A study among female sex workers in Senegal found no evidence of increased sexual risk behavior after preexposure prophylaxis initiation as measured by self-report or Y-chromosomal DNA detection.Supplemental digital content is available in the text. Preexposure prophylaxis (PrEP) can reduce HIV acquisition among female sex workers (FSWs). However, changes in condomless sex frequency after PrEP initiation could reduce PrEP effectiveness when PrEP adherence is suboptimal as well as increase the risk of acquiring other sexually transmitted infections. Objective measures of condomless sex may be more accurate for determining changes in sexual behavior than self-reported measures.We longitudinally measured self-reported condom use, number of clients, and presence of Y-chromosomal DNA (Yc-DNA) in vaginal swabs among 267 FSWs accessing PrEP at 4 clinics in Senegal between 2015 and 2016. We assessed trends in sexual behavior over time since PrEP initiation using generalized estimating equations and evaluated predictors of Yc-DNA detection.We found no increase in self-reported condomless sex with clients , main partners , or Yc-DNA detection  over time since initiation. Y-chromosomal DNA was detected in 34 (22%) of 154 swabs tested and in 15 (26%) of 58 swabs from FSW reporting consistent condom use among both clients and main partners. Self-reported condom use with clients or main partners did not predict Yc-DNA detection.In a FSW PrEP demonstration project in Senegal, we found no evidence of risk compensation among FSWs on PrEP as measured by self-reported behavior or through Yc-DNA detection. Y-chromosomal DNA detection was frequently detected among FSWs reporting consistent condom use, highlighting limitations of self-reported sexual behavioral measures. Our objectives were to assess changes in self-reported sexual behavior and Yc-DNA detection from time since initiation, to evaluate whether self-reported sexual behavioral measures such as recent partners and condom use were associated with vaginal Yc-DNA detection, and to evaluate predictors of Yc-DNA detection.Sex work has been legal in Senegal since 1969 and is regulated by requiring sex workers to register at a health facility and attend routine checkups.24 Briefly, 267 HIV-negative active FSWs (reported paid sex within the past 6 months) medically eligible for PrEP were offered daily oral tenofovir disoproxil fumarate/emtricitabine  at 4 clinics in Senegal and followed up at 1 month, 3 months, and every 3 months thereafter for 1 year. Study visits occurred from 2015 to 2016 and included testing for HIV-1 and HIV-2 and other STIs, medication adherence counseling, condom distribution, risk reduction counseling, clinical examination, and creatinine testing. At each visit, trained staff conducted standardized interviewer-administered questionnaires to assess demographic, clinical, and sexual behavior characteristics among participants continuing to receive PrEP services. Retention in PrEP care was 67% at 12 months after PrEP initiation . No HIV seroconversions were detected over the course of the study among participants retained in care. The study was registered at ClinicalTrials.gov (NCT02474303). All participants in this study provided written informed consent, and the study was approved by the Human Subjects Division Institutional Review Board at the University of Washington, the Institutional Review Board at Westat, and the Senegalese National Ethics Committee for Health Research.The design, methods, and primary outcomes of the Senegal PrEP Demonstration Project have been described previously.At initiation and each follow-up visit, participants were asked to report the following measures: number of clients in the last 7 days, frequency of condom use during vaginal or anal sex with clients in the last month , whether the participant has a “main” partner , number of main partners in the last month, and frequency of condom use during vaginal or anal sex with main partners in the last month . Participants were also asked if they used a condom the last time they had sex with a client and the last time they had sex with a main partner.http://links.lww.com/OLQ/A483). Vaginal swabs were frozen at −80°C and shipped on dry ice in bulk to the University of Washington in Seattle. DNA extraction was conducted using the QIAamp96 DNA blood kit  as described previously.25 The Quantifiler Duo DNA Quantification Kit  was used for Yc-DNA detection per the manufacturer's instructions as described previously.26 All Yc-DNA polymerase chain reaction analyses were conducted by female laboratory staff  who were blinded to study data. We excluded one sample that produced an invalid result . Two swabs from the same participant at the same visit  were inadvertently analyzed and returned discordant results. We excluded the negative result because the likelihood of cross-contamination was low (adjacent samples were negative), the detection level in the positive swab was near the limit of detection, and the assay is highly specific because of low levels of cross-reactivity. Therefore, our sample for our final analysis included 154 swabs from 121 women.Vaginal swabs were self-collected by women at each visit. We used nonproportional quota sampling  to choose 156 swabs from 121 FSWs for Yc-DNA testing throughout the study period . Neisseria gonorrhoeae and Chlamydia trachomatis nucleic acid amplification testing was performed in Senegal at the Institut de Recherche en Santé de Surveillance Epidemiologique et de Formations using the Roche cobas 4800 System  per the manufacturer's instructions. Syphilis testing was performed by clinic staff using rapid plasma reagin and Treponema pallidum hemagglutination assays.Limited STI testing was conducted because of logistical constraints such as equipment failure and reagent stockouts and funding  and a Gaussian model with identity link to model the number of clients reported in the last week. All models included month since initiation as a linear predictor and were adjusted for age, education, ethnic group, and clinic site. To evaluate changes in sexual behavior over time since initiation, we tested whether the estimated coefficient on the month since initiation variable was statistically significantly different from 0 (linear models) or 1 (logistic models).We summarized demographic and behavioral characteristics of participants using descriptive methods. We dichotomized self-reported condom use into always (consistent) or not always (inconsistent). To investigate changes in sexual risk behaviors over time since PrEP initiation, we calculated the average number of clients reported in the last 7 days and the proportion of participants reporting inconsistent condom use in the last month with main partners and clients by study visit among all women enrolled in the demonstration project. We also calculated the proportion of swabs with detectable Yc-DNA by study visit. We estimated 95% confidence intervals (CIs) for proportions using the Wilson score interval to constrain limits between 0 and 1.To compare Yc-DNA detection by reported partnerships, we stratified the proportion of swabs with detectable Yc-DNA by reported sex with a client (in the 7 days before swab collection), main partner (in the month before swab collection), or both. To compare Yc-DNA detection by reported condom use, we calculated the proportion of swabs with detectable Yc-DNA by condom use in the last month with clients, main partners, or both, as well as condom use at most recent sex with clients, main partners, or both. We assessed condom use with main partners in the last month only among those reporting at least one main partner in the last month; because the number of clients was ascertained in the prior week, we did not perform a similar restriction for condom use with clients in the last month. We also compared Yc-DNA detection across baseline demographic and socioeconomic measures hypothesized a priori as potential predictors of condomless sex frequency. We estimated odds ratios (ORs) and 95% CIs using generalized estimating equations assuming an exchangeable working correlation structure. All analyses were conducted using R version 3.6.1.T. pallidum hemagglutination assay test result at either baseline or at any point throughout the study period. The distribution of demographic and baseline characteristics among the subsample of participants for Yc-DNA testing was similar to that of all the participants in the demonstration project .The demographic and baseline characteristics of the 267 participants enrolled in the PrEP Demonstration Project are shown in Table Figure P = 0.053), whereas the odds of inconsistent condom use with main partners was stable over time . The estimated change in number of reported clients for a 1-month increase in time since PrEP initiation was negative , although this difference was not statistically significant. The median number of clients reported in the past 7 days did not change over time . We found no evidence of changes in the odds of Yc-DNA detection over time .In adjusted logistic regression models, we estimated the ORs of inconsistent condom use for a 1-month increase in time since PrEP initiation. The odds of inconsistent condom use with clients decreased over time . Y-chromosomal DNA detection did not differ by whether participants reported having had sex with a client in the last week . Nearly all (96%) of participants reported always using condoms with clients in the month before swab collection, but 22% of samples from these participants had detectable Yc-DNA. Of 58 participants who reported always using condoms with both their main partner and clients in the last month, 15 (26%) had swabs with detectable Yc-DNA. The odds of Yc-DNA detection did not differ significantly by whether or not participants reported inconsistent condom use in the last month with clients , main partners ; P = 0.67), or both . Results were similar when condom use was assessed at most recent sex rather than over the last month. In addition, none of the other variables we evaluated  were statistically significantly associated with Yc-DNA detection in unadjusted analyses .Thirty-one of 121 women tested had at least one swab with detectable Yc-DNA , and Yc-DNA was detected in 34 (22.1%) of 154 swabs overall . Table 30 A recent analysis of a cohort of FSWs initiating PrEP in Benin found no changes in the frequency of prostate-specific antigen or Yc-DNA detection for 24 months since initiation.22 Several reasons could explain the lack of risk compensation observed in our study. It is possible that changes in risk behavior may not manifest within the first year of follow-up during PrEP demonstration projects; alternatively, risk reduction counseling and condom provision during PrEP delivery may counteract any perceived economic incentives for engaging in condomless sex. Furthermore, because condoms protect against other STIs and unwanted pregnancy, PrEP use may not have impacted participants' desire to use condoms. Prior research has established a relationship between sexual violence and condomless sex that is partially mediated by difficulties in condom negotiation.31 If