Sexual and gender minority content in undergraduate medical education in the United States and Canada: current state and changes since 2011

PURPOSE

To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities.

METHOD

Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content.

RESULTS

Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%).

CONCLUSION

Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

Understanding how primary care providers report discussing substance use with transgender and gender diverse patients

OBJECTIVES

To explore how primary care providers report discussing substance use with transgender and gender diverse (TGD) adult patients within the context of discussing gender-affirming interventions.

METHODS

Between March and April 2022, in-depth, semi-structured qualitative interviews were conducted with 15 primary care providers who care for TGD patients in the Northeastern US. Thematic analysis was used to analyze interview data and identify themes.

RESULTS

Two primary themes emerged among providers: 1) placing a focus on harm reduction, emphasizing reducing negative consequences of substance use, and 2) using access to gender-affirming interventions as an incentive for patients to change their substance use patterns.

CONCLUSIONS

Focusing on harm reduction can emphasize reducing potential adverse outcomes while working with TGD patients towards their gender-affirmation goals. Future research should explore varying approaches to how substance use is discussed with TGD patients, as well as the interpretation of gender-affirming clinical guidelines.

PRACTICE IMPLICATIONS

Findings from this study indicate a need for enhancing provider knowledge around the appropriate application of gender-affirming care guidelines. Investing in training efforts to improve gender-affirming care is critical for encouraging approaches that prioritize harm reduction and do not unnecessarily prevent access to gender-affirming interventions.

Comparison of faculty and student perceptions of sexual and gender minority content in a preclerkship medical curriculum

BACKGROUND

Sexual and gender minority (SGM) persons experience stark health disparities. Efforts to mitigate disparities through medical education have met some success. However, evaluations have largely focused on subjective perspectives rather than objective measures. This study aimed to quantify Boston University School of Medicine's sexual and gender minority (SGM) education through surveys of course directors (CDs) and medical students regarding where SGM topics were taught in the preclerkship medical curriculum. Responses were compared to identify concordance between faculty intention and student perceptions regarding SGM education.

METHODS

A cross-sectional survey was distributed to preclerkship CDs and current medical students in Spring 2019 and 2021, respectively, regarding where in the mandatory preclerkship curriculum CDs deliberately taught and where first- and second-year students recalled having learned 10 SGM topic domains.

RESULTS

64.3% of CDs (n = 18), 47.0% of the first-year class (n = 71), and 67.3% of the second-year class (n = 101) responded to the surveys. Results indicate that, as anticipated, deliberate SGM teaching correlates with greater student recall as students recalled topics that were reported by CDs as intentionally taught at a significantly higher rate compared to those not intentionally taught (32.0% vs. 15.3%; p < 0.01). Students most commonly recalled learning SGM-related language and terminology, which is likely partly but not entirely attributed to curricular modifications and faculty development made between distribution of the faculty and student surveys, indicating the importance of all faculty being trained in appropriate SGM terminology and concepts. Discordance between faculty intention and student recall of when topics were taught reveals opportunities to enhance the intentionality and impact of SGM teaching.

CONCLUSIONS

Students perceive and recall SGM content that is not listed as learning objectives, and all faculty who utilize this material in their teachings should receive foundational training and be thoughtful about how information is framed. Faculty who intentionally teach SGM topics should be explicit and direct about the conclusions they intend students to draw from their curricular content.

Risk-Stratification using the 40-Gene Expression Profile (40-GEP) Test Identifies Patients with Node Negative Cutaneous Squamous Cell Carcinoma (cSCC) at Higher Risk of Metastasis Who May Benefit from Adjuvant Radiation Therapy (ART)

PURPOSE/OBJECTIVE(S)

ART is a standard treatment used to reduce the risk of metastasis and recurrence in moderate‒to‒high-risk cSCC patients. Indications for ART have been largely based on pathologic risk factors and informed by staging systems, and while radiation oncologists generally designate a >10% risk threshold for usage of ART, there is no consensus on which groups of tumors may benefit from ART. The 40-GEP test has been independently validated to predict a cSCC patient's risk for regional/distant metastasis in patients with one or more high-risk clinicopathologic factors and reports three biologic risk groups: Class 1 (low, ∼7%), Class 2A (moderate, 20-25%), and Class 2B (high risk, >50%) for metastasis. This study aims to evaluate whether a biomarker informed risk stratification approach using a 40-GEP result could refine the ability to select patients with node negative cSCC at higher risk of metastasis who are most likely to benefit from ART.

MATERIALS/METHODS

In this retrospective study, all patients had primary cSCC tissue with verified clinicopathologic information of tumors with one or more high-risk factors, met clinical testing criteria, were comprehensively staged, and had outcomes data (n = 954). Patients with node positive disease, or those with nodal failure within 3 months of diagnosis were excluded (n = 19). From the n = 935, an intermediate risk population wherein ART is often considered was defined as Brigham and Women's Hospital (BWH) ≥T2a (n = 489). Kaplan-Meier survival analysis and log-rank test were used to assess metastasis free survival (MFS). Univariate Cox regression compared metastasis rates between 40-GEP results.

RESULTS

The 3-year MFS rate for this eligible for ART cohort was 82.4% The 40-GEP demonstrated statistically significant risk stratification with MFS rates of 92.4%, 76.1% and 59.4% for Class 1, Class 2A and Class 2B, respectively (p<0.0001). Cox regression was significant for Class 2A and 2B compared to Class 1, with a 3.2-fold and 6.4-fold increase in metastasis, respectively (p<0.0001). 64% (59/92) of all metastases received a Class 2A result, and 44% (14/32) of Class 2B patients metastasized. 46% (223/489) of the cohort received a Class 1 result. Of patients staged BWH T1 (n = 446), those with a Class 2A and 2B had an 88.7% and 66.7% MFS rate, respectively.

