared the cost-effectiveness of two successful implementation strategies for improving nurses’ hand hygiene (HH) compliance and reducing hospital acquired infections (HAI’s).A cost-effectiveness analysis alongside a cluster randomised controlled trial was conducted in 67 nursing wards of three hospitals in the Netherlands, with inpatient wards as the unit of randomisation. The evaluation used a hospital perspective. The control group received a state-of-the-art strategy (SAS) including education, reminders, feedback and optimising materials and facilities. The experimental group received a team and leaders-directed strategy (TDS) which included all elements of the SAS supplemented with interventions aimed at social influence within teams and enhancing leadership. The most efficient strategy was determined by the incremental cost-effectiveness ratio per extra percentage of HH compliance gained, and the incremental cost-effectiveness ratio per additional percentage reduction in the HAI rate. Bootstrap methods were used to determine confidence intervals for these incremental cost-effectiveness ratio’s.Two scenarios of 15 and 30% were used to express the association between increased HH compliance and the reduction in HAIsThe TDS was significantly more effective in improving HH compliance. The mean difference effect was 8.91%. This extra increase was achieved at an average cost of € 5497 per ward. The incremental cost per extra percentage of HH gained on ward level was € 622. The incremental cost per additional percentage reduction in the HAI rate on ward level was € 2074 (30% scenario) and € 4125 (15% scenario). Within the 30% scenario, there is a probability of 90% that the TDS is cost-effective and within the 15% scenario, there is a probability of 70% that the TDS is cost-effective.Optimising hand hygiene compliance through a team and leaders-directed strategy is cost-effective as compared to a state-of-the-art strategy.None declared


It is desirable that those at highest risk of cardiovascular disease should have priority for preventive measures, eg. treatment with prescription drugs to modify their risk. We wanted to investigate to what extent present use of cardiovascular medication (CVM) correlates with cardiovascular risk estimated by three different risk scores  ten years ago.Prospective logitudinal observational study of 20 252 participants in The Hordaland Health Study born 1950-57, not using CVM in 1997-99. Prescription data obtained from The Norwegian Prescription Database in 2008.26% of men and 22% of women aged 51-58 years had started to use some CVM during the previous decade. As a group, persons using CVM scored significantly higher on the risk algorithms Framingham, SCORE and NORRISK compared to those not treated. 16-20% of men and 20-22% of women with risk scores below the high-risk thresholds for the three risk scores were treated with CVM, while 60-65% of men and 25-45% of women with scores above the high-risk thresholds received no treatment. Among women using CVM, only 2.2% (NORRISK), 4.4% (SCORE) and 14.5% (Framingham) had risk scores above the high-risk values. Low education, poor self-reported general health, muscular pains, mental distress  and a family history of premature cardiovascular disease correlated with use of CVM. Elevated blood pressure was the single factor most strongly predictive of CVM treatment.Prescription of CVM to middle-aged individuals by large seems to occur independently of estimated total cardiovascular risk, and this applies especially to females. The ability to predict future risk of cardiovascular disease (CVD) in asymptomatic persons, in order to implement preventive measures, is important for clinicians as well as for public health. Several risk predicting tools have been developed for this purpose -4 and elIn this prospective longitudinal observational study in a Norwegian population born 1950-57, we investigated to which extent results from three different risk score algorithms  predicted use of CVM ten years later . Our aimIn this population based, longitudinal observational study, a total of 20 252 men and women born 1950-57 and living in Hordaland County in Western Norway participated. Their individual cardiovascular risk was mapped in 1997-99, and in 2008 their use of CVM was investigated. Data sources were the Hordaland Health Study (1997-99) and the Norwegian Prescription Database (2008).In 1997-99 a population based health survey was carried out in Hordaland County in Western Norway: The Hordaland Health Study (HUSK) [Of the 33 549 individuals born 1950-57 invited to participate in HUSK, 22 289 (66.6%) responded: 10 249 men (59.1%) and 12 040 women (74.3%). The 9 283 men (90.6%) and 10 969 women (91.1%) not using any CVM in 1997-99, comprised the target population for the present study (Table The Norwegian Prescription Database (NorPD) provides information on all prescription drugs dispensed from Norwegian pharmacies . The regIn the present study we investigated HUSK-participants' (1997-99) use of prescription CVM in 2008 (record linkage with NorPD data). CVMs were defined as drugs with ATC codes C01 (cardiac therapy), C02 (antihypertensives), C03 (diuretics), C07 (beta blocking agents), C08 , C09 (agents acting on the renin-angiotensin system), and C10 (lipid modifying agents).On the basis of data recorded in HUSK during 1997-99, we were able to apply the following risk algorithms, which are all intended for risk stratification for primary prevention of CVD:• The Framingham risk algorithm published in 1991 predicts the ten year risk for all kinds of coronary events, fatal and non-fatal [• The SCORE  risk algorithm presented in 2003 is based on a pooled dataset of cohort studies from 12 European countries, including Norway [We extrapolated the values of Framingham and SCORE to the age of 60 years.