FSWs have little control over condom use, then PrEP use may have little impact on the frequency of condomless sex. Although difficulty negotiating condom use is an important consideration, study participants reported high confidence in their ability to use condoms with clients and main partners, suggesting that participants in our study had considerable agency in determining their frequency of condomless sex. Because PrEP is rolled out to FSW in resource-limited settings, ongoing assessments of HIV acquisition, STIs, and risk behavior will be needed.Our objectives were to assess changes in sexual behavior after PrEP initiation, to compare self-reported measures with Yc-DNA detection among FSWs in Senegal, and to assess predictors of Yc-DNA detection. We found no evidence of risk compensation after PrEP initiation as measured by changes in number of clients, condom use, or Yc-DNA detection. Although prior studies in Africa have shown that FSW may charge more for condomless sex, and a discrete choice experiment among FSWs in South Africa predicted that PrEP use would more than double the frequency of condomless sex, our results are consistent with previous studies in PrEP demonstration projects among FSWs in South Africa and Benin that have shown no evidence of risk compensation.34 In our study, Yc-DNA was detectable in 26% of swabs from participants reporting consistent condom use in the past month with both clients and main partners. This discrepancy may be explained by several factors. Participants may have overreported condom use because of fear of judgment or stigma by health care workers and study staff.35 Incorrect condom usage or condom failure could have resulted in unnoticed semen exposure detected by the Yc-DNA assay.19 Our measures of reported condom use may not adequately capture nonconsensual condom removal or forced breakage, which have been reported in other settings.36 In addition, participants may have misinterpreted the questions or misremembered their condom use. The accuracy of self-reported sexual behavior tends to decrease with longer recall periods or when behavior frequency is high.13 These results warrant caution in the use of self-reported sexual behavior for assessing individual-level HIV risk.Despite high levels of reported condom use, Yc-DNA was detected in 22% of swabs tested, and self-reported condom use, partnerships, and demographic characteristics did not predict Yc-DNA detection. Prior studies among sex workers in sub-Saharan Africa have not identified consistent predictors of misreporting as compared with prostate-specific antigen detection.17 We did not assess menstruation or female genital hygiene practices, such as vaginal washing or douching, that potentially could have affected assay performance. Although we ascertained sexual behavior among clients and main partners, we did not ascertain whether participants had other types of partnerships. Our estimate of underreporting may be too high if these partnerships are common and if participants who reported consistent condom use with both clients and main partners would have reported not using a condom with other types of partners. Last, our results may not be generalizable to FSW in other settings or in routine PrEP delivery outside demonstration projects, where factors influencing condom use, partnerships, and sexual behavior reporting could differ. Nevertheless, these results highlight the limitations of using self-reported measures to assess sexual risk behaviors in this population.Our study builds on prior research of risk compensation by assessing changes in objective biomarker-based measures of sexual behavior over time since PrEP initiation. However, our analysis has several limitations. Our sample size for Yc-DNA analysis was limited by funding and reduced our power to detect predictors of Yc-DNA detection or trends in Yc-detection over time. As condom use was assessed in the month before swab collection, and the sensitivity of Yc-DNA assays is limited beyond 2 weeks after semen exposure, the level of underreporting may be underestimated in our study. Oral sex and/or digital vaginal penetration by clients or main partners may have left traces of Yc-DNA detectable by vaginal swabs, potentially explaining some of the positive Yc-DNA results among women reporting consistent condom use.In our study of PrEP initiation among FSWs in Senegal, we found no evidence of risk compensation using self-reported condom use, using self-reported number of clients, or by Yc-DNA detection. However, condomless sex as measured by detectable Yc-DNA in vaginal swabs was common among FSWs who self-reported consistent condom use. Studies that rely on accurate measurement of sexual behavior should consider using biomarker measures when feasible. Additional efforts are needed to improve the accuracy of self-reported sexual behavior data.


Secondary endpoints include vaccine-induced immune responses and clinical response of patients with measurable disease.Sahin et al. recently reported interim data from a phase 1 clinical trial (NCT02410733) treating melanoma patients with a RNA-lipoplex vaccine (RNA-LPX), targeting melanoma TAA.Cancer vaccines have a mixed track record but the recent marked success of immune checkpoint blockade (ICB) immunotherapy has renewed interest in cancer vaccines. Cancer vaccine targets include TAA and more recently, cancer neoantigens. TAA include proteins that are aberrantly expressed in tumors compared with normal tissues , or proteins that are expressed in tumors but are normally sequestered in immune-privileged sites, or produced only in certain differentiation stages. The prevalence of TAA in cancers makes it possible to design and manufacture off-the-shelf vaccines targeting TAA.2 Finally, TAA vaccines may result in autoimmunity. Such off-tumor, on-target toxicity, although tolerable, has been observed in clinical studies. It remains unclear if the disappointing results of studies targeting TAA is a result of the inability to induce robust immune responses, or the inability (until recently) to effectively target immune checkpoints.Unfortunately, there are challenges targeting TAA, and cancer vaccines targeting TAA have proven to be disappointing. TAA vaccines must overcome central and acquired tolerance, limiting the magnitude of induced T-cell responses. Many vaccine platforms have proven to be suboptimal, inducing weak and/or short-lived immune responses.3The trial involved 89 patients with advanced melanoma that express at least one of the four targeted TAA. Patients were treated with repeated doses of intravenously delivered BNT111 ranging from 7.2 to 400 µg. Some cohorts received vaccine alone, whereas others were also treated in combination with anti-PD1 therapy. Of note, almost all patients had received prior ICB therapy . Most patients experienced mild to moderate, transient flu-like symptoms including pyrexia (82%) and chills (71%). The investigators also documented a transient upregulation of plasma cytokines  accompanied by a transient increase of body temperature, indicating an inflammatory response induced by RNA interaction with toll-like receptors (TLR). This is consistent with the RNA-LPX vaccine’s proposed mechanism of action  showed immune responses against at least one TAA, indicating a robust response to the vaccine. Most of the responses were CD8Clinical activity was evaluated in a subset of 42 ICB-experienced patients with measurable disease. Twenty-five patients received the vaccine as a single agent. Three experienced a partial response, and seven showed stable disease. Seventeen patients were treated with the vaccine in combination with anti-PD1. Six of them developed a partial response (35%), a response rate similar to response rates for PD1 blockade alone in ICB-naïve melanoma patients. There was a correlation between T-cell responses and favorable clinical outcomes.3 RNA also activates the TLR7 signaling pathway and induces an inflammatory cytokine response, driving DC maturation, and the presentation of TAA by both MHC class I and class II molecules. The ability to induce robust immune responses to TAA suggest that RNA-LPX vaccines represent an attractive delivery platform to target TAA. Other vaccine platforms are currently under active investigation . It remains unclear if the low rate of clinical benefit is related to the limited ability of many vaccine platforms to induce robust responses or other factors such as the inability to overcome immune checkpoints and/or regulatory networks that restrain immune responses in the tumor microenvironment.2It is notable that the RNA-LPX vaccines are able to induce robust immune responses to TAA. The RNA-LPX platform is formulated as a liposome to protect RNA from degradation and target immature DCs in lymphoid tissues.4 The investigators demonstrated that PD1 blockade of suboptimally primed CD8+ T cells  results in dysfunctional T cells characterized by upregulation of CD38, and the inability to respond to subsequent antigen or vaccine stimulation. This suggests that cancer vaccine administration following failed ICB may not be ideal. The RNA-LPX vaccine study shows that it may be possible to reverse this anti-PD1-induced CD8+ T-cell dysfunction under certain conditions. Additional study will be necessary to determine the best strategies to combine ICB and cancer vaccines.There is currently great interest in combining ICB with other immune therapies including cancer vaccines. It remains unclear how to best combine these therapies. The RNA-LPX vaccine study is notable given that some patients who failed previous ICB experienced a clinical response to the RNA-LPX vaccine. A recent study by Verma et al. highlights some of the challenges of trying to combine ICB with cancer vaccines.5 The present study highlights the potential of cancer vaccines leveraging robust vaccine platforms in combination with ICB. Given the safety profile of cancer vaccines, additional study should be prioritized to best define strategies to integrate cancer vaccines into existing clinical treatment paradigms. Given recent insights into the biology of immune checkpoints and the tumor microenvironment, cancer vaccines will likely need to be combined with other immune therapies to reach full potential.Overall, the results of the RNA-LPX vaccine targeting melanoma TAA are encouraging. Success targeting melanoma TAA has important implications beyond melanoma given that promising TAA have been identified in other cancer types. In addition to TAA, RNA-LPX, peptide, and DNA vaccines targeting cancer neoantigens are being tested. Unlike TAA, neoantigens are derived from genetic alterations and are tumor specific. Targeting neoantigens requires a personalized approach with minimal risk of collateral damage. Neoantigens are also not subject to central tolerance and can trigger robust immune responses. Early results of neoantigen cancer vaccines are promising but limited clinical data make it difficult to meaningfully compare neoantigen vaccines to TAA vaccines. Vaccines targeting both TAA and cancer neoantigens may prove more effective than targeting either TAA or neoantigens alone.