CONCLUSION

Within this eligible for ART population, patients with Class 2A or 2B 40-GEP results have inferior rates of MFS, while Class 1 patients have <10% risk of metastasis. Nearly half of this population received a 40-GEP Class 1 result and could be considered for treatment de-intensification trials. Conversely, patients with low-risk BWH T1 stage, who are traditionally not considered for ART, that received a Class 2A or 2B (>10% risk of metastasis) could be considered for adjuvant therapy.

Examining Differences in Substance Use Outcomes and Related Correlates among Transfeminine and Transmasculine Adults Using the 2017 New York State Patient Characteristics Survey

Background: Transgender persons in the U.S. experience high levels of violence and discrimination which have been linked to adverse substance use outcomes. Despite transgender women's higher exposure to such deleterious events compared to transgender men, studies have often aggregated both transgender women and men, obfuscating potentially unique differences between these groups. The current study, guided by the Minority Stress Model, examines differences in substance use outcomes and related correlates among transfeminine and transmasculine adults. Methods: A secondary data analysis was conducted using the 2017 Patient Characteristics Survey of public mental health facilities in the state of New York (N = 1387). Controlling for theoretically relevant factors, logistic regression models were estimated to examine differences between transfeminine and transmasculine adults in alcohol-related disorder (ARD) and drug use-related disorder (DURD) diagnoses, and tobacco use. Correlates of substance use disparities were also examined within gender identity groups. Results: Overall, 35% of participants were documented as using tobacco products whereas 14 and 19% were diagnosed with ARDs and DURDs, respectively. Transfeminine participants were 1.44-times more likely to be diagnosed with ARDs relative to transmasculine adults. Compared to transmasculine and White participants, transfeminine and Black participants were 1.64- and 1.59-times more likely to be diagnosed with DURDs. Conclusions: Recognizing the observed higher hazardous substance use risk among transfeminine and Black participants, findings indicate the potential role of minority stress in health outcomes of stigmatized communities. Our findings emphasize the need for identifying prevention and treatment strategies aimed at mitigating the implications of minority stress.

Identifying Common and Unique Barriers and Facilitators to Implementing Evidence-Based Practices for Suicide Prevention across Primary Care and Specialty Mental Health Settings

OBJECTIVE

We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts.

METHOD

Twenty-six clinicians and practice leaders from behavioral health (n = 2 programs) and primary care (n = 4 clinics) settings participated. Participation included a semi-structured qualitative interview on barriers and facilitators to implementing evidence-based suicide prevention practices. Within that interview, clinicians participated in a chart-stimulated recall exercise to gather additional information about decision making regarding suicide screening. Interview guides and qualitative coding were informed by leading frameworks in implementation science and behavioral science, and an integrated approach to interpreting qualitative results was used.

RESULTS

There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging.

CONCLUSION

Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.HIGHLIGHTSWe examined barriers and facilitators to suicide prevention across health settings.Common and unique barriers and facilitators across health-care settings emerged.Findings can enhance suicide prevention implementation across health-care settings.

Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk

BACKGROUND

Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination.

SETTING

This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019.

METHODS

We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing).

RESULTS

Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services.

CONCLUSIONS

Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.

Gender and Sexual Diverse Health Education: A Needs Assessment Among Internal Medicine Residents

Purpose: The purpose of this study was to assess perception of competency and comfort level of internal medicine (IM) residents in caring for gender and sexual diverse (GSD) patients, and to identify residents' preferred educational modalities and perceived facilitators and barriers to GSD curriculum implementation. Methods: A survey was distributed among IM residents during a mandatory didactic session between November 9 and December 18, 2020. Categorical variables were analyzed using Fisher's exact test. Open-ended questions were analyzed using content and theme analysis. Results: Of 138 residents, 89 (64%) completed the survey. Residents had varying levels of comfort and perceived competence. Small group (n = 61, 69%) and case-based learning (n = 58, 66%) formats were preferred. Content and theme analysis resulted in four major themes on facilitators and three major themes on barriers to GSD curricular implementation. Conclusion: This study provides unique insight to facilitate implementation of a learner-centered and developmentally appropriate curricular approach to GSD health education.

A Novel Curriculum Assessment Tool, Based on AAMC Competencies, to Improve Medical Education About Sexual and Gender Minority Populations

PROBLEM

Medical education aspires to mitigate bias in future professionals by providing robust curricula that include perspectives of and practices for caring for sexual and gender minority (SGM) populations; however, implementation of these ideals remains challenging. Medical school leaders motivated to improve curricula on caring for SGM populations must survey their school's current curricula to identify strengths and opportunities for improvement. In 2014, the Association of American Medical Colleges (AAMC) published 30 SGM competencies that curricula should address. Here the authors describe the development of a tool to efficiently assess whether an undergraduate medical education (UME) curriculum adequately incorporates the AAMC-recommended SGM competencies.

APPROACH

In 2018, Boston University School of Medicine (BUSM) convened a group of faculty and students with experience and expertise regarding SGM health. The group distilled the 30 AAMC competencies into 12 SGM topic areas that should be addressed in any UME curriculum, and they developed a curriculum assessment tool to evaluate the presence and timing of these topic areas in the BUSM curriculum. This tool was distributed to all course and clerkship directors responsible for the required UME curriculum at BUSM to investigate where these topic areas are addressed (May-June 2019).

OUTCOMES

The curriculum assessment tool identified several strengths in the preclerkship and clerkship curricula, including faculty willingness and enthusiasm to include SGM content. The assessment tool also revealed that some SGM topic areas are underrepresented in the BUSM curriculum, particularly during clerkships.

NEXT STEPS

The curriculum assessment tool described here is a straightforward, standardized instrument to map SGM topic areas within any UME curriculum. It is designed to be comprehensible by individuals who are not familiar with SGM health. The tool minimizes barriers to medical curricular change by providing a mechanism to assess and understand how SGM health is incorporated into existing curricula.