• The NORRISK risk algorithm . This riStatistical analyses were carried out using SPSS version 18. Bivariate comparisons were done by chi-square test  or independent samples t-test (conituous variables).The study was approved by the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate, for the 1997-99 as well as the 2008 data collection. A written consent allowing future use of their data for research was obtained from each HUSK-participant at the screening station.During the 9-11 years from 1997-1999 to 2008, 26% of men (n = 2 411) and 22% of women (n = 2 448) not on CVM in 1997-99, had started such treatment . 152 out of these 343 persons could be traced in the Norwegian Cancer Registry [In this study we found that close to one in four persons 51-58 years of age had started to use some CVM during the previous decade: 22% of women and 26% of men. Around one in eight used more than one drug and a corresponding proportion used a statin.th percentile  47-48% used no CVM (data not shown in table). It may thus seem that prescription of CVM to a large degree had occured independently of the patient's total cardiovascular risk, as expressed by these commonly used risk algorithms.High cardiovascular risk scores  calculated 9-11 years previously were all significantly associated with subsequent medication use, although there was a substantial overlap: A considerable proportion of individuals with risk scores below the "high-risk" thresholds used CVM . Among women using CVM, at least eight out of ten had risk score values below the defined "high-risk" thresholds. On the other hand, around 60% of men with risk scores above the "high risk" level, did not use any CVM. Even in the group of men with risk score levels on or above the 90Maybe even more striking is that the proportion of females on medication roughly corresponded to that of males (22.3% versus 26.0%), despite females' substantially lower risk score levels-the majority of women on CVM had risk score levels well below the "high-risk" limits.The study has some limitations. It was done by a population survey and a subsequent linkage to a prescription database, not by intentionally following a well designed cohort. Among others, we can not tell if the medications had been prescribed for present CVD or for primary- or secondary prevention. The response rate of the population survey was as high as 66.6%, but those not participating were found to differ from participants on several aspects, as non-participants were less educated, had lower income and more frequently received social security grants . There iThe cohort of women on CVM differed from those not on medication regarding several parameters: They had generally lower education, their self-reported health was poorer, and they more frequently reported muscular pains, anxiety and depression. They also smoked more, exercised less, and more frequently abstained from alcohol. Compared to men on CVM, women on treatment reported poorer general health, more muscular pains, anxiety, and depression. Psychosocial factors have been extensively linked to CVD -12. In aIn our study population covering a possible age span from 40 to 58 years, more than one in four males and one in five females had started on CVM during a decade. Recommended risk algorithms for CVD at baseline only to a limited degree correlated with later medication use, especially in females, while psychosocial factors correlated stronger with use of CVM in females compared to males. Possible reasons for underusing total risk assessment tools in clinical practice may be that the tools are considered inaccurate or poorly validated. Whether their use improves patient outcomes has in fact rarely been evaluated -17. FurtThe newly developed CVD risk score QRISK2 includes the traditional Framingham risk factors, but also includes BMI, a family history of CVD, social class measured by Townsend score, self-assigned ethnicity, and presence of several listed diseases known to be associated with CVD, among others diabetes mellitus and rheumatoid arthritis . This scOfficial guidelines on calculating global risk were implemented in Norway in 2009, that is after our data collection took place, but GPs had already been educated in global risk assessment during the previous 20 years, through guidelines provided by the National College of GPs. We would therefore expect the average physician to be informed about the recommendations regarding total risk assessment in 2008. But even if clinicians do calculate patients' total risk score, little is known about how this knowledge affects the physicians' decision making in terms of prescribing CVM . We havePrescription of cardiovascular medication to middle-aged persons to a large degree was found to occur independently of the indviduals' total cardiovascular risk, especially in women. Despite their substantially lower total cardiovascular risk, middle aged women by large recieved as much cardiovascular medications as men. At least eight out of ten middle aged women using cardiovascular medication in 2008 had cardiovascular risk scores  below defined "high-risk" thresholds ten years before.Cardiovascular drug prescription practice still seems to be based on single factor assessments , but psychosocial factors seem to influence which patients will be put on treatment, especially in women.The authors declare that they have no competing interests.The authors planned the study together. MB carried out the data analyzes and drafted the article. JS actively participated in revising the manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/144/prepub