We evaluated a 2-way short messaging service (SMS) communication platform to improve continuation of pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan pregnant and postpartum women who initiated PrEP within routine maternal child health and family planning clinics. SMS increased support for PrEP, provided opportunities for dialogue beyond the clinic, and enabled women to ask and receive answers in real-time, which facilitated continued PrEP use. We evaluated a 2-way short messaging service (SMS) communication platform to improve continuation of pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan pregnant and postpartum women who initiated PrEP within routine maternal child health and family planning clinics. SMS increased support for PrEP, provided opportunities for dialogue beyond the clinic, and enabled women to ask and receive answers in real-time, which facilitated continued PrEP use. We evaluated a 2-way short message service (SMS) communication platform to improve continuation of pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan women who initiated PrEP within routine maternal child health (MCH) and family planning clinics.We adapted an existing SMS platform (Mobile WACh [mWACh]) to send PrEP-tailored, theory-based SMS and allow clients to communicate with a remote nurse. Women who did not have HIV and who were initiating PrEP at 2 MCH/family planning clinics in Kisumu County, Kenya, from February to October 2018, were offered enrollment into the mWACh-PrEP program; SMS communication was free. We evaluated acceptability, satisfaction, and implementation metrics. In a pre/postevaluation, we compared PrEP continuation at 1-month postinitiation among women who initiated PrEP in the period before (n=166) versus after mWACh-PrEP implementation, adjusting for baseline differences.P=.008) and more likely to continue PrEP . Among those who returned, 99% reported successful receipt of SMS through the mWACh-PrEP system and 94% reported that mWACh-PrEP helped them understand PrEP better. Concerns about PrEP use, how it works, and side effects accounted for the majority (80%) of issues raised by participants using SMS.Of the 334 women who were screened for enrollment into the mWACh-PrEP program; 193 (58%) were eligible and of those, 190 (98%) accepted enrollment. Reasons for ineligibility (n=141) included no phone access (29%) and shared SIM cards (25%). Median age was 25 years (interquartile range=22–30), and 91% were MCH clients. Compared to women who initiated PrEP in the month before mWACh-PrEP implementation, women who enrolled in mWACh-PrEP were more likely to return for their first PrEP follow-up visit (40% vs. 53%; adjusted risk ratio [aRR]=1.26; 95% confidence interval [CI]= 1.06, 1.50; Two-way SMS expanded support for PrEP and opportunities for dialogue beyond the clinic and enabled women to ask and receive answers in real time regarding PrEP, which facilitated its continued use. SMS messages incorporated behavioral theory-informed counseling framed in the informational-motivational-behavioral skills model, specifically tailored to women receiving PrEP in the context of MCH/family planning services . The intBOXMotivational Interviewing {name}, this is {nurse} from {clinic}. It can be difficult to take medications every day especially if you are trying to be discrete. Many people ask a friend to help remind them, set a timer on their phone, or take it with a meal. You can also put it in a different container you can carry with you in private. How do you remember to take your medication? Do you have any challenges taking it every day?Theory of Planned Behavior {name}, this is {nurse} from {clinic}. Side effects from PrEP affect each person differently. Most side effects lessen after the first few weeks of use, once the body is used to the medication. Please let us know if you are having any side effects. We can help you manage them or know if it is okay to continue.Health Belief Model {name}, this is {nurse} from {clinic}. You are doing a great job taking care of yourself. PrEP is very effective at preventing you from getting HIV if you take it every day. It also helps prevent HIV infection to your baby if you are pregnant. If you miss too many doses it may not work. Are you having any challenges taking the medication?Social-Cognitive Theory Good job coming in for your visit! You will receive weekly SMS to help support taking your medication. Please SMS back and tell us any questions or concerns you have. Please tell us if you need assistance with your prevention medication. If you have any challenges or stop PrEP, please let us know.From February to October 2018, we approached women on the same day they initiated PrEP at the 2 selected MCH/family planning clinics and offered them participation in the mWACH-PrEP program. Women were eligible if they initiated PrEP that day, had a functioning cellphone in-hand that they did not share with anyone, and had an active SIM card on the Safaricom network (Kenya's largest network provider). Reasons for ineligibility were captured. We did not exclude women who expressed confidentiality concerns related to their PrEP use or content of the SMS. All women were free to decline enrollment and welcome to stop receiving SMS at anytime.Women registered into the mWACh-PrEP platform indicated their preferences for message delivery including a preferred name for messaging, language , and day of the week and time for SMS delivery. All automated push messages included participant nickname, clinic, and nurse name, an educational message or actionable advice targeting PrEP adherence and continuation and/or MCH/family planning topics, and a question related to the content. SMS topics included adherence encouragement, PrEP efficacy and safety, self-efficacy for prevention of HIV, support for potential PrEP side effects, behavioral skills (tips for remembering PrEP medications), and visit reminders. During enrollment, the program nurse explained that replies to the automated SMS questions were voluntary, though women were enrouraged to reply. Women were also encouraged to send SMS with their concerns or questions whenever they arose. The program nurse was available to answer SMS during normal business hours on weekdays. All messaging was free of charge to the participant using a reverse billed short code. SMS were sent from enrollment until December 2018. Participants could voluntarily and autonomously exit the program by texting “STOP,” which would end all platform communication.All SMS communication was conducted through our custom web application designed for 3‐way communication between the automated push system, program staff, and participants. SMS data were downloaded biweekly by program data managers to track SMS outages and data on implementation activity . When a participant sent an unprompted question or sent a reply to an automated message that was not in English, program nurses translated the SMS into English within the system daily to ensure interpretation consistency and allow for quality assurance/quality control. We defined utilization using 2 metrics: responding to automated push messages and sending an unprompted question or concern using SMS.Program nurses administered questionnaires to women enrolled in mWACh-PrEP at routine 1-month PrEP follow-up visits to assess satisfaction using a series of items on a 5-point Likert scale . Closed-ended items assessed self-reported utilization experiences with the platform . We also abstracted PrEP indicators from the Kenya Ministry of Health client encounter form that included data on attendance of a PrEP follow-up visit, self-reported adherence (number of missed PrEP doses in the past month), and PrEP refills. We defined PrEP continuation as confirmed dispensation of a PrEP refill at an attended follow-up visit. PrEP discontinuation was defined as no PrEP refill or no attendance at a follow-up visit. Data from PrEP follow-up visits were abstracted for all women who initiated PrEP in the month before implementation of the mWACh-PrEP program and from all women who were screened for mWACh-PrEP enrollment.,P<.05 level.We used descriptive statistics to summarize acceptability, satisfaction, and utilization indicators. We used Chi-squared tests for proportions and Kruskall-Wallis tests for continous measures to compare baseline demographic and behavioral characteristics of women who were eligible and enrolled in the mWACh-PrEP program with (1) women who initiated PrEP in the month before implementation of mWACh-PrEP and (2) women who were screened for enrollment but were ineligible/declined. We compared PrEP continuation and self-reported adherence among women who enrolled in mWACh-PrEP with women in the other 2 groups using Chi-squared tests and multivariate Poisson regression models with robust error variance, an approach used when the outcome prevalence is not rare .At the completion of the mWACh-PrEP program, transcripts of SMS conversations were analyzed using a modified constant comparative approach. Our primary goal was to identify issues raised by women who initiated PrEP through unprompted questions or concerns sent to nurses using the mWACh-PrEP system. We developed an initial codebook based on a review of a subset of transcripts and input from nurses who responded to participants' messages, and the codebook was iteratively refined. SMS transcripts were transferred into Microsoft Excel for data management. All transcripts were coded by 2 research team members (ZR and JP), and coding disagreements were resolved through discussion. Key issues raised by women who enrolled in mWACh-PrEP were identified by reading transcripts to identify similarities and differences across conversations, and codes were subsequently organized within thematic categories to identify trends. We also selected representative quotations pertaining to each main category.Our primary qualitative analysis goal was to identify issues that women who initiated PrEP raised through unprompted messages.Protocols were reviewed and approved by the Kenyatta National Hospital-University of Nairobi Ethics Research Committee and University of Washington Human Subjects Review Committee. In addition, approval was obtained from the Kisumu County Department of Health and administrators in respective health facilities. Women provided informed consent for all activities.Overall, 334 women were screened for participation in the mWACH-PrEP program ; 193 58. Almost P<.001). Compared to women who initiated PrEP in the period before mWACh-PrEP, eligible and enrolled women were also slightly older , more frequently married , and more frequently attending first ANC visits, if pregnant . There were no other differences in demographic and behavioral characteristics between women who were eligible and enrolled and women who were either ineligible/declined or who initiated PrEP before mWACh-PrEP . Most women (94%) reported that the SMS helped them understand PrEP better and 89% reported that the SMS helped them adhere to PrEP. Almost all (95%) would recommend mWACh-PrEP to other women who use PrEP, and 95% would also use the program again, if offered .Overall, 100 of 190 (53%) women who enrolled returned for a follow-up visit at a median of 29 days (IQR=28–40) since PrEP initiation. Almost all (99%) reported successful receipt of SMS messages through the mWACh-PrEP system. Among the 99 women who