Meeting the Patient Care, Education, and Research Missions: Academic Medical Centers Must Comprehensively Address Sexual and Gender Minority Health

While sociopolitical advances have improved the rights of sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, queer [LGBTQ+] persons), they continue to face a health system that discriminates against them and does not provide competent, comprehensive care. Despite calls for advancing research, there remains limited sexual and gender minority health research funding, mentorship, and institutional support. Academic medical centers are best suited to systematically tackle disparities and improve care for all sexual and gender minority people through their tripartite missions of patient care, education, and research. In this article, the authors outline discrimination experienced by LGBTQ+ persons and highlight the unique disparities they experience across access and outcomes. The authors posit that by systematically improving clinical care of, incorporating education and training about, and research with LGBTQ+ people into their core missions, academic medical centers can dramatically change the health care landscape. Academic medical centers can eliminate health disparities, expand necessary research endeavors about sexual and gender minorities, and prepare the health care workforce to address the unique needs of these overlooked populations.

Improved risk stratification in an adjuvant radiation therapy (ART) eligible cutaneous squamous cell carcinoma (cSCC) patient population by integration of the 40-gene expression profile prognostic test (40-GEP)

e21589

Background: Although cure rates are high for cSCC, an estimated 2-6% of cSCC patients will develop regional/distant metastasis and due to high incidence, mortality levels are similar to melanoma. ART is used for high-risk cSCC (HRcSCC) patients to reduce the risk of recurrence and/or metastasis, but guidelines are confounding and lack clarity regarding which patients may benefit from ART. The 40-GEP test has been validated to predict a patient’s risk for regional/distant metastasis: Class 1-low; Class 2A-moderate; and Class 2B-high risk for metastasis. We hypothesize that a 40-GEP Class result could help further stratify patient risk within an ART-eligible population. Methods: Using criteria within NCCN guidelines and other high-risk features to determine ART-eligibility, 86 cases of the 420 HRcSCC patients having known outcomes from the 40-GEP multicenter validation cohort were identified. Criteria included patients presenting with two or more risk factors: tumor diameter ≥2 cm, poor differentiation, perineural invasion ≥0.1 mm, invasion beyond subcutaneous fat, and immunosuppression. Kaplan-Meier survival analysis and log rank test were used to assess metastasis free survival (MFS). Univariate Cox regression compared metastasis rates between 40-GEP Class results. Results: The 3-year MFS rate for the overall ART-eligible cohort was 65% (n = 86, 32 events, 95% CI: 56 – 76%). The 40-GEP demonstrated statistically significant stratification of risk with MFS rates of 79%, 63% and 33% for Class 1, Class 2A and Class 2B, respectively (p = 0.005). Cox regression was significant between Class 1 and Class 2B 40-GEP results (p = 0.002), with Class 2B having a 4.59-fold increase in metastases. 40% (34/86) of the cohort received a Class 1 result, highlighting HRcSCC patients who may be considered for reduction or avoidance of ART. In 14% (12/86) of cases with a Class 2B result, 2 of 3 patients went on to have metastasis and thus may be appropriate for more aggressive intervention in the setting of a clinical trial. Those cases meeting eligibility for 40-GEP testing but not ART-criteria (n = 334) and with a Class 2B result (n = 11) had a 64% MFS rate, similar to the ART-eligible population. Conclusions: The 40-GEP test stratifies a patient’s risk of regional and/or distant metastasis in patients for whom ART is typically considered. Incorporation of 40-GEP testing may help guide patient management decisions in HRcSCC by potentially decreasing over-treatment of patients with HRcSCC and identifying patients with otherwise lower risk disease who may benefit from ART and/or other adjunctive therapies.

The Annual Examination for Lesbian, Gay, and Bisexual Patients

The annual examination is a comprehensive evaluation of patients in which all aspects of health and well-being are considered, including proper screening, appropriate preventive care, and recommendations and resources for healthy living. Clinicians commonly avoid certain topics with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients because they may be unprepared to address their health needs. Therefore, clinicians should learn how to conduct an LGBTQ-friendly annual examination in order to provide high-quality care. This article focuses on both the general and unique health needs of lesbian, gay, bisexual, and queer patients; care for transgender and gender-diverse patients is considered elsewhere.

A randomized phase IIa study of quantified bone scan response in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with radium-223 dichloride alone or in combination with abiraterone acetate/prednisone or enzalutamide

BACKGROUND

In metastatic castration-resistant prostate cancer (mCRPC), assessing treatment response and bone lesions with technetium-99m is limited by image resolution and subjectivity. We evaluated bone scan lesion area (BSLA), a quantitative imaging assessment of response in patients with mCRPC receiving radium-223 alone or in combination with androgen receptor pathway inhibitors (abiraterone/prednisone or enzalutamide).

PATIENTS AND METHODS

This randomized, non-comparative phase IIa three-arm trial (NCT02034552) evaluated technetium-99m-based BSLA response rate (RR), safety, radiologic progression-free survival (rPFS), and time to first symptomatic skeletal event (SSE) in men with mCRPC and bone metastases receiving radium-223 with/without abiraterone/prednisone or enzalutamide. The primary endpoint was week 24 BSLA RR.

RESULTS

Overall, 63 patients received treatment (abiraterone/prednisone combination, n = 22; enzalutamide combination, n = 22; radium-223 monotherapy, n = 19). Median treatment duration (first to last dose of any study treatment) was 12 months (abiraterone/prednisone combination), 10 months (enzalutamide combination), and 3 months (radium-223 monotherapy). Week 24 BSLA RR was 58% [80% confidence interval (CI) 41% to 74%; one-sided P < 0.0001; 11/19 patients] with abiraterone/prednisone combination, 50% (32% to 68%; one-sided P < 0.0001; 8/16 patients) with enzalutamide combination, and 22% (10% to 40%; one-sided P = 0.0109; 4/18 patients) with radium-223 monotherapy. Median rPFS was not evaluable for combination arms and 4 months (80% CI 4 to 12) for monotherapy. SSEs were reported in 32% of patients; median time to first SSE was not estimable. Fatigue and back pain were the most commonly reported treatment-emergent adverse events (TEAEs); more patients receiving combination therapy than monotherapy had TEAEs. Fractures were reported in 18% receiving abiraterone/prednisone, 32% receiving enzalutamide, and 11% receiving radium-223 monotherapy. Fracture rates were lower in patients taking bone health agents versus not taking bone health agents at baseline.

