Effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections: observational study, systematic reviews and mathematical modelling

BACKGROUND Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification. OBJECTIVE To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs). DESIGN Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness. SETTING General population and genitourinary medicine clinic attenders. PARTICIPANTS Heterosexual women and men. INTERVENTIONS Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT). MAIN OUTCOME MEASURES Population prevalence; index case reinfection; and partners treated per index case. RESULTS Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, > 10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage. CONCLUSIONS There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Strategies for partner notification for sexually transmitted infections, including HIV

BACKGROUND Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re-infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission. OBJECTIVES To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection. SEARCH METHODS We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) or quasi-RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date. DATA COLLECTION AND ANALYSIS We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta-analyses where appropriate. We performed a sensitivity analysis for the primary outcome re-infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information. MAIN RESULTS We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV-positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.The review found moderate-quality evidence that expedited partner therapy is better than simple patient referral for preventing re-infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I(2) = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I(2) = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I(2) = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re-infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I(2) = 33%, low-quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re-infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non-gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies. AUTHORS' CONCLUSIONS The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re-infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high-quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

BACKGROUND: Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. METHODS: We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. RESULTS: Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). CONCLUSIONS: Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

Simple Estimation of Incident HIV Infection Rates in Notification Cohorts Based on Window Periods of Algorithms for Evaluation of Line-Immunoassay Result Patterns

Background Tests for recent infections (TRIs) are important for HIV surveillance. We have shown that a patient's antibody pattern in a confirmatory line immunoassay (Inno-Lia) also yields information on time since infection. We have published algorithms which, with a certain sensitivity and specificity, distinguish between incident (< = 12 months) and older infection. In order to use these algorithms like other TRIs, i.e., based on their windows, we now determined their window periods. Methods We classified Inno-Lia results of 527 treatment-naïve patients with HIV-1 infection < = 12 months according to incidence by 25 algorithms. The time after which all infections were ruled older, i.e. the algorithm's window, was determined by linear regression of the proportion ruled incident in dependence of time since infection. Window-based incident infection rates (IIR) were determined utilizing the relationship ‘Prevalence = Incidence x Duration’ in four annual cohorts of HIV-1 notifications. Results were compared to performance-based IIR also derived from Inno-Lia results, but utilizing the relationship ‘incident = true incident + false incident’ and also to the IIR derived from the BED incidence assay. Results Window periods varied between 45.8 and 130.1 days and correlated well with the algorithms' diagnostic sensitivity (R2 = 0.962; P<0.0001). Among the 25 algorithms, the mean window-based IIR among the 748 notifications of 2005/06 was 0.457 compared to 0.453 obtained for performance-based IIR with a model not correcting for selection bias. Evaluation of BED results using a window of 153 days yielded an IIR of 0.669. Window-based IIR and performance-based IIR increased by 22.4% and respectively 30.6% in 2008, while 2009 and 2010 showed a return to baseline for both methods. Conclusions IIR estimations by window- and performance-based evaluations of Inno-Lia algorithm results were similar and can be used together to assess IIR changes between annual HIV notification cohorts.

Implementation of a mandatory donor RHD screening in Switzerland

Starting in 2013, blood donors must be tested at least using: (1) one monoclonal anti-D and one anti-CDE (alternatively full RhCcEe phenotyping), and (2) all RhD negative donors must be tested for RHD exons 5 and 10 plus one further exonic, or intronic RHD specificity, according to the guidelines of the Blood Transfusion Service of the Swiss Red Cross (BTS SRC). In 2012 an adequate stock of RHD screened donors was built. Of all 25,370 RhD negative Swiss donors tested in 2012, 20,015 tested at BTS Berne and 5355 at BTS Zürich, showed 120 (0.47%) RHD positivity. Thirty-seven (0.15%) had to be redefined as RhD positive. Routine molecular RHD screening is reliable, rapid and cost-effective and provides safer RBC units in Switzerland.

Mandatory communication skills training for oncologists: enforcement does not substantially impact satisfaction.

PURPOSE Even though there is evidence that both patients and oncology clinicians are affected by the quality of communication and that communication skills can be effectively trained, so-called Communication Skills Trainings (CSTs) remain heterogeneously implemented. METHODS A systematic evaluation of the level of satisfaction of oncologists with the Swiss CST before (2000-2005) and after (2006-2012) it became mandatory. RESULTS Levels of satisfaction with the CST were high, and satisfaction of physicians participating on a voluntary or mandatory basis did not significantly differ for the majority of the items. CONCLUSIONS The evaluation of physicians' satisfaction over the years and after introduction of mandatory training supports recommendations for generalized implementation of CST and mandatory training for medical oncologists.

Improved hand hygiene compliance after eliminating mandatory glove use