received messages, 72 (73%) women reported consulting by SMS with the nurse and, of those, 47 (66%) reported continuing PrEP because of the nurse's advice (Most women reported that the SMS helped them understand PrEP better and helped them adhere to PrEP.P=.008). Compared to women who initiated PrEP in the month before mWACh-PrEP implementation, women who enrolled in mWACh-PrEP were almost twice as likely to continue PrEP after adjustment for age and marital status . Among women who returned for follow-up, 74 (73%) of women who enrolled in mWACh-PrEP self-reported high PrEP adherence (<1 missed pill/week) compared to 37 (55%) of women who initiated PrEP before mWACh-PrEP . Compared to women in a contemporaneous cohort who were ineligible or declined enrollment, women enrolled in mWACh-PrEP were also more likely to return for a follow-up visit  and continue PrEP ; among those who attended follow-up visits, self-reported high adherence was similar across those contemporaneous groups .Among the 166 women who initiated PrEP in the month before mWACh-PrEP implementation, 67 (40%) attended a PrEP follow-up visit compared to 101 (53%) of women who enrolled in mWACh-PrEP  women who enrolled in the mWACh-PrEP program. Among 170 women with analyzed transcripts, 97 (57%) ever responded to the automated messages. Median duration of enrollment in the mHealth program was 24 weeks (IQR=17–31). Frequency of responding to automated messages was highest at week 1 (29%) and substantially lower by week 6 (14%) . The medOverall, 74 of the 170 (44%) participants ever sent unprompted questions or concerns to the nurse using SMS during follow-up, and a total of 183 unprompted SMS were received and answered by nurses. The median number of unprompted questions/concerns sent per client was 2 (IQR=1–3). Seven major topics were raised by participants in their SMS queries . PrEP coIn this mixed-methods evaluation of an mHealth tool within a programmatic PrEP delivery setting, we found very high acceptance (98%) among the subset of women who met inclusion criteria, an almost 2-fold greater early PrEP continuation, and higher self-reported adherence among women who were enrolled in mWACh-PrEP than those who initiated PrEP before mWACh-PrEP implementation. We also found high satisfaction with the mWACh-PrEP system and high utilization. Almost half (44%) of the women who enrolled had unprompted questions or concerns addressed using SMS, most of which were PrEP-related. To our knowledge, this is the first evaluation of an mHealth intervention for PrEP adherence targeting pregnant and postpartum women, and this communication platform addressed topics very specific to pregnancy and the postpartum period. As PrEP delivery within routine MCH/family planning settings expands, mHealth strategies tailored to pregnant and postpartum women may improve PrEP continuation and adherence in this unique population.This is the first evaluation of an mHealth intervention for PrEP adherence targeting pregnant and postpartum women.,We previously reported that PrEP counseling before initiation in the PrIYA program lasted approximately 18 minutes per client.,–Ongoing studies are testing mHealth tools that address various stages of the PrEP care continuum in diverse populations, including using mHealth to increase uptakeAlthough we found high acceptability in our evaluation, 42% of screened women were ineligible due to cell phone-related issues. The most frequent reason for ineligibility was not having a cell phone in the clinic; this was required to confirm registration was successful. Future iterations of the mWACh-PrEP platform could incorporate off-site registration options for clients to complete self-registration at a later time. Additionally, not having a SIM card compatible with the mWACh system was another major reason for ineligibility. We partnered with Safaricom for mWACh-PrEP as this is the largest network provider in Kenya. Inclusion of other network providers within the platform, which is feasible at a modest additional cost, would increase accessibility and reach.Our evaluation has limitations. We did not collect information on mWACh-PrEP eligibility criteria  during the period before mWACh-PrEP implementation. Therefore, our pre/postevaluation design produced less rigorous results than a randomized trial, and we may have unmeasured differences between our comparison groups that could influence effect size. However, this nonrandomized evaluation provides insight into how mHealth interventions work in a real-world context. Within a program setting, we found nearly a 2-fold increase in PrEP continuation among women who enrolled in the mWACh-PrEP compared to both women who initiated PrEP before mWACh-PrEP implementation and a concurrent cohort of women who were ineligible/declined.We intentionally restricted our comparison group to only January 2018, the month immediately preceding mWACh-PrEP implementation. Several events during the period before January 2018 were beyond control of the program and limited the program's ability to consistently provide PrEP in a representative population. A national nurses strike in Kenya from June through November 2017 halted service delivery in public-sector facilities,We did not offer incentives or reimbursement for enrollment into mWACh-PrEP and did not conduct any procedures beyond routine clinical care and satisfaction surveys, including intensive follow-up procedures or contact tracing. Additionally, we offered mWACh-PrEP enrollment to all PrEP initiators, regardless of partner HIV status or other behavioral HIV risk factors. Therefore, our results may be more representative of what could be expected if mWACh-PrEP were to be programmatically rolled out than a randomized trial or an approach targeted to only women who self-disclose high behavioral HIV risk.–We relied on routinely collected data to measure PrEP continuation and self-reported adherence without an objective biomarker for PrEP exposure, which could have introduced reporting bias or misclassification. Studies comparing self-reported PrEP adherence to objective drug levels among men who have sex with men, transgender women, and individuals in HIV-serodiscordant couples in real-world settings have found reasonably high concordance.In summary, we found very high acceptance of the mWACh-PrEP program among pregnant and postpartum women and improved early PrEP continuation and adherence among those enrolled compared to women who initiated PrEP before the mWACH-PrEP program. mWACh-PrEP extended the reach of the clinic and enabled clients to promptly address concerns about PrEP which, in turn, appeared to help them continue and/or adhere to PrEP. Women found a short period of SMS support helpful. It is plausible that this system could be readily scalable and cost-effective, potentially improving outcomes and offsetting costs from unused or misused medicines.


Hosted virtually by the Feinstein Institutes for Medical Research, September 23, 24th, 2020Sponsored by CorTec , BMC-Bioelectronic Medicine , and Feinstein Institutes for Medical Research/Northwell HealthIn animal experiments involving vagus nerve stimulation (VNS), standardization of dose within and across subjects is achieved by determining the physiological threshold (PT), often defined as the minimum stimulation intensity needed to elicit a physiological response. Factors affecting PT in the context of VNS in rodents, the most common preclinical animal model, have not been studied systematically. We determined the effect on PT of common factors known to play in role in neurostimulation. Adult rats were acutely or chronically implanted with a vagus nerve electrode. Acute experiments were performed under anesthesia while experiments involving chronic implants were performed either under anesthetized or in awake conditions. Physiological responses to VNS of increasing intensity included changes in blood pressure, bradycardia and apnea, in anesthetized and awake experiments. PT was smaller when the VN electrode was better insulated. PT and in vivo impedance increased with implant age over the course of 4-6 weeks, but PT had a weak correlation with impedance on a single measurement basis. PT was lowest in awake condition, followed by anesthesia with ketamine/xylazine and with isoflurane. Similarly, the cardioinhibitory effects of VNS for supra-threshold stimulation intensities were maximum in awake condition, followed by ketamine/xylazine, and lastly isoflurane.Transmural endoscopy for the purposes of performing per oral endoscopic myotomy (POEM) is a well-established and routine procedure for treating achalasia. During this procedure, an endoscopic tunnel is formed between the esophageal mucosa to the outer muscle layers, thereby gaining access to thoracic and abdominal cavities. Previously, we have shown that it is possible to identify and localize peripheral branches of the vagus nerve using commercially available endoscopes with digital/optical magnification and narrow band imaging. In this study, we explore the feasibility of recording nerve activity from the esophageal and gastric vagus branches within the abdominal and thoracic cavity in a swine model, by using transmural endoscopy. We will use custom-built nerve cuff and spiral electrodes that can be placed endoscopically to monitor for nerve activity and stimulate at different sites along the peripheral vagal branches. Additionally, we will also record the evoked compound action potentials (CAPs) in response to cervical and auricular vagus nerve stimulation applied directly on the nerve.Transmural endoscopy opens up the possibility of localizing and recording from the vagal nerve branches via a minimally invasive surgical procedure. Further studies are needed to explore its potential for delivering bioelectronic medicine.Spinal cord injury (SCI) affects approximately 18,000 individuals every year in the United States, with over half of the cases resulting in upper limb impairment. Restoring hand movement and dexterity is one of the key, albeit largely unmet, priorities of SCI survivors. Recently, transcutaneous spinal cord stimulation (tSCS) in conjunction with activity-based training has shown considerable promise in improving motor performance of incomplete SCI patients. However, conventional tSCS training requires intensive physical therapy for long periods, typically 80 sessions. This is because conventional tSCS uses an all-or-none stimulation pattern that simultaneously activates multiple motor pools and hence, it requires a needlessly laborious effort to isolate multiple hand movements, which is not clinically viable.2 to 1000mm2. Further, by recording hand movements and muscle activity through electromyogram recordings of both able-bodied and SCI participants during tSCS, we can potentially identify the optimal stimulation parameters and electrode sizes for targeting specific hand movements using tSCS. Future studies will explore automatic optimization of tSCS combined with intent-driven (through an implantable brain interface and non-invasive wearable sensing technologies) targeting of specific spinal nerves and its benefits on hand restoration.In this study we explore the effect of stimulation pattern and electrode area on targeting specific spinal nerves via tSCS for hand restoration. We have developed a custom transcutaneous neurostimulator with fatigue-resistant waveforms