CONCLUSIONS

Technetium-99m imaging BSLA may offer objective, quantifiable assessment of isotope uptake changes, and potentially treatment response, in patients with mCRPC and bone metastases treated with radium-223 alone or in combination with abiraterone/prednisone or enzalutamide. In this largely treatment-naive population, BSLA RR was numerically lower with radium-223 monotherapy versus combination therapy, indicating a limited role as first-line treatment. Use of radium-223 should follow evidence-based treatment guidelines and the licensed indication.

THU0328 SAFETY AND EFFICACY OF SUBCUTANEOUS TOCILIZUMAB IN SYSTEMIC SCLEROSIS: RESULTS FROM THE OPEN-LABEL PERIOD OF THE PHASE 3 FOCUSSCED TRIAL

Background:

The anti–interleukin-6 (IL-6) receptor-α antibody tocilizumab (TCZ) demonstrated skin score improvement and forced vital capacity (FVC) preservation in patients with systemic sclerosis (SSc) in a phase 2 randomized controlled trial.1,2Data from the 48-week, double-blind (DB), placebo (PBO)-controlled period of the focuSSced phase 3 trial were previously presented,3and open-label (OL) data up to week 96 are presented herein.

Objectives:

To assess the long-term safety and efficacy of TCZ in SSc patients.

Methods:

Adult patients with active SSc (≤60-month duration, modified Rodnan skin score [mRSS] 10-35, and elevated acute-phase reactants) treated with PBO or TCZ in the DB period received OL TCZ 162 mg SC weekly from weeks 48 to 96 in the OL period (PBO→OL TCZ and TCZ→OL TCZ, respectively). Exploratory analysis of data up to week 96 included no formal statistical analyses. Changes in mRSS and percent predicted FVC (ppFVC) were assessed.

Results:

Overall, 92/105 TCZ (88%) and 89/107 PBO (83%) patients entered the OL TCZ treatment period at week 48, and 85/105 TCZ→OL TCZ (81%) and 82/107 PBO→OL TCZ (77%) patients completed treatment up to week 96. Continued decline in mRSS was observed in the OL period for PBO→OL TCZ and TCZ→OL TCZ patients (Table). Change in ppFVC for patients who switched from PBO to TCZ (PBO→OL TCZ) was comparable between weeks 48 and 96 (OL period) to the change in patients who received TCZ from BL to week 48 in the DB period (Table). Rates (95% CI) of serious adverse events from weeks 48 to 96 were 15.8 (8.6, 26.5) per 100 PY for TCZ→OL TCZ patients, 14.8 (7.9, 25.3) per 100 PY for PBO→OL TCZ patients, and 15.4 (11.0, 20.9) for all TCZ exposure over 96 weeks (n = 193). Rates (95% CI) of serious infections were 2.3 (0.3, 8.1) per 100 PY for TCZ→OL TCZ patients, 3.4 (0.7, 10.0) per 100 PY for PBO→OL TCZ patients, and 3.0 (1.3, 5.9) for all TCZ exposure over 96 weeks. One death occurred during the OL period in each arm.

Conclusion:

Although OL data have to be interpreted with caution, results from OL TCZ treatment show numeric improvements in mRSS and FVC preservation similar to those of the DB period, with a beneficial effect on trajectory of FVC decline in patients who switched from PBO to TCZ. Long-term safety results were consistent with the known safety profile of TCZ, and no new or unexpected events were observed.

References:

[1]Khanna D et al.Lancet2016;387:2630-40.

[2]Khanna D et al.Ann Rheum Dis.2018;77:212-20.

[3]Khanna D et al.Arthritis Rheumatol2018;70(suppl 10):abst 898.

Table.

Change in Efficacy From Baseline

Baseline to Week 48Baseline to Week 96Week 48 to Week 96PBOTCZPBO→OL TCZTCZ→OL TCZPBO→OL TCZTCZ→OL TCZmRSS, mean (95% CI)a–5.3 (–6.9, –3.7)n = 92–6.7 (–8.0, –5.4)n = 97–8.4 (–10.0, –6.8)n = 83–9.6 (–10.9, –8.4)n = 85–2.5(–3.3, –1.6)n = 82–2.3(–3.2, –1.5)n = 85ppFVC, mean (95% CI) [median]–4.1 (–5.8, –2.4) [–3.9]n = 92–0.2 (–1.6, 1.2) [–0.7]n = 94–3.3 (–5.1, –1.5) [–3.1]n = 79–0.5 (–2.4, 1.3) [–1.4]n = 840.6 (–0.7, 1.9) [0.3]n = 78–0.3 (–1.7, 1.1) [0.0]n = 82Decline in ppFVC ≥10%, n/N (%)a15/91(16.5)5/93(5.4)14/79 (17.7)11/84 (13.1)NANAImprovement in ppFVC, n/N (%)a26/91(28.6)43/93(46.2)22/79(27.8)35/84(41.7)NANA

aObserved data. NA, not assessed.