Isolates were spa- and SCCmec-, and in selected cases, multilocus sequence-typed. Susceptibilities to 13 antimicrobials were determined by broth microdilution. Statistical analysis was carried out using backward stepwise logistic regression to calculate odds ratios with the MRSA test result as the outcome and herd characteristics as categorical covariates.The purpose of this study was to investigate the prevalence of MRSA in herds of fattening pigs in different regions of Germany, and to determine factors associated with the occurrence of this pathogen. For this purpose pooled dust samples were collected, and a questionnaire covered information regarding herd characteristics and management practices. Samples were pre-enriched in high-salt medium followed by selective enrichment containing cefoxitin/aztreonam, and culturing. Presumptive colonies were confirmed by multiplex-PCR targeting Overall, 152 of 290 (52%) fattening pig farms tested positive for MRSA. The prevalence in the east, north- and south-west of Germany ranged from 39 to 59%.pa-types, and 85% of isolates carried SCCmec Type V. Identified spa-types were all associated with clonal complex CC398. Susceptibility testing revealed that all isolates were resistant to tetracycline. High resistance rates were also found for sulfamethoxazole/trimethoprim (40%), and quinupristin/dalfopristin (32%). In addition, 83% of strains displayed multidrug resistant (> 3 substance classes) phenotypes.t011 (66%) and t034 (23%) were the most commonly identified sLogistic regression revealed herd size , and production type  as risk factors associated with a positive MRSA finding in fattening pig operations.MRSA CC398 is widely distributed among herds of fattening pigs in Germany. Farm management plays a crucial role in the dissemination of MRSA with herd size, and production type representing potential major indicators. In recent years, the emergence of the MRSA multilocus sequence type (MLST) CC398 has been reported in livestock in Europe and North America mainly in pigs, but also in veal calves and poultry -4. CharaAnimal disease involving MRSA CC398 has been described, especially in horses -7 and daTypically, livestock isolates display a variety of multiresistant profiles, including resistance to β-lactams and tetracycline in most of them. It has been shown, that phenotypic resistance to several antimicrobials largely used in clinical practice is encoded by genes located on mobile elements, which reflects the potential for spread and acquisition of new traits, and the relevance of monitoring ,17.In order to evaluate the risk posed to humans, and to assess possible routes of transmission, several studies have been undertaken to estimate the prevalence of MRSA CC398 focussing on the pig population as a starting point. At herd level, prevalence of MRSA CC398 has been reported with 45% positive farms in North America, and ranging between 0 and 46% among breeding holdings in European Union Member States ,4,18. DaA total of 290 operations housing more than 100 finishers distributed across seven federal states agreed to take part in the survey. These operations were allocated to three regions. The north-western (NW) region was represented by 72, the eastern (E) by 65, and the south-west (SW) by 153 operations. A brief overview of the prevalence according to the main farm characteristics is provided in Table Overall, 152 (52%) herds tested positive for MRSA. The prevalence in the SW was 59%, 51% in the NW, and 39% in the E. The prevalence of MRSA varied at state level between 29 and 70% (data not shown).spa-typing. Altogether, twelve different spa-types were identified  SCCmec-type V followed by 11% type V* (a variant first identified as III) [spa- and SCCmec-types were t011/V (63%), t034/V (13%) and t034/V* (9%)  . In one  as III) . The mos%) Table .spa-types t2997, t2582, t1451, t5488, and t2383 revealing in all cases sequence type ST398.MLST was performed once for spa-type t011. Resistance to SXT was observed in 17 resistance profiles of which 16 were MDR profiles. QUI/DAL resistance occurred in 13 resistance profiles always associated with resistance to four or more substance classes (data not shown).Susceptibility testing results are shown in Table The majority (57%) of operations reported the application of antimicrobials as group medication during the fattening period. The reported spectrum of applied antimicrobials was broad, with tetracyclines (28%), macrolide/lincosamide antibiotics (25%) and beta-lactams (22%) constituting the most commonly administered classes of antibiotics in the survey. Up to five different substances were reported at farm level. MRSA was detected in 60% farms with reported, and in 42% with no reported antibiotic use at group level. Application of antibiotics was associated  with the presence of MRSA in the univariate analysis only  with a significant univariate association with the test outcome based on a p-value < 0.05 were subjected to further Chi-squared tests to detect correlations among themselves. The correlation matrix revealed strong multicollinearity (data not shown), especially for the variable "region", which was then