and high-density electrodes  that allow highly focalized activations of nerve fibers. Using FocalStim, we can generate individual or burst mode stimulation patterns, as well as, vary the electrode area from 100mmArtificial somatosensory feedback is an important component for a sensorimotor brain-computer interface system that is intuitive to use and reduces dependence on visual feedback. For people with tetraplegia, targeted electrical stimulation of the somatosensory cortex has been used to provide somatotopically relevant sensory feedback. Currently, microelectrode arrays and electrocorticography (ECoG) grids are the most widely used modes of delivering such feedback through intracortical stimulation. These two kinds of electrode arrays are complementary in their advantages and deficiencies. While microelectrode arrays evoke highly focal percepts, they provide access to a very limited area of the cortex whereas ECoG grids provide a wider coverage of the cortex but evoke more diffuse percepts. In addition, neither approach can access the sulcal areas of the somatosensory cortex where the receptive fields pertaining to the fingertips are located in humans. Here, we reliably target the hand regions of the primary somatosensory cortex stereotactic electroencephalography (SEEG) depth electrodes guided by high-resolution fMRI and myelin maps. The SEEG electrodes allow us to access even the sulcal regions S1. We elicited highly focal sensory percepts in the fingers, including fingertips, and the hand. Using within-patient comparisons, we also show that percepts evoked by SEEG electrodes are more focal and can be localized to fingertips more often than those evoked by high density ECoG grid electrodes.Multi-conductor electrical leads are a critical and underappreciated aspect of implanted medical devices, and they represent one of the largest failure mechanisms for marketed devices such as DBS and VNS implants. We are developing a new helical lead with gold wires as part of a large NIH-funded program to develop and translate a new hearing prosthesis that uses a penetrating Utah array in combination with a marketed cochlear stimulator. The helical leads for this project are tested to confirm compliance with requirements for cochlear implants (e.g. AAMI/ANSI CI86:2017), while safe and effective for use in the small clinical investigations. The mechanical tests are to evaluate lead performance for surgical use, minimize tethering forces, enable anchoring, and have sufficient fatigue resistance for our study. The helical leads joining the Auditory Nerve Utah Slanted electrode (AN-USEA) and the MED-EL Synchrony 2 stimulator pass the testing standards with expected biomechanical loads, in which are demonstrated with vigorous benchtop tests following a 10-day saline pre-soak and sterilization including: continuity, leakage current (<0.1 μA), bend testing , tensile testing to at least 10% elongation, and insulation test between channels in the wire bundle to have impedance values of >100 kΩ. The helical leads are exposed to representative stresses and have not shown signs of failure visually, electrically, nor mechanically which illustrates the robustness and flexibility of the leads. Consistent with standards for cochlear implants, the helical leads show to be a resilient and reliable component of cochlear devices.The autonomic nervous system (ANS) regulates many physiological processes, since organs receive reciprocal input from the parasympathetic and sympathetic branches of ANS to maintain homeostasis. Dysregulation of the ANS can occur due to disorders or injury, including diabetes, sepsis, spinal cord injury, and other conditions. Development of quantitative biomarkers of ANS function can yield novel insights to such dysregulation and provide a useful tool to diagnose and assess the severity of these disorders. Such a metric was extracted here from physiological signals obtained by clinically standard techniques during controlled autonomic testing. Nineteen healthy, able-bodied individuals attended four sessions, each consisting of five autonomic tests; non-invasive sensors were used to capture continuous physiological data, including electrocardiography (ECG), blood pressure (BP), respiration, galvanic skin response, and pupil diameter. Raw ECG and BP signals were used to calculate heart rate, mean arterial pressure, and a heart rate variability measure, root mean square of successive differences (RMSSD) between heartbeats. Calculated signals were averaged by test and recording modality, and a template matching method was developed to characterize individual responses by determining features that represented duration and amplitude scales compared to the average response. As measured by the derived index, sympathetic amplitude responses significantly increased with higher body mass index among participants. Longer and larger sympathetic and longer parasympathetic responses were observed in afternoon testing, but larger parasympathetic responses were measured in morning testing sessions. Quantifying ANS function can provide crucial information about disease presence or intensity and treatment efficacy.TTFields are frequency-specific, alternating electrical fields developed for the treatment of cancer. They are delivered non-invasively to the tumor region using a home-use medical device. TTFields’ mechanism of action is based on exertion of directional forces on polarizable microtubules, interfering with the assembly of the normal mitotic spindle. Such interference results in mitotic arrest, ultimately leading to cell death. To date, FDA has approved TTFields for recurrent and newly-diagnosed glioblastoma, and for mesothelioma.The only frequently-reported adverse event related to TTFields is skin irritation underneath the transducer arrays applied to the skin. Since their mechanism of action suggests anti-mitotic activity in many other solid tumors, TTFields have been successfully investigated in preclinical and pilot studies in additional cancers. They are currently investigated in phase 3 trials in pancreatic, lung and ovarian cancers, and in brain metastasis. Pilot trials are ongoing in gastric and liver cancers.The establishment of TTFields as a new treatment modality in oncology involved extensive multi-disciplinary research and development activities. The tight collaboration between physicians, biologists, physicists and engineers enabled the concept of targeting cancer cells with electric fields to become a therapy available at the clinic. This same collaboration continues to move the technology forward, with novel hardware and software advancements being implemented these days. They include more sophisticated design and materials, as well as treatment planning software for further improvements in treatment efficacy. These advancements make TTFields a more personalized modality, tuned to target the disease of an individual patient in the most effective way.P < 0.01, 2-way RM ANOVA). pFUS also significantly reduced adipokine levels  and circulating lipids  in obese mice. Hepatic pFUS significantly reduced liver inflammation observed with reduced cytokine levels  and leukocyte infiltration . Our findings demonstrate the efficacy of end-organ targeted focused ultrasound to the porta hepatis for alleviating diet-induced obesity and improving several aspects of metabolic health in mice. Our results highlight the possibility that hepatic focused ultrasound might be used as a novel noninvasive treatment for obesity.Obesity is associated with increased mortality and significant comorbidities, including insulin resistance, metabolic syndrome, and cardiovascular disease. Chronic low-grade inflammation is a hallmark of the pathophysiology of obesity. Recent studies have utilized noninvasive peripheral focused ultrasound stimulation (pFUS) to the liver to improve glucose metabolism in endotoxemia. Here we reasoned that pFUS of the liver may alleviate diet-induced obesity related inflammation and other comorbidities. After 16 weeks, obese mice that received daily hepatic pFUS, from weeks 9 to 16, had significantly decreased body weights compared to sham-stimulated mice on the same diet , can be modularly designed to permit existing fluorescent reporters to be efficiently adapted for simultaneous measurement of many nodes in a signal transduction network within single living cells. We created SiRIs for indicators of second messengers and kinases and used them to image up to 5 signals at once in a single living neuron. Applied to hippocampal neurons in both culture and brain slice, we discovered relationships between the speed of calcium signaling and the amplitude of PKA cellular signaling, upon receiving a cAMP-driving cellular input. Thus, SiRIs will enable understanding the relationships between the components of molecular decision-making in immune cells, neurons, and other cell types. Being fully genetically encoded, SiRIs will hopefully become an easy-to-use component of the bioelectronic medicine development toolbox.**Co-senior authors with equal contributionChinese studies reported predictors of severe disease and mortality associated with coronavirus disease 2019 (COVID-19). A generalizable and simple survival calculator based on objective data from US patients hospitalized with COVID-19 has not yet been introduced. Our goal was to develop and validate a clinical tool to predict 7-day survival in patients hospitalized with COVID-19. We used electronic health record data of 13027 adult patients hospitalized with a confirmed diagnosis of COVID-19 from thirteen acute care hospitals in the New York City area, 12 of which were part of Northwell Health. Demographic, laboratory, clinical, and outcome data were extracted from the electronic health records. Optimal predictors and performance were identified using least absolute shrinkage and selection operator (LASSO) regression with receiver operating characteristic curves and measurements of area under the curve (AUC). Serum blood urea nitrogen, age, oxygen saturation, serum sodium, red cell distribution width, and absolute neutrophil count were identified as the 6 optimal of 41 possible predictors of survival. These factors constitute the NOCOS  Calculator. Performance in the prospective validation and external validation were marked by AUCs of 0.80 , and 0.78 , respectively. Collectively, the NOCOS Calculator uses 6 factors routinely available at hospital admission to predict 7-day survival for patients hospitalized with COVID-19, and outperforms existing calculators like SOFA  that are not specifically designed for COVID-19. The calculator is publicly available at https://feinstein.northwell.edu/NOCOS.BackgroundCombined traumatic brain injury (TBI) and hemorrhagic shock (HS) (TBI+HS), is associated with high levels of morbidity and mortality. The current resuscitative approach to TBI+HS involves intravascular volume expansion, vasopressors, and oxygen supplementation which requires access to medical care and yet inadequately address the severe hypoperfusion that distinguishes this condition. For decades, large spontaneous oscillations in blood pressure (BP) and cerebral blood flow (CBF) have been observed in individuals with high tolerance to hypovolemia. These hemodynamic waves represent an endogenous physiologic mechanism that improves cerebral perfusion and confers protection to cerebral tissue. In the