Disclosure of Interests:

Dinesh Khanna Shareholder of: Eicos, Grant/research support from: NIH NIAID, NIH NIAMS, Consultant of: Acceleron, Actelion, Bayer, BMS, Boehringer-Ingelheim, Corbus, Galapagos, Genentech/Roche, GSK, Mitsubishi Tanabi, Sanofi-Aventis/Genzyme, UCB Pharma, Celia J. F. Lin Employee of: Genentech, Helen Spotswood Shareholder of: Roche Products Ltd, Employee of: Roche Products Ltd, Jeff Siegel Employee of: Genentech, Daniel Furst Grant/research support from: AbbVie, Actelion, Amgen, BMS, Corbus Pharmaceuticals, the National Institutes of Health, Novartis, Pfizer, and Roche/Genentech, Consultant of: AbbVie, Actelion, Amgen, BMS, Cytori Therapeutics, Corbus Pharmaceuticals, the National Institutes of Health, Novartis, Pfizer, and Roche/Genentech, Speakers bureau: CMC Connect (McCann Health Company), Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer

THU0215 WHOLE BLOOD TRANSCRIPTIONAL CHANGES FOLLOWING SELECTIVE INHIBITION OF JANUS KINASE 1 (JAK1) BY FILGOTINIB IN ADULTS WITH MODERATELY-TO-SEVERELY ACTIVE RHEUMATOID ARTHRITIS WITH PRIOR INADEQUATE RESPONSE TO METHOTREXATE (FINCH1)

Background:

Filgotinib (FIL), an oral selective JAK1 inhibitor, has shown efficacy and safety in multiple phase 3 studies in adults with moderately-to-severely active rheumatoid arthritis (RA). We have previously described the molecular response to FIL in large-scale RNA sequencing studies of gene expression in other RA populations1-3and herein conducted a similar study in RA patients (pts) with prior inadequate response to methotrexate (MTX; FINCH1).

Objectives:

Identify RA-associated gene transcripts and biological pathways that are altered in response to FIL treatment.

Methods:

RA pts who had an inadequate response to MTX were enrolled in FINCH1 (ClinicalTrials.govNCT02889796) and randomized to receive either a stable dose of MTX with placebo (PBO+MTX), adalimumab (ADA+MTX), or one of two doses of FIL (FIL 100mg+MTX, FIL 200mg+MTX) once daily (QD). Whole blood samples were collected from pts using PAXgene tubes at baseline, week 4, and week 12. RNA from these samples was extracted and sequenced on the Illumina HiSeq 2500 platform following globin RNA depletion. Correlations between baseline gene expression and disease measurements were performed using Spearman’s rank partial correlation with covariates. Differentially expressed genes (DEGs) were identified using voom-limma. Pathway analysis was performed on v6.1 of the Molecular Signature Database using single sample gene set enrichment analysis (GSEA) with the focus on immune signaling pathways from the Kyoto Encyclopedia of Genes and Genomes (KEGG). A false-discovery rate of 5% was applied for all analyses.

Results:

Differential gene expression analyses comparing baseline samples with after-treatment samples revealed more rapid transcriptional kinetics for FIL-treated pts compared to ADA+MTX-treated pts. No significant DEGs were observed in PBO-treated pts. More significant DEGs were observed in the FIL 200mg+MTX arm compared to the FIL 100mg+MTX arm, consistent with the superior clinical efficacy of the FIL 200mg dosage. As with other FIL clinical trial RNA-seq studies and consistent with the selective MoA of FIL, JAK-STAT pathway-induced genes SOCS2 and CISH were significantly downregulated across both FIL treatment arms and timepoints, but not in the ADA+MTX arm. RA disease activity associated genes2-3FAM20A and METTL7B were significantly reduced at both 4 and 12 weeks only in the FIL 200mg+MTX arm. While no significant changes in KEGG immune signaling pathways were observed in the PBO+MTX arm, a dose-dependent effect on pathway modulation was observed in the FIL arms. The most prominently down-regulated KEGG pathways included JAK-STAT signaling and leukocyte transendothelial migration.

Conclusion:

More rapid and sustained changes of transcriptional activity were observed in the whole blood transcriptional profile of RA pts following FIL 200mg+MTX compared to ADA+MTX treatment. Dose-dependent changes were observed in FIL-treated pts, most notably in the KEGG JAK-STAT signaling pathway. These observations confirm an inhibition of JAK-STAT signaling by FIL and are consistent with the observed clinical efficacy of FIL in these pts.

References:

[1]Taylor PC, et al. (EULAR 2018).http://dx.doi.org/10.1136/annrheumdis-2018-eular.3759

[2]Taylor PC, et al. (ACR 2018).https://doi.org/10.1093/rheumatology/kez105.001

[3]Taylor PC, et al. (EULAR 2019).http://dx.doi.org/10.1136/annrheumdis-2019-eular.2509

Acknowledgments :

This study was funded by Gilead Sciences, Inc. Editorial support was provided by Fishawack Communications Inc and funded by Gilead Sciences, Inc.

Disclosure of Interests: :

Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Bryan Downie Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Emon Elboudwarej Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Sam Kim Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Angie Hertz Shareholder of: Gilead Sciences Inc, Employee of: Gilead Sciences Inc, Amer M. Mirza Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Jeffrey Siegel Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Rachael E. Hawtin Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Jinfeng Liu Shareholder of: Gilead Sciences Inc., Roche, Employee of: Gilead Sciences Inc.

SAT0155 WHOLE BLOOD TRANSCRIPTIONAL CHANGES FOLLOWING SELECTIVE INHIBITION OF JANUS KINASE 1 (JAK1) BY FILGOTINIB IN MTX-NAÏVE ADULTS WITH MODERATELY-TO-SEVERELY ACTIVE RHEUMATOID ARTHRITIS (RA) (FINCH3)

Background:

Filgotinib (FIL), an oral selective JAK1 inhibitor, has shown efficacy and safety in multiple phase 3 studies in adults with moderately-to-severely active rheumatoid arthritis (RA). We have previously described the molecular response to FIL in large-scale RNA sequencing studies of gene expression in other RA populations1-3and conducted a similar study in methotrexate (MTX)-naïve RA patients (pts) (FINCH3).

Objectives:

Identify gene transcripts and biological pathways associated with RA and those altered in response to FIL treatment.