included as a fixed variable in the regression model. The multivariate logistic regression analysis included 273 cases with full information on the factors significantly associated with the test outcome (n = 8) according to Chi-squared test. The results of univariate and multivariate logistic regression are summarized in Table The multivariate model comprises the variables herd size, and production type. Large (> 1000 finishers) and medium-sized (500-999 finishers) farms were more likely to harbour MRSA compared to small operations housing less than 500 fatteners. Production types wean-to-finish and grow-to-finish were also associated with a higher likelihood of a MRSA finding in the herd. In the univariate analysis the purchase of pigs showed an impact on the MRSA test. A distribution of the positive MRSA results among farm characteristics according to the purchase of pigs is shown in Table The final logistic regression analysis to test robustness showed that the variables herd size and production type had a stable predictive value in all seven data subsets (data not shown).The present study reflects the wide dissemination of MRSA CC398 among German herds of fattening pigs. Additionally, farms that harbour more than 500 finishers, and wean- as well as grow-to-finish production types were identified as risk factors for a positive MRSA test result.From a production chain point of view, the fattening sector takes a middle position between breeding pig herds and the slaughter pigs previously studied in Germany ,20. Alth2, p < 0,001). The production types covered by this study differed in their purchase patterns of pigs for fattening. While wean- and grow-to-finish operations bought piglets in 76 and 95% of cases respectively, only 17% of farrow-to-finish herds purchased pigs. Furthermore, the size of herds is a risk factor for the presence of MRSA CC398 in a pig farm [2, p = 0,001). It has already been proposed, that MRSA is spread between farms via trade of colonized animals [In the present study, three farm production types were targeted. The prevalence for MRSA in wean- and grow-to-finish production holdings exceeded 58%. By contrast, farrow-to-finish operations tested only in 31% positive, on average. Multicollinearity among variables is a limitation of the present study that hampers the interpretation of the effect of a single factor on MRSA prevalence. The variable "production type" strongly correlated with the "purchase of pigs"  for each region was only reached in the southwest of Germany, in which the highest prevalence (59%) was observed.mecA-positive isolates were phenotypically susceptible to oxacillin. This has previously been reported and may in part be explained by heteroresistance [vatA, vatB, vatC, vgaA, vgaB, vgaC, vgbA and vgbB in 9 MRSA CC398 isolates phenotypically resistant to QUI/DAL [spa-type t011, as our results indicate, requires further clarification.Molecular characterization of the isolates mirrors the reported variety of strains in Europe ,20,28. Tsistance . To addrsistance ,30. Resi QUI/DAL , suggest QUI/DAL ,30. HoweThe results of the present study reveal a high prevalence of MRSA CC398 in German fattening pig herds, mainly in large herds and wean-to-finish operations. The implication of pig trade and other factors in the spread of this microorganism requires further investigation since MRSA has been detected to a high extent in German breeding and closed breeding (nucleus) herds .mec- and spa-types confirm circulating clones in the European pig industry. Susceptibility testing reveals a high amount of quinupristin/dalfopristin and sulfamethoxazole/trimethoprim non-wild-type phenotypes.Identified SCCS. aureus (NRL Staph) at the BfR for primary isolation of MRSA 13 days after sampling at the latest. Sample collection, shipping and storage complied with the methods described in Commission Decision 2008/55/EC.In the period between May and December 2008, federal states of Germany were asked to collaborate in the present study to determine the spread of MRSA in herds of fattening pigs. Following the technical specifications in the course of the EU-wide survey in breeding pig herds as outlined in Commission Decision 2008/55/EC, the sampling plan aimed to collect five dust samples from different positions within the compartments with fattening pigs between 10 and 30 weeks of age of randomly chosen operations housing more than 100 finishers. Sample size was calculated based on an estimated prevalence of 50%, a 95% confidence interval, and 7.5% accuracy. To obtain representative results for Germany the sampling plan aimed to enrol a total of 510 herds located in the eastern (n = 170), north- (n = 170) and south-western (n = 170) regions of Germany, distributed within each region among federal states according to the proportion of fattening pig operations with > 100 animals. A questionnaire was used to determine the herd size, animal flow system, production type, flooring, health status in the herd, and application of antimicrobials as group medication in a four-month interval prior to sampling (fattening period), location of the operation, and housing of other animal species. Details of collected data are given in Table Primary isolates obtained at regional laboratories were sent for confirmation, further typing and antimicrobial susceptibility testing of MRSA to the NRL Staph.Primary isolation was performed in all laboratories as follows and in accordance with Commission Decision 2008/55/EC. Samples were pooled per farm and cultured for pre-enrichment in Mueller Hinton broth supplemented with 6.5% NaCl. After incubation for 16-20 h at 37°C, 1 ml was inoculated into 9 ml of tryptic soy broth containing 3.5 μg/ml cefoxitin and 75 μg/ml aztreonam, and incubated again at 37°C for 16-20 h. A loopful was then plated onto sheep blood agar and chromogenic MRSA screening agar . After incubation for 24-48 h at 37°C regional laboratories sent five presumptive colonies as subcultures to the NRL Staph for confirmation.