present study, we explored the ability of electrical trigeminal nerve stimulation (TNS) to mimic the hemodynamic oscillations shown in individuals with high hypovolemia tolerance, and investigated its beneficial effects in a rat model of TBI+HS.Methods and ResultsbrO2 reduced hypoxic stress as confirmed by HIF-1a expression in the hippocampus. Furthermore, non-specific TNS did not induce hemodynamic oscillations and did not show any the beneficial effects in this animal model of TBI+HS.TBI+HS was induced by controlled cortical impact, and subsequent pressure-controlled HS (27±2 mmHg) for 35 minutes in male Sprague-Dawley rats. TNS induced large, synchronized oscillations in BP and CBF. These bio-mimicked hemodynamic oscillations attenuated the severity of brain injury, improved the survival rates, and facilitated functional recovery after TBI+HS. Secondary oscillations of PConclusionsbrO2 can be induced by specifically calibrated TNS to provide rapid pre-hospital treatment and improve survival outcomes following TBI+HS.Bio-mimicked synchronized fluctuations of BP and CBF, and secondary oscillations of P*These authors contributed equally to this workVagus nerve stimulation (VNS) is an emerging bioelectronic therapy with the potential to treat a wide range of conditions in which inflammation is implicated. Anti-inflammatory actions of VNS require norepinephrine (NE) release into the spleen by post-ganglionic neurons in abdominal ganglia. Real-time detection of NE could provide a marker to calibrate and optimize VNS anti-inflammatory effects in individual subjects. Here, we describe a method to study in vivo VNS-elicited NE release in the spleen, using fast scan cyclic voltammetry (FSCV). Initially, NE oxidation potential was determined in vitro to be approximately 0.6 V, using standard cycling parameters. In experiments in anesthetized mice instrumented with ECG, a carbon fiber voltammetry electrode was inserted into the exposed spleen. VNS was delivered using a bipolar cuff electrode placed on the left cervical VN. Short trains of VNS  induced a peak oxidation current at 0.6 V indicating NE release at pulsing frequencies >5Hz . NE currents were detected <10 s after VNS onset, peaked at 20-30 s, and returned to baseline within 1 to 10 min (N=5). Peak NE oxidation current was proportional to VNS intensity and to the concomitant VNS-elicited reduction in heart rate (N=3). These preliminary findings indicate that FSCV may be a reliable method for the real-time measurement of NE release in the spleen, thereby providing an in vivo marker of anti-inflammatory effects of VNS.et al, Nature Comm 10: 952, 2019). It is unclear whether FUS has similar metabolic effects in large animals with similar anatomy and physiology to humans, in the absence of inflammation. In healthy mini-pigs, we validated whether FUS targeting the porta hepatis (PH) of the liver could lead to changes in glucose metabolism. First, in a series of hyperinsulinemic-euglycemic clamp experiments, we used different insulin infusion rates (IIRs) and determined the glucose infusion rate that achieved an euglycemic equilibrium (eGIR), a measure of insulin sensitivity independent of blood glucose levels. We found that measures of insulin sensitivity were larger at low IIRs (“unsaturated”) than at high IIRs (“saturated”). Then, in a second series of experiments, eGIR was determined during low and high IIRs, before and after 4-min-long FUS of the PH. FUS during saturated IIR euglycemia conditions  resulted in increase of eGIR in 1 experiment, decrease in 1 experiment and no changes in 5 experiments. FUS delivery during unsaturated IIR euglycemia  resulted in increase of eGIR in 4 experiments and no change in 1 experiment. No significant changes in liver tests and other biochemical and hematological parameters were associated with FUS. In conclusion, these preliminary results suggest that, in a swine model, FUS neuromodulation of the PH may increase insulin sensitivity without inducing liver injury.Recently, focused ultrasound (FUS) neuromodulation was shown to have organ-specific effects in rodents undergoing acute inflammation, including a decrease in blood glucose levels when targeting the liver . Using calcium imaging and whole cell patch clamp recordings, we observed nodose ganglion neurons deficient in TRPA1 do not respond to IL-1β application. In addition, IL-1β induced calcium influx was inhibited by administration of the TRPA1 antagonist AM0902. These results elucidate a novel role for the TRPA1 cation channel as a necessary component for IL-1β induced vagus nerve signaling.Flex electrodes with Ir/IrOx electrode sites was fabricated via a microelectromechanical system (MEMS) process, and an integration strategy was developed for the chronic interface with the mouse vagus nerve, including an epoxy reinforcement for the joints between electrode bonding pads and platinum wire leads, and a thermoforming process to shape the Flex electrodes for intimiate contact with the nerve. The electrochemical properties of the flex electrode, such as impedance and charge storage capacity (CSC), were characterized using electrochemical impedance spectroscopy (EIS) and cyclic voltammetry (CV), respectively. The impedance of the Flex electrode at 1 kHz was as low as 617.15 ± 13.17 Ω. The impedance spectra were fitted with an equivalent circuit model to clarify the electrode-electrolyte interface. Compared to the state-of-the-art with respect to the neural electrode with IrOx stimulation sites, the Flex electrode developed in this study has the CSC of 17.02 ± 3.04 mC/cm2. This study represents one of dedicated efforts to develop the chronic mouse vagus nerve interface, using microfabricated electrodes.Micro-fabricated polyimide (PI)-based neural electrodes have been actively pursued with innovations including electrode materials, architectures, microfabrication processes, and seamless integration with nervous tissues. Mouse vagus nerve (~100 μm) is a key therapeutic and research target in the field of bioelectronic medicine. However, the technology to interface delicate nerves for chronic endpoints has been a challenge. In this study, a PI flexible neural Quantitative descriptions of the morphology and structure of peripheral nerves is important for bioelectronic and brain-machine interface devices. While histological procedures and microscopy techniques yield high-resolution detailed images of individual axons, automated methods to extract relevant information at the single-axon level are not widely available. We implemented a computer vision segmentation algorithm that allows for subsequent feature extraction in immunohistochemistry (IHC) images of peripheral nerves at the single fiber scale. These features include short and long cross-sectional diameter, area, and perimeter, thickness of surrounding myelin and polar coordinates of single axons within a nerve or nerve fascicle. To improve the performance of our computer vision algorithm, we generated a dataset of segmented immunohistochemical images and trained a deep convolutional neural network (Mask R-CNN) on instance segmentation. The dataset of segmented examples was produced by the original algorithm and subsequently refined by human annotators, yielding a significant 4-fold decrease in human labor compared to the process of manual annotation from scratch. A combined solution of the original algorithm and the deep convolutional neural network achieved a single-axon detection accuracy of 98%, as opposed to 82% using the traditional computer vision algorithm alone, on a held-out nerve section of 36 fascicles of the swine cervical vagus.P<0.02). Opto-VNS did not change TNF levels in TRPV1-ChR2 or VGlut2-ChR2 mice compared to sham-stimulated controls. We also found that opto-VNS induced varying degrees of transient bradycardia in all three strains: ChAT-ChR2 , TRPV1-ChR2 , VGlut2-ChR2 . Respiration rate increased during opto-stimulation in TRPV1-ChR2 , and VGlut2-ChR2 , but not in ChAT-ChR2 mice . Our results indicate selective optogenetic activation of vagal fibers produces distinct physiological changes based on the population activated, and that opto-VNS can be used to change serum cytokine levels in acute endotoxemia.Electrical stimulation of the vagus nerve inhibits expression of proinflammatory cytokines, such as tumor necrosis factor (TNF), through a neural circuit termed the inflammatory reflex. To determine whether vagus fiber populations could be selectively activated to control inflammatory and physiological function, we created ChAT-ChR2-eYFP, TRPV1-ChR2-eYFP, and VGlut2-ChR2-eYFP mice expressing light-sensitive channelrhodopsin-2 (ChR2) in specific neuronal and fiber populations. Utilizing in situ cervical vagus nerve preparations, we optogenetically stimulated vagal fibers (opto-VNS) with the following parameters: 470 nm, 1000 mA, 10 Hz, 50 ms, 5 min. After stimulation mice were then injected i.p. with lipopolysaccharide (0.3 mg/kg) to induce acute endotoxemia, then killed 90 mins later. Serum TNF was measured by ELISA. We observed that in a subset of ChAT-ChR2 mice, opto-VNS significantly decreased levels of TNF compared to sham-matched controls  mice to specifically ablate TRPV1 expressing neurons. TRPV1-DTA mice were subjected to immunization with keyhole limpet hemocyanin (KLH) and antigen-specific antibody responses were measured over 28 days. KLH-specific antibody responses were significantly blunted in TRPV1-DTA mice as compared to wild-type controls for 28-days post immunization. Next, we optogenetically activated TRPV1 neurons during immunization. TRPV1-Cre/Rosa-ChannelRhodopsin2 (TRPV1-ChR2) mice received optical stimulation on the dorsum of the paw with blue light immediately prior to a local immunization of KLH. Direct optogenetic stimulation of TRPV1+ neurons significantly increased KLH-specific antibody responses as compared to wild-type mice. Collectively these findings reveal that TRPV1-expressing sensory neurons modulate antigen-specific immune responses. This is the first genetic and selective functional evidence that nociceptors are required during immunization to produce antigen-specific antibodies.The goal of this work is to (1) create pipelines for entity data extraction using multiple medical NLP tools, (2) extract the signs and symptoms from an EHR  corpus via this pipeline, and (3) compare results from the pipeline with manual annotations by clinicians. The NLP tools chosen for comparison in this particular study are CTAKES and CLAMP. Software pipelines based on Java and Python were built to process health records via these tools. Signs and symptoms that were extracted via these tools as XMI files were then standardized using Python-based data extraction techniques. The resulting signs and symptoms were further classified as positive (present), and negative (absent) by the tools. Clinicians also created a manually annotated ground truth to enable quantitative analysis of accuracy of each tool. The Jaccard (dice coefficient) was used to determine the degree of overlap between the 2 NLP tools and 3 annotators, resulting in a 2-by-3 matrix of values. For each tool-annotator comparison, the Jaccard coefficient was computed on a per-record basis and then averaged. For a single record, the overlap across each sign/symptom entity was averaged to get a record-level score. As a result, the NLP tools were evaluated against a manual