Methods:

MTX-naïve RA pts who were enrolled in FINCH3 (ClinicalTrials.govNCT02886728) received a stable dose of MTX with placebo (PBO+MTX), FIL 200mg alone (FIL 200mg monotherapy), or one of two doses of FIL once daily (QD) together with MTX (FIL 100mg+MTX, FIL 200mg+MTX). Whole blood samples were collected from pts using PAXgene tubes at baseline, week 4, week 12, and week 24. RNA from these samples was extracted and sequenced on the Illumina HiSeq 2500 platform following globin RNA depletion. Correlations between baseline gene expression and disease measurements were performed using Spearman’s rank partial correlation to account for covariates. Differentially expressed genes (DEGs) were identified using voom-limma. Biological pathway analyses were performed on v6.1 of the Molecular Signature Database using single sample gene set enrichment analysis (GSEA) with the focus on immune signaling pathways from the Kyoto Encyclopedia of Genes and Genomes (KEGG). A false-discovery rate of 5% was applied for all analyses.

Results:

Differential gene expression analyses comparing baseline samples with after-treatment samples revealed rapid onset of transcriptional changes in FIL-treated pts, most notably for the two FIL 200mg arms. Fewer DEGs were observed at all timepoints in PBO+MTX treated patients with a peak number at week 24, an observation consistent with the clinical response kinetics of MTX.4Up to 3x as many significant DEGs were observed in the FIL 200mg+MTX arm compared to the FIL 100mg+MTX arm, a finding consistent with the superior clinical efficacy of the FIL 200mg dosage. As with other FIL clinical trial RNA-seq studies and consistent with the selective MoA of FIL, JAK-STAT pathway-induced genes SOCS2 and CISH were significantly downregulated across FIL treatment arms and timepoints, but not for PBO+MTX. RA disease activity-associated genes2-3FAM20A and METTL7B were significantly reduced at all timepoints in FIL-treated pts, but only at week 24 in PBO+MTX pts. While no significant changes in KEGG immune signaling pathways were observed in the PBO+MTX arm, a dose-dependent effect on pathway modulation was observed in the FIL arms, including reductions in JAK-STAT, toll-like receptor, chemokine, and RIG-I like receptor signaling.

Conclusion:

More rapid and sustained changes of transcriptional activity in the whole blood transcriptional profile of RA pts after FIL treatment were found compared to PBO+MTX. Dose-dependent changes were observed in FIL-treated pts, most notably in the KEGG JAK-STAT signaling pathway. These observations confirm an inhibition of JAK-STAT signaling by FIL and are consistent with the observed clinical efficacy of FIL in these pts.

References:

[1]Taylor PC, et al. (EULAR 2018).http://dx.doi.org/10.1136/annrheumdis-2018-eular.3759

[2]Taylor PC, et al. (ACR 2018).https://doi.org/10.1093/rheumatology/kez105.001

[3]Taylor PC, et al. (EULAR 2019).http://dx.doi.org/10.1136/annrheumdis-2019-eular.2509

[4]Taylor PC, et al. J Clin Med. 2019;8(4): pii: E515. doi: 10.3390/jcm8040515

Acknowledgments:

This study was funded by Gilead Sciences, Inc. Editorial support was provided by Fishawack Communications Inc and funded by Gilead Sciences, Inc.

Disclosure of Interests:

Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Bryan Downie Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Emon Elboudwarej Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Sam Kim Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Angie Hertz Shareholder of: Gilead Sciences Inc, Employee of: Gilead Sciences Inc, Amer M. Mirza Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Jeffrey Siegel Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Rachael E. Hawtin Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Jinfeng Liu Shareholder of: Gilead Sciences Inc., Roche, Employee of: Gilead Sciences Inc.

"They Dumped Me Like Trash": The Social and Psychological Toll of Victimization on Latino Day Laborers' Lives

Although recent rhetoric links undocumented immigrants to criminality, reports indicate undocumented immigrants commit less crime than their native-born counterparts and that this vulnerable group may be at increased risk for criminal victimization. Immigrants living in new immigrant settlement cities may be particularly at risk for exposure to criminal victimization due to the vulnerabilities associated with a lack of an established Latino community and limited availability of culturally appropriate social services to provide support. This ethnographic study examines the experiences of victimization and its social and psychological toll of a street-recruited sample of Latino day laborers (LDLs) (N = 25) living and working in Baltimore, a new immigrant settlement city. Findings elucidate and describe the specific types of victimization experienced by LDLs, including workplace victimization (wage theft, abandonment at the jobsite, poor working conditions, verbal abuse) and street-level victimization (assault and robbery), as well as reveal the social and psychological toll of victimization (sociocultural alienation, despair or desesperación, and problem drinking) on their lives. Findings have implications for community psychology, through research and practice, as they provide insights for prevention and intervention within the intersection of structural vulnerability (i.e., undocumented immigration status), violence, and mental health.

0012 REM Sleep in Ostrich Chicks

Introduction

It was reported that adult ostriches displayed the longest REM sleep episodes (up to 5 min) and more REM sleep (24% of the nighttime) than any other avian species. In all mammals studied so far REM sleep predominates at early age suggesting it promotes development of the brain. The aim of this study was to examine REM sleep in ostrich chicks.

Methods

EEG, electrooculogram and electromyogram of the neck muscles were recorded in 4 chronically implanted 2–3 month old ostrich chicks over 3 nights. The last night was scored in 4-sec epochs for waking, nonREM and REM sleep.

Results

NonREM sleep and REM sleep in the ostrich chicks occurred when they were sitting or lying with the head held above the ground or rested on the ground. REM sleep was characterized by distinct rapid eye movements, head drops and eye closure. The amplitude of the EEG during episodes of REM sleep ranged between low voltage EEG, as recorded during quiet waking and high voltage slow waves, as recorded during nonREM sleep EEG. The ostrich chicks spent on average 70.7 + 2.2% of the nighttime in nonREM sleep and 12.3 + 3.9% in REM sleep. The episodes of REM sleep lasted on average 9 + 1 sec and ranged between 4 and 36 sec.