® Bacteria DNA Mini Kit" . MRSA isolates were confirmed by multiplex PCR targeting 16S rRNA-, nuc-, and mecA-genes, as described previously [DNA extraction was performed using the "RTPeviously .mec-typing for the identification of types I-V [spa-typing [mec- and spa-typed. A multilocus sequence type (ST) was determined for selected spa-types [Further characterization of the isolates involved SCCypes I-V , and spaa-typing . One MRSpa-types . SequencSpa-types were assigned using the Ridom StaphType software , and MLST sequence analysis was carried out by matching with S. aureus MLST database (http://saureus.mlst.net).S. aureus strain ATCC 25923 was used as a control. Evaluation of resistance was based on epidemiological cut-off values published by the European committee for antimicrobial susceptibility testing for MRSA and S. aureus (http://www.eucast.org).Susceptibility tests were carried out using the broth microdilution method according to CLSI guidelines . Custom-Data analysis was performed using the statistical software program SPSS 18.0 . Univariate analysis was performed using Chi-squared test to select for herd parameters significantly associated  with the test outcome, and to estimate correlations among variables. Multivariate analysis of the data included backward stepwise binary logistic regression with the test result as the outcome (negative = 0/positive = 1) and the herd characteristics as categorical covariates to estimate odds ratios (OR) including those variables significantly associated with the outcome in the univariate analysis. For this purpose, only cases with complete information on variables included in the model were considered.To test the robustness of the model, the original sample (n = 290) was randomly divided into seven sub-samples (~41 cases each), and then subjected seven times to stepwise binary logistic regression each time excluding one of the subsamples.KA carried out data analyses and drafted the manuscript. AF participated in the microbiological testing of the strains. JAH and SH carried out the molecular genetic studies. AS and BG were responsible for susceptibility testing of the strains. NS, AG and CMG investigated statistical analyses made by KA. JB, AK, AH and BA contributed to the drafting of the manuscript. BAT is responsible for study design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.


As HIV infection continues unabated, there is a need for effective interventions targeting at-risk men who have sex with men (MSM). Engaging MSM online where they meet sexual partners is critical for HIV prevention efforts.A randomized controlled trial (RCT) conducted online among U.S. MSM recruited from several gay sexual networking websites assessed the impact of 2 HIV prevention videos and an HIV prevention webpage compared to a control condition for the study outcomes HIV testing, serostatus disclosure, and unprotected anal intercourse (UAI) at 60-day follow-up. Video conditions were pooled due to reduced power from low retention . No participant incentives were provided.Follow-up was completed by 1,631 (53%) of 3,092 eligible men. In the 60 days after the intervention, men in the pooled video condition were significantly more likely than men in the control to report full serostatus disclosure (‘asked and told’) with their last sexual partner . Comparing baseline to follow-up, HIV-negative men in the pooled video  and webpage condition  significantly reduced UAI at follow-up. HIV-positive men in the pooled video condition significantly reduced UAI  and serodiscordant UAI  at follow-up.Findings from this online RCT of MSM recruited from sexual networking websites suggest that a low cost, brief digital media intervention designed to engage critical thinking can increase HIV disclosure to sexual partners and decrease sexual risk. Effective, brief HIV prevention interventions featuring digital media that are made widely available may serve as a complementary part of an overall behavioral and biomedical strategy for reducing sexual risk by addressing the specific needs and circumstances of the target population, and by changing individual knowledge, motivations, and community norms.NCT00649701ClinicalTrials.gov  Only an estimated 19% of the more than 1 million HIV-infected persons in the U.S have an undetectable viral load, Early in the epidemic, community-wide safer sex messages delivered through print ads and media campaigns were effective at educating the gay community and lowering transmission risk behaviors. Technology-based HIV behavioral interventions are increasingly incorporating digital media, ranging from brief, untailored video interventions to complex computer-tailored multimedia interventions that target individual behaviors. Although online research studies tend to report higher attrition than offline research as there are fewer social constraints, We report findings from a theoretically grounded online randomized controlled trial (RCT), evaluating the use of HIV prevention videos and a prevention website to deliver risk reduction content to