ground truth and baseline performance metrics were extracted. In the future, this work could enable analysis and accuracy comparison of various NLP tools for the purpose of a variety of entity recognition purposes from health records, as was done with signs and symptoms in the case above.in vivo studies of the physiological effects of neurostimulation. Numerous disease models available in small rodents provide ideal research settings; however, developing implants for small animals with cm-sized anatomies poses a technological challenge. Size constraints derive from limits on the energy capacity of ultra-miniature batteries, integration of electrical circuits, and the need for resilient biocompatible packaging. While commercial medical devices offer multi-year lifetimes, devices for animal research typically target shorter lifetimes of weeks to months in order to reduce their volume, mass, and cost.The development of modern bioelectronic therapeutics frequently relies upon Previously, our lab has demonstrated a novel constant-current neurostimulator providing basic control of stimulation parameters. We present an updated, fully-wireless design that utilizes near-field communication for dynamic control, enabling precise control of stimulation and more sophisticated experiments, as well as improved output characteristics. The device offers 0-3 mA amplitude, as short as 100 μs pulses, and frequency from DC to 10 kHz. Data from acute and chronic experiments validate the core functionality in the mouse model. Preliminary results suggest a usable lifetime longer than one month.Vertebrates control homeostasis during infection or injury by balancing the activity of pro- and anti-inflammatory responses. Reflex neural circuits inhibiting inflammation are well established, but the role of neurons stimulating inflammation is not clear. High mobility group box 1 (HMGB1), an established mediator in both infectious disease and sterile injury, is abundantly expressed in neurons. To elucidate the role of neuron-derived HMGB1 in neurogenic inflammation and nociceptive response, we generated neuronal-specific conditional HMGB1 knockout mice. Selective silencing of HMGB1 in neuronal tissues attenuates neurogenic inflammation in animal model of sciatic nerve chronic constriction injury (CCI). Genetic silencing of neuronal HMGB1 attenuated local HMGB1 expression, as well as CXCL1, IL-18 and TNF levels in the inflamed paws as compared to HMGB1 flox or wild type control mice. Sciatic nerve CCI-induced hyperalgesia  was inhibited in the neuronal-HMGB1 deficient mice. Administration of anti-HMGB1 monoclonal antibodies conferred significant protection against sciatic nerve CCI-induced mechanical and thermal hyperalgesia. Furthermore, in collagen antibody-induced arthritis (CAIA), genetic silencing of neuronal HMGB1 significantly inhibited CAIA-induced joint edema formation, hyperalgesia and inflammatory cell infiltration as compared to CAIA in HMGB1 flox and wild type controls. Collectively, these findings reveal a previously unrecognized critical role for neuronal HMGB1 in initiating inflammation and nociceptive responses in the sciatic nerve CCI and CAIA models.A great demand exists for minimally-invasive neuromodulation technologies to enable next-generation bioelectronic medicine. We report on our developments of ultrathin (opto)electronic devices for neurostimulation. All of these devices rely on far red/near infrared irradiation in the tissue transparency window to actuate nanoscale organic semiconductor components. Our flagship technology is the organic electrolytic photocapacitor (OEPC) – a device that mimics biphasic current-pulse neurostimulation and thus transduces an optical signal into directly-evoked action potentials in neurons. These devices are not only wireless, but also 100-1000 times thinner than existing technologies. We will discuss chronic implants capable of stimulating peripheral nerves (sciatic and vagus) when actuated from outside of the body using diode lasers. Light power can be safely and effectively transmitted to implants up to 15 mm below the skin surface. We have observed stable operation in rodent models for at least 100 days. We believe that the combination of deep red light and ultrathin photovoltaic devices can account for a new paradigm in wireless bioelectronic medicine.Reliable recording and modulation of excitable tissue using implantable electronic devices have implications in diagnosing and treating many types of diseases. The advent of flexible electronics has enabled new concepts in interfacing devices with soft tissues. However, to date, most flexible electronics achieve mechanical compliance by using substrates composed of thin curable resins or elastomers. These materials are suboptimal for tissue interfacing because they: (1) exhibit Young’s moduli that are orders of magnitude larger than many excitable tissues, such as peripheral nerves; (2) are difficult to integrate with hydrated tissue in vivo. Here I will present recent advances in materials and fabrication from our lab to address current limitations in flexible electronics. Specifically, the synthesis and formulation of adhesive hydrogels and transfer printing to create ultracompliant peripheral nerve interfaces will be described. Details regarding the in vitro and in vivo performance of ultracompliant electronics will be presented. Future prospective applications for this concept will also be highlighted, too.CorTec develops a chronically implantable brain-computer interface called “Brain Interchange” for bi-directional communication with the brain. The system consists of various components: cortical grid electrodes, implantable electronics protected by ceramic hermetic package and body-external transceiver that communicates wirelessly with the implant and also wirelessly supplies the implant with energy via an inductive link. The system streams neural data from 32 electrode contacts to a computer where the data is processed and stored. Based on the incoming neural data, algorithms on the computer can take decisions on therapeutic actions, e.g. sending a stimulation command wirelessly to the implant which then delivery electrical pulses via the implanted electrodes to the brain, modulating brain activity. This closed-loop system can be used for patient-individual and situation-specific brain therapy, treating a variety of central nervous system related disorders. The system can also be used as bi-directional communication tool between brain and computer.Besides the development of Brain Interchange as a platform for central nervous system related therapy discovery and brain-machine interface studies, CorTec provides the innovative technology that permitted building the individual components of Brain Interchange to others. Especially the technology for producing laser-micromachined neural electrodes that permit high production precision while using only traditional implant materials such as medical grade silicone rubber and PtIr noble metal foil is applied to wide range of applications, also in the field of spinal cord stimulation and peripheral nerve interfacing, in preclinical as well as in clinical studies.Another technology made available to others is a ceramic hermetic package for electronic implant circuits that permits a very high number of electrical feedthroughs (100s) while providing excellent hermeticity.With these and other technologies, CorTec is dedicated to improving the field of neurotechnology and neural therapy discovery.Current clinical vagus nerve stimulation (VNS) therapies rely on engaging vagal fibers in a relatively uncontrolled manner, sometimes resulting in sub-therapeutic doses to targeted organs and side-effects from non-targeted organs. We discuss our efforts to quantify engagement of vagal fibers and end-organs, and strategies to target sub-populations of fibers in an individual subject basis. Our work is carried out in different animal models of VNS with clinically-preferred, non-penetrating cuff electrodes. Such methods for “targeted vagal neuromodulation” may contribute to using VNS to treat diseases in which hemodynamic state can easily be compromised, like heart failure and pulmonary hypertension.Atherosclerosis is a chronic nonresolving inflammatory disease of medium- and large-sized arteries causing heart attacks and strokes. As atherosclerotic plaques in the inner intimal layer and aortic media of these arteries lack nerve fibers, the impact of innervation on atherosclerosis remains unknown. However, nerves use the adventitia as their primary conduit to reach target tissues. We and others characterized artery tertiary lymphoid organs (ATLOs) in the aorta adventitia of apolipoprotein E knock-out mice and also found such aggregates in human diseased coronary arteries and other arterial tree segments. In view of these observations, we postulated that the peripheral nervous system may interact with diseased arteries via adventitial immune cells. We found in aged hyperlipidemic mice and in human atherosclerotic tissues that widespread neuro-immune-cardiovascular-interfaces (NICIs) establish atherosclerosis-brain circuits (ABCs) capable of sensing and affecting atherosclerosis: (i) ATLOs interact with the peripheral nervous system (PNS) by stimulating axon growth; (ii) the adventitia is innervated by the sensory and sympathetic NS but not by the parasympathetic NS system; (iii) the adventitia is wired directly to the brain stem through lower thoracic dorsal-root-ganglia and sympathetic perivascular ganglia; (iv) advanced atherosclerosis is associated with increased nerve activities in splenic and celiac vagus nerves; and (v) elimination of the sympathetic NS disrupts ATLOs, attenuates atherosclerosis progression, and reduces plaque vulnerability. Our data demonstrate the pathophysiological relevance of NICIs in atherosclerosis and that the PNS employs NICIs to assemble ABCs. We hypothesize that intervention into neural circuits creates multiple unexpected opportunities to treat atherosclerosis.The nervous system and the immune system share the common ability to exert gatekeeper roles at the interfaces between internal and external environment. Although interaction between these two evolutionarily highly conserved systems is long recognized, the investigation into pathophysiological mechanisms regulating their reciprocal cross-talk has been the object of pathbreaking immunology and neuroscience research only in recent decades. In the last years, our group elucidated how the autonomic nervous system controls the splenic immunity recruited by hypertensive challenges. In this lecture, I will focus on the molecular mechanisms that regulate the neuro-immune crosstalk in hypertension. I will elaborate on the mechanistic insights into this brain-spleen axis led us uncover a new molecular pathway mediating the neuroimmune interaction established by noradrenergic-mediated release in the spleen of placental growth factor (PlGF), an angiogenic growth factor potentially targetable with pharmacological approaches.It is consensual that increased carotid body (CB) activity contributes to the sympathetic overactivation that characterizes essential hypertension, hypertension associated with obstructive sleep apnea and chronic heart failure (1). Additionally, we described that CB dysfunction is in the genesis of metabolic diseases via sympathetic nervous