Conclusion

Similar to adult birds, 2–3 mo old ostrich chicks displayed a “mixed” sleep state which has features of both slow wave sleep / nonREM and REM sleep, as we have described in the platypus and echidna. An unexpected result of this study is the total amount and duration of episodes of REM were considerably smaller than has been reported in adult ostriches. More studies need to be done on the developmental and environmental determinants of REM sleep in the ostrich.

Support

The Russian Foundation for Basic Research (18-04-01252) and HL148574

Web Exclusive. Annals Graphic Medicine - Morning Thoughts on Day 7 of COVID-19 Social Isolation

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Tailoring metal-dielectric nanocomposite materials with ultrashort laser pulses for dichroic color control

Metal-dielectric nanocomposites are multiphase material systems containing nanostructures, whose size and arrangement determine the optical properties of the material, enabling the production of new materials with custom-designed response. In this paper, we exploit a femtosecond laser-based strategy to fabricate nanocomposites based on silver nanoparticles (Ag NPs) with tunable optical spectral response. We demonstrate how the spectral response, specifically color and dichroic response, is linked to Ag NPs growth and self-organization processes that are controlled locally by the choice of the laser irradiation parameters, such as scan speed and laser light polarization. When the scan speed increases, the Ag NPs are formed at larger depths below the film surface and give rise to the formation of embedded NPs gratings. As a result, the effective optical properties of the films are strongly modified enabling the display of a broad range of solid colors in the visible region. Furthermore, the choice of the laser light polarization allows to fabricate films either with iridescent or dichroic properties (linear polarization) or with non-diffractive and non-dichroic colors (circular polarization). Finally, the high spatial control over the transformed areas achieved with the laser processing, allows the building of hybrid nanostructures by means of interlacing structures with different optical responses. These results demonstrate the high potential of fs-laser technology to process Ag-based nanocomposites to fabricate coatings with a designed reflectivity, transmission, diffraction, as well as polarization anisotropy response. The Ag nanocomposites investigated in this work hold great promise for a broad range of applications especially for coloring, for enhanced visual effects, and for smart information encoding for security applications.

Integrating Social Determinants of Health Into Graduate Medical Education: A Call for Action

Social determinants of health (SDH) are the major drivers of health and disparate health outcomes across communities and populations. Given this, the authors assert that competency in recognizing and mitigating SDH should become a vital component of graduate medical education in all specialties. Although the most effective approaches to educating trainees about SDH are uncertain, in this Invited Commentary, the authors offer several key principles for implementing curricula focusing on SDH. These include universalization of the material, integration into clinical education, identification of space for trainee introspection, clarification of specific competencies in identification and mitigation of SDH, and creation of robust faculty development programming. The authors highlight several examples of curricular approaches to SDH, touching on orientation, experiential learning, community-based and service-learning opportunities, interprofessional activities, and the hidden curriculum. The authors argue that all clinical trainees must learn to recognize and mitigate SDH and that doing so will allow them to achieve meaning and mastery in medicine and to better meet society's pressing health needs.

Surface characterization and antibacterial response of silver nanowire arrays supported on laser-treated polyethylene naphthalate

Polymeric biomaterials with antibacterial effects are requisite materials in the fight against hospital-acquired infections. An effective way for constructing a second generation of antibacterials is to exploit the synergic effect of (i) patterning of polymeric materials by a laser, and (ii) deposition of noble metals in their nanostructured forms. With this approach, we prepared highly-ordered periodic structures (ripples) on polyethylene naphthalate (PEN). Subsequent deposition of Ag under the glancing angle of 70° resulted in the formation of self-organized, fully separated Ag nanowire (Ag NW) arrays homogenously distributed on PEN surface. Surface properties of these samples were characterized by AFM and XPS. Vacuum evaporation of Ag at the glancing angle geometry of 70° caused that Ag NWs were formed predominantly from one side of the ripples, near to the top of the ridges. The release of Ag⁺ ions into physiological solution was studied by ICP-MS. The results of antibacterial tests predetermine these novel structures as promising materials able to fight against a broad spectrum of microorganisms, however, their observed cytotoxicity warns about their applications in the contact with living tissues.

Cytotoxicity of Pd nanostructures supported on PEN: Influence of sterilization on Pd/PEN interface

Non-conventional antimicrobial agents, such as palladium nanostructures, have been increasingly used in the medicinal technology. However, experiences uncovering their harmful and damaging effects to human health have begun to appear. In this study, we have focused on in vitro cytotoxicity assessment of Pd nanostructures supported on a biocompatible polymer. Pd nanolayers of variable thicknesses (ranging from 1.1 to 22.4nm) were sputtered on polyethylene naphthalate (PEN). These nanolayers were transformed by low-temperature post-deposition annealing into discrete nanoislands. Samples were characterized by AFM, XPS, ICP-MS and electrokinetic analysis before and after annealing. Sterilization of samples prior to cytotoxicity testing was done by UV irradiation, autoclave and/or ethanol. Among the listed sterilization techniques, we have chosen the gentlest one which had minimal impact on sample morphology, Pd dissolution and overall Pd/PEN interface quality. Cytotoxic response of Pd nanostructures was determined by WST-1 cell viability assay in vitro using three model cell lines: mouse macrophages (RAW 264.7) and two types of mouse embryonic fibroblasts (L929 and NIH 3T3). Finally, cell morphology in response to Pd/PEN was evaluated by means of fluorescence microscopy.

Benefit-cost analysis of commercially available activated carbon filters for indoor ozone removal in single-family homes

This study involved the development of a model for evaluating the potential costs and benefits of ozone control by activated carbon filtration in single-family homes. The modeling effort included the prediction of indoor ozone with and without activated carbon filtration in the HVAC system. As one application, the model was used to predict benefit-to-cost ratios for single-family homes in 12 American cities in five different climate zones. Health benefits were evaluated using disability-adjusted life-years and included city-specific age demographics for each simulation. Costs of commercially available activated carbon filters included capital cost differences when compared to conventional HVAC filters of similar particle removal efficiency, energy penalties due to additional pressure drop, and regional utility rates. The average indoor ozone removal effectiveness ranged from 4 to 20% across the 12 target cities and was largely limited by HVAC system operation time. For the parameters selected in this study, the mean predicted benefit-to-cost ratios for 1-inch filters were >1.0 in 10 of the 12 cities. The benefits of residential activated carbon filters were greatest in cities with high seasonal ozone and HVAC usage, suggesting the importance of targeting such conditions for activated carbon filter applications.