HIV-negative, HIV-positive and untested MSM. The two HIV prevention videos used in this trial were designed to reflect issues specific to MSM, while incorporating social learning theory, situated cognition, and developmental learning theory into the dialogue, storyline, and realism of the characters The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Checklist S1 and Protocol S1. Survey outcome rates and methodological terminology are based on the reporting standards of the American Association for Public Opinion Research (AAPOR). This online 5-arm RCT, with a 1∶1 allocation ratio, compared the impact of three HIV prevention video conditions, an HIV prevention webpage, and a no-content control on three primary outcomes  at 60-day follow-up. The study design was based on an online pre-post test video-based intervention pilot conducted in 2005. The primary objective of this 5-arm RCT was to assess the feasibility and efficacy of implementing a large-scale single-session online intervention, using HIV prevention videos or an HIV prevention webpage versus a no-content control, among sexually active U.S. MSM, aged 18 and over, who were recruited from four gay-oriented sexual networking websites.Eligibility criteria for the intervention were programmed into the online baseline survey. Participants had to: 1) identify as a man; 2) be age 18 or older; 3) reside in the U.S.; 4) provide an email address; 5) report oral or anal sex with a current male partner (new or not), and oral, anal, or vaginal sex with at least one new partner  in the previous 60 days; 6) and have the ability to read and respond in English. Men who completed the baseline survey but were ineligible for the intervention were automatically transferred to the exit page that contained links to health-related websites and hotlines.In April 2008, a banner ad was placed on four gay-oriented sexual networking websites for U.S. men. The demographic characteristics of the banner ad sampling frame are undefined as we do not know who was exposed to ad views. After several weeks of slow recruitment, one of the websites agreed to send emails through its internal system to all of its U.S. members . Members of this site are automatically assigned an email address upon becoming a member, thus ensuring a valid user email address. The email sent to members contained a study banner, and all email recipients were considered potentially eligible for study inclusion. The institutional review boards at Public Health Solutions (a nonprofit organization in New York City) and the Centers for Disease Control and Prevention (CDC) approved all study procedures. A waiver of documentation of written consent was obtained, given the internet-based research approach. Men who clicked on the study banner ad provided informed consent online by reading the consent form and clicking agreement to participate in the baseline survey. Following completion of the baseline survey, participants who met the inclusion criteria for the RCT were provided a second consent form inviting them to participate in additional study activities.http://hivbigdeal.org/) were designed to promote critical thinking about HIV disclosure, HIV testing, and condom use. The videos were based on social learning theories and strategies The five study conditions included a: 1) dramatic video; 2) documentary video; 3) both dramatic and documentary videos; 4) prevention webpage; and 5) control . Both the dramatic and documentary HIV prevention videos . The 60-day follow-up period was slightly extended to September 2008  in order to send an additional email reminder to all intervention participants who did not complete the 60-day follow-up survey; this resulted in an additional 194 responses (12%).We hypothesized that between baseline and 60-day follow-up, there would be increases in HIV disclosure and HIV testing, and decreases in UAI among those randomized to an HIV prevention video or a prevention webpage, compared to those in the control condition. The three primary outcome measures were increased HIV testing, HIV disclosure, and decreased UAI with sex partners at 60-day follow-up. At baseline, HIV testing variables included ever testing for HIV and month/year of last test and the result. At follow-up, HIV testing was measured as receiving an HIV test during the 60-day follow-up period. HIV disclosure was defined as partial  or full  with a partner in a sexual encounter. Anal intercourse was defined as ‘any’ insertive and/or receptive sex (yes/no). UAI was defined as ‘any’ unprotected (without a condom) insertive and/or receptive sex (yes/no). Men were asked about the three most recent sexual partners in the past 60 days beginning with the most recent. Due to a software programming error, baseline HIV disclosure data captured information for only the last partner reported in the past 60 days. To address this limitation, we compared primary outcome data between the last partner reported at baseline and the corresponding last partner reported during follow-up.Based on the prevalence of behaviors in our previous studies, we calculated true proportions and sample sizes using chi-square tests for this 5-group design. We estimated that by enrolling approximately 600 men per group and retaining 70% at 60 days follow-up, we would have 80% power at a 5% alpha level to detect behavioral change differences between 10–15% for the dichotomous primary outcomes  between the video conditions and control condition at 60-day follow-up. As an example of the actual range of power that