system overactivation .The CBs are arterial chemoreceptors that sense changes in blood O2, CO2, and pH levels. Apart from ventilatory control, the CBs have been reported to act as metabolic sensors being implicated in the control of energy homeostasis. We have recently described that CB activity is increased in animal models of metabolic disease  and in prediabetes patients (5). Also, we showed that abolishment of CB activity via bilateral resection of CB-sensitive nerve, the carotid sinus nerve (CSN), or via CB ablation in animals prevents and reverses diet-induced insulin resistance and glucose intolerance as well as sympathoadrenal overactivity, meaning that the beneficial effects of decreasing CB activity on glucose homeostasis are modulated by target-related efferent sympathetic nerves, through a reflex initiated in the CBs . In agreement with our pre-clinical data, we described that hyperbaric oxygen therapy, that dramatically reduces CB activity, improves glucose homeostasis in type 2 diabetes (T2D) patients (7). Unilateral and/or bilateral CB surgical ablation has been also proposed as therapeutic option for sympathetic-mediated diseases. However, despite the promising results, neither hyperbaric oxygen therapy nor surgical CSN resection are optimal therapeutic approaches for CB-mediated diseases, as these procedures entail several side effects. My team recently showed that electrical modulation of the CSN restores glucose homeostasis in T2D animals implying that bioelectronic medicines might be suitable and selective therapeutic strategy for metabolic diseases. The present talk will provide a state-of-the-art update on the mechanisms of sensory transduction, neural circuitry, and reflex regulation of CBs chemoreceptor in metabolic diseases and will discuss the recent findings showing the efficacy of continuous kilohertz frequency alternative current device implanted on the CSN to reverse clinical features of T2D in rats (6) as well as the use of CSN neural recordings to detect metabolic information (8) that could be used for closed-loop control of CSN neuromodulation.1. Iturriaga R. 2018 J Physiol. 596:3067-30772. Ribeiro MJ et al. 2013 Diabetes. 62:2905-163. Sacramento JF et al. 2017 Diabetologia. 60:158-1684. Dos Santos E et al. 2018 Adv Exp Med Biol 1071:103-1085. Cunha-Guimaraes JP et al. 2020 Eur J Endocrinol. 182:549-5576. Sacramento JF et al. 2018 Diabetologia 61:700-7107. Vera-Cruz P et al. 2015 Adv Exp Med Biol. 860:221-58.Cracchiolo M et al. 2019 IEEE Trans Neural Syst Rehabil Eng. 27:2034-2043Supported by: Portuguese Foundation for Science and Technology , L’Oreal/FCT/Unesco MedalsArtificial intelligence and machine learning are methods by which a computer system can generate complex, non-linear algorithms from data inputs that have the potential to be more accurate and deployed in real-time. In bioelectronics medicine, there are multiple pieces of complex electrophysiologic data that are acquired. While traditional diagnostic and therapeutic responses from these data are, by necessity, based on relatively simple models, the use of artificial intelligence may allow for the creation of more dynamic and complex responses that better mirror how normal human physiology responds to these electrical impulses. In the field of cardiac electrophysiology, for example, it has been demonstrated that, using a standard 12-lead electrocardiogram, it is possible to detect several diseases that are not apparent according to traditional interpretation methods, such as the risk of having a low ejection fraction, atrial fibrillation, or hypertrophic cardiomyopathy. In turn, dynamic, closed loop feedback systems that integrate several pieces of electrophysiologic data and determine appropriate responses that mirror physiologic needs may be feasible. Future research will focus on how bioelectronics data may be aggregated, used to build predictive algorithms, and how these algorithms may be integrated into diagnostic and therapeutic systems to advance bioelectronic devices.Organic electronic materials are unique as the signal translator across the biology-technology gap. These biocompatible materials are also easily complexed with polyanions, polycations and functional biomaterials and can be included in various device architectures to form flexible, stretchable and even gelled device systems. Such organic bioelectronics can then process electronic, ionic and charged biomolecules in combination. These combined features make organic electronic materials unique in many aspects as the recorder and actuator of various functions and physiology of biological systems.A brief review of some of the recent achievements from the Laboratory of Organic Electronics is here given. In the BioComLab technology platform various organic bioelectronic sensors and actuators are combined with communication technology to form a body area network for future healthcare applications. Various sensors are included within electronic skin patches, then connected to electronic drug delivery components via capacitive body-coupled communication. This system provides sensor-actuator feedback and improves its decision-making performance using deep-learning protocols provided from cloud connectivity. With the BioComLab platform we target an array of neuronal disorders and diseases, such as epilepsy, Parkinson’s disease and chronical pain.A sphincter is a ring like muscle that normally maintains constriction of a body passage or orifice and that relaxes as required by normal physiological functioning. Sphincters are control mechanisms in the gastrointestinal tract. They control forward passage and prevent or allow the backwards passage of solids, liquids and gases. Direct electrical stimulation of the sphincter can lead to contraction while stimulation of the Vagus Nerve can lead to contraction or relaxation of the sphincter, depending on the parameters of stimulation.Currently most vagal nerve stimulation is performed at the level of the Cervical Vagus Nerve. This stimulation leads to specific targeted physiologic effects at the expense of other untargeted physiologic effects. We propose stimulating peripheral branches of the vagus nerve near the target organ to more precisely target desired specific physiologic effects without the unwanted physiologic effects.We have developed tunneling techniques in a porcine model in which a Z tract is created within the submucosal space of the esophagus, stomach, small intestine or colon. These techniques can be used to access peripheral branches of the Vagus Nerve in order to place electrodes and more precisely target beneficial effects of nerve stimulation while eliminating unwanted effects. Through the esophagus one can reach vagal branches to lungs, heart, esophagus, and stomach. Through the stomach one can reach vagal branches to stomach, liver, pancreas, kidneys, small intestine, spleen and colon.We have also developed the use of endoscopic ultrasound, in a porcine model, to direct needle electrodes to target, access and stimulate nerves and ganglion within the Celiac, Superior Mesenteric and inferior Mesenteric Plexus.Using FLIP technology to evaluate the contraction and relaxation of the pyloric sphincter and the lower esophageal sphincter we have demonstrated both contraction and relaxation of these sphincters using direct electrical stimulation of muscle and indirect electrical stimulation of the vagus nerve.We believe that these techniques may be used in the future to access and stimulate peripheral branches of the Vagus Nerve to treat many diseases including, chronic hypertension, diabetes, gastroesophageal reflux disease (GERD), gastroparesis, end stage congestive heart failure (CHF), end stage pulmonary disease such as pulmonary hypertension, asthma, diabetes, renal failure, IBD, other inflammatory diseases and obesity, as well as diseases related to dysfunction of gastrointestinal sphincters.This abstract from this presentation is adapted from the following publication: Beauchamp MS, Oswalt D, Sun P, Foster BL, Magnotti JF, Niketeghad S, Pouratian N, Bosking WH, Yoshor D. Dynamic Stimulation of Visual Cortex Produces Form Vision in Sighted and Blind Humans. Cell. 2020;181(4):774-83 e5. Epub 2020/05/16. doi: 10.1016/j.cell.2020.04.033. PubMed PMID: 32413298; PMCID: PMC7331799.A visual cortical prosthesis (VCP) has long been proposed as a strategy for restoring useful vision to the blind, under the assumption that visual percepts of small spots of light produced with electrical stimulation of visual cortex (phosphenes) will combine into coherent percepts of visual forms, like pixels on a video screen. In prior decades, a number of research teams tested early prototypes of a VCP, but these efforts were limited by the technology of the day. The remarkable advances in computer science and engineering have spurred a renewed interest in developing VCPs that is now well underway. In this presentation I review past and ongoing work in developing VCPs. In addition, I highlight the challenges involved in using phosphenes as combinatorial elements, and describe an alternative strategy in which shapes are traced on the surface of visual cortex by stimulating electrodes in dynamic sequence. In our experience testing both sighted and blind participants, dynamic stimulation enabled accurate recognition of letter shapes predicted by the brain's spatial map of the visual world. Forms were presented and recognized rapidly by blind participants, up to 86 forms per minute. These findings demonstrate that a brain prosthetic can produce coherent percepts of visual forms.The abstract from this presentation is adapted from the following publication: Rothbard JB, Kurnellas MP, Ousman SS, Brownell S, Rothbard JJ, Steinman L. Small Heat Shock Proteins, Amyloid Fibrils, and Nicotine Stimulate a Common Immune Suppressive Pathway with Implications for Future Therapies. Cold Spring Harb Perspect Med. 2019 Jul 1;9(7):a034223. doi: 10.1101/cshperspect.a034223. PMID: 30249602; PMCID: PMC6601455.The α7 nicotinic acetylcholine receptor (α7nAChR) is central to the anti-inflammatory function of the vagus nerve in a physiological mechanism termed the inflammatory reflex. Studies on the inflammatory reflex have been instrumental for the current development of the field of bioelectronic medicine. An independent investigation of the biological role of αB-crystallin (HspB5), the most abundant gene transcript present in active multiple sclerosis lesions in human brains, also led to α7nAChR. Induction of experimental autoimmune encephalomyelitis (EAE) in HspB5−/− mice results in greater paralytic signs, increased levels of proinflammatory cytokines, and T-lymphocyte activation relative to wild-type animals. Administration of HspB5 was therapeutic in animal models of multiple sclerosis, retinal and cardiac ischemia, and stroke. Structure–activity studies established that residues 73–92 were as potent as the parent protein, but only when it formed amyloid fibrils. Amyloid fibrils and small heat shock proteins (sHsps) selectively bound α7nAChR on peritoneal macrophages (MΦs) and B lymphocytes, converting the MΦs to an immune suppressive phenotype and mobilizing the migration of both cell types from the peritoneum to secondary lymph organs. Finally, our approach in translation to the clinic is for the development of small molecules that are orally active to modulate the α7nAChR.