Anatomic variation and orgasm: Could variations in anatomy explain differences in orgasmic success?

Though the public consciousness is typically focused on factors such as psychology, penis size, and the presence of the "G-spot," there are other anatomical and neuro-anatomic differences that could play an equal, or more important, role in the frequency and intensity of orgasms. Discovering these variations could direct further medical or procedural management to improve sexual satisfaction. The aim of this study is to review the available literature of anatomical sexual variation and to explain why this variation may predispose some patients toward a particular sexual experience. In this review, we explored the available literature on sexual anatomy and neuro-anatomy. We used PubMed and OVID Medline for search terms, including orgasm, penile size variation, clitoral variation, Grafenberg spot, and benefits of orgasm. First we review the basic anatomy and innervation of the reproductive organs. Then we describe several anatomical variations that likely play a superior role to popular known variation (penis size, presence of g-spot, etc). For males, the delicate play between the parasympathetic and sympathetic nervous systems is vital to achieve orgasm. For females, the autonomic component is more complex. The clitoris is the primary anatomical feature for female orgasm, including its migration toward the anterior vaginal wall. In conclusions, orgasms are complex phenomena involving psychological, physiological, and anatomic variation. While these variations predispose people to certain sexual function, future research should explore how to surgically or medically alter these. Clin. Anat. 29:665-672, 2016. © 2016 Wiley Periodicals, Inc.

Antibacterial properties of palladium nanostructures sputtered on polyethylene naphthalate

Scheme of pen processing resulting in “curtain” effect of Pd.

Particle characterization in retail environments: concentrations, sources, and removal mechanisms

Particles in retail environments can have consequences for the occupational exposures of retail workers and customers, as well as the energy costs associated with ventilation and filtration. Little is known about particle characteristics in retail environments. We measured indoor and outdoor mass concentrations of PM10 and PM2.5 , number concentrations of submicron particles (0.02-1 μm), size-resolved 0.3-10 μm particles, as well as ventilation rates in 14 retail stores during 24 site visits in Pennsylvania and Texas. Overall, the results were generally suggestive of relatively clean environments when compared to investigations of other building types and ambient/occupational regulatory limits. PM10 and PM2.5 concentrations (mean ± s.d.) were 20 ± 14 and 11 ± 10 μg/m(3), respectively, with indoor-to-outdoor ratios of 1.0 ± 0.7 and 0.88 ± 1.0. Mean submicron particle concentrations were 7220 ± 7500 particles/cm(3) with an indoor-to-outdoor ratio of 1.18 ± 1.30. The median contribution to PM10 and PM2.5 concentrations from indoor sources (vs. outdoors) was 83% and 53%, respectively. There were no significant correlations between measured ventilation rates and particle concentrations of any size. When examining options to lower PM2.5 concentrations below regulatory limits, the required changes to ventilation and filtration efficiency were site specific and depended on the indoor and outdoor concentration, emission rate, and infiltration level.

PRACTICAL IMPLICATIONS

Little is known about particle concentrations, contribution of indoor sources, and emission rates in retail environments. Knowledge of these particle characteristics informs health scientists with input parameters to include in exposure modeling. The predicted concentration change in response to different ventilation rates and filtration efficiencies may be used for guidance to develop control strategies to lower particulate matter concentrations in retail environments.

High speed inscription of uniform, large-area laser-induced periodic surface structures in Cr films using a high repetition rate fs laser

We report on the fabrication of laser-induced periodic surface structures in Cr films upon high repetition rate fs laser irradiation (up to 1 MHz, 500 fs, 1030 nm), employing beam scanning. Highly regular large-area (9  cm2) gratings with a relative diffraction efficiency of 42% can be produced within less than 6 min. The ripple period at moderate and high fluences is 0.9 μm, with a small period of 0.5 μm appearing at lower energies. The role of the irradiation parameters on the characteristics of the laser-induced periodic surface structures (LIPSS) is studied and discussed in the frame of the models presently used. We have identified the polarization vector orientation with respect to the scan direction as a key parameter for the fabrication of high-quality, large-area LIPSS, which, for perpendicular orientation, allows the coherent extension of the sub-wavelength structure over macroscopic distances. The processing strategy is robust in terms of broad parameter windows and applicable to other materials featuring LIPSS.

The Public Health Workforce and Willingness to Respond to Emergencies: A 50-State Analysis of Potentially Influential Laws

Law plays a critical role in all stages of a public health emergency, providing an infrastructure for planning, response, and recovery efforts. A growing body of research has underscored the potential for certain types of state laws, such as those granting liability protections to responders, to influence the public health workforce's participation in emergency responses. It is therefore especially important to focus on particular state-level laws that may be associated with individuals' increased or decreased willingness to respond. We conducted a systematic identification and analysis of specific state emergency preparedness laws that may affect individuals' willingness to respond and offer recommendations for policymakers seeking to promote more effective responses to public health emergencies.

Ion migration assisted inscription of high refractive index contrast waveguides by femtosecond laser pulses in phosphate glass

In this Letter, we report on the successful fabrication of low loss, high refractive index contrast waveguides via ion migration upon femtosecond laser writing in phosphate glass. Waveguides were produced in two different phosphate glass compositions with high and low La(2)O(3) content. In the La-rich glass, a large refractive index increase in the guiding region was observed due to the incoming migration of La accompanied by the out-diffusion of K. The much smaller refractive index change in the La-less glass is caused by rearrangements of the glass structure. These results confirm the feasibility of adapting the glass composition for enabling the laser writing of high refractive index contrast structures via spatially selective modification of the glass composition.