we had to detect a difference between the control and video conditions, the power ranged from 57% to 82% across the individual video conditions for asking a sex partner’s HIV status at follow-up. After combining the video conditions, we had 90% power to detect a difference in HIV disclosure at follow-up.Those who consented were randomized into one of the five study conditions using a computerized randomization program, which included a blocking scheme to balance randomization across the study conditions using a non-deterministic algorithm. Once participants consented and were randomized, they were kept in their original assignment condition and sent a link to the 60-day follow-up survey . Thus, we used an ITT approach for primary outcome analyses. Since randomization was not stratified, for Analyses in One of the four sexual networking websites agreed to send emails to all of its U.S. members . A total of 23,213 (3.8%) men clicked on the study recruitment email hyperlink or banner ad that took them to the study landing page . Of thosAmong the consenting 11,798, the following were excluded: 157 residing outside of the US; 25 female, 17 female-to-male transgender, and 4 male-to-female transgender; 311 duplicate cases were detected and excluded. In addition, 5,449 men were ineligible for study enrollment, and 2,743 men were eligible but refused participation. A total of 3,092 participants were eligible and randomized into the study as follows: 609 in the control arm, 609 in the prevention webpage arm, 625 in the dramatic video arm, 633 in the documentary video arm, and 616 in the dramatic/documentary video arm . The droAmong randomized respondents, 32% (n = 976) were recruited through banner ads and 68%  through an e-mail member list. Most (93%) respondents recruited via banner ads were from the same sexual networking site that sent the study e-mail. Compared to men recruited through emails, men recruited via banner ads were significantly more likely to complete 60-day follow-up . No demographic or primary outcome differences were found between the two recruitment methods, except for HIV status; HIV-positive men were significantly more likely to have been recruited through a banner ad than by email  (data not shown).Compared to men who did not complete 60-day follow-up, men who did complete follow-up were significantly older , and more likely to be white , college-educated , HIV-positive , and earn more than $50,000 per year . Men who completed follow-up were also significantly more likely to have non-main partners at baseline  and to report more than 100 lifetime anal sex partners  than men who did not complete follow-up.Overall retention at 60-day follow-up was 53%  and there was no differential attrition by study condition or baseline demographic and behavioral characteristics in At follow-up , men in With McNemar’s test , we examContrary to expectations, men in both the webpage and control conditions had significant reductions in asking their partner’s HIV status at follow-up compared to baseline . For full disclosure, men in the pooled video condition were significantly less likely to ask and tell, overall (OR 0.76), and among HIV-positive participants (OR 0.35), at follow-up compared to baseline. Regarding HIV testing from baseline to follow-up, no changes were seen in any of the conditions.Comparing men who did and did not complete follow-up, we assessed the potential impact of attrition by conducting sensitivity analyses. We assessed HIV disclosure at follow-up with the last sexual partner for parsimony and made two different assumptions about HIV disclosure among those lost to follow-up. First, we assumed that all men lost to follow-up were disclosers and found that asking a sex partner’s HIV status would be significantly higher in the pooled video condition than in the control . Second, we assumed that all those lost to follow-up were non-disclosers and found that there would also be a significant difference, albeit smaller, in asking between conditions .To assess whether men who did not complete follow-up differed significantly on the primary outcome estimates from those who did complete follow-up, we tested for non-response bias. The full sample baseline primary outcome estimates for past 60-day behaviors were 44% for asking HIV status, 53% for telling HIV status, 58% for any UAI, and 18% for HIV testing. Using the baseline primary outcome estimates, we calculated follow-up non-response bias by subtracting the mean difference between men who responded to follow-up and the baseline sample, divided by the baseline sample estimate. Men who did complete follow-up had lower baseline mean estimates than men who did not complete follow-up for the baseline primary outcomes asking HIV status (41% vs. 47%), telling HIV status (52% vs. 53%), reporting any UAI (57% vs. 58%), and HIV testing (16% vs. 17%). We found significant non-response bias for asking HIV status, though the magnitude was small and was biased towards the null. Thus, men who completed the follow-up survey were significantly less likely to have asked their last sexual partner’s HIV status than men who did not complete the follow-up survey . No differences were found between men who did and did not complete follow-up for the other primary outcomes.Findings from this online RCT of MSM recruited from sexual networking websites suggest that a low cost, brief digital media intervention conducted completely online can increase HIV disclosure to sexual partners and decrease sexual risk. Theoretically grounded HIV prevention videos, designed to engage critical thinking, and an HIV prevention website were evaluated for their impact on HIV disclosure, UAI, and HIV testing. MSM participating in the online trial were predominantly white with high income and education and were from every U.S. state. As reporting a new sex partner at baseline was one eligibility criterion for inclusion into the online trial, men participating in our study reported considerable HIV transmission risk at enrollment. On average, men reported 2 anal sex partners in the past 60 days, with more than half reporting UAI with non-main partners. Men who completed 60-day follow-up differed from men who did not complete follow-up by demographic and behavioral characteristics; most notably, men completing follow-up were significantly more likely to be HIV-positive, report non-main partners at baseline, and report more lifetime anal sex partners than men not completing follow-up.At 60-day follow-up, modest group-level effects were seen for HIV disclosure. Men in the pooled video condition were significantly more likely than men in the control condition to report full (“asking and telling”) and partial (“asking”) HIV disclosure with sexual partners. Among men who had non-main partners during follow-up, partial HIV disclosure was significantly higher in the video condition than control condition. Significant changes in sexual behavior and HIV testing were not seen at the group level.Contrary to expectations, some men were significantly less likely to disclose their HIV status to sex partners from baseline to 60-day follow-up. In contrast, within-person effects were found for reduced UAI at follow-up compared to baseline, with men reporting significant reductions in UAI in both the pooled video (OR 0.61) and webpage conditions (OR 0.42). The reduction in UAI among men in the pooled video condition is similar to a previously published one-group, pre-post pilot intervention – using one of the same videos used in the current trial – among MSM recruited from one of the same gay-oriented sexual networking websites that assessed within-person reduction of UAI (OR 0.55). From baseline to 60-day follow-up, HIV-negative men reported significant reductions in UAI in both the pooled video and webpage condition. HIV-positive men in the pooled video condition also reported significant reductions in UAI, but the most striking finding for HIV-positive men in the video condition was their significant reduction in UAI with HIV-negative or unknown status partners at follow-up compared to baseline (OR 0.53). It appears that that this low intensity digital media intervention may have resonated most with sexually active HIV-positive MSM, who may not be reached by traditional offline prevention messages.While HIV disclosure during follow-up was significantly higher across several sex partners  it was significantly lower when examined by participants’ baseline-to-follow-up corresponding partner. UAI was also significantly lower with corresponding partners from baseline to follow-up, which suggests that, rather than having a potentially awkward discussion about sex and serostatus, some men may have opted not to have unprotected sex. Disclosure to sexual partners and its relationship to sexual risk is complex and varies by partner type and venue Historically, online research has had lower retention rates than offline research as there are fewer social constraints compared to in-person interviewing. Within a given study, non-response bias can occur when respondents differ from non-respondents, though non-response, in and of itself, does not mean that the data are inherently biased. Even within the context of these limitations, in this predominantly white sample of MSM recruited from one of the largest U.S. sexual networking websites for gay men, there was a modest effect from this online digital media intervention, with an overall increase in HIV disclosure and reduced sexual risk in both HIV-positive and HIV-negative men. The reduction in serodiscordant UAI among HIV-positive participants suggests that the videos resonated most with HIV-positive men, who may have been more amenable to change in an online intervention setting, The development of online HIV prevention interventions is a burgeoning field. But in the overall landscape of HIV prevention, how do technology-based interventions fit in? There has been a recent push in HIV prevention for “combination prevention.” The use of theoretically grounded dramatic or documentary video designed to engage critical thinking, in combination with biomedical science, is a largely unexplored area. Brief, widely available, effective digital media interventions like the HIV prevention videos and webpage described here may serve as a complementary part of an overall strategy for increasing HIV disclosure and reducing sexual risk. Even if modestly effective, online social marketing campaigns have the potential to expose a much broader audience to brief, digital media prevention interventions. Delivering HIV prevention content to MSM online where they seek sexual partners is an efficient way to reach large samples of geographically dispersed at-risk men and has the potential for a public health impact through addressing the specific needs and circumstances of the target population, and by changing individual knowledge, motivations, and community norms.Checklist S1CONSORT Checklist.(DOCX)Click here for additional data file.Protocol S1Trial Protocol.(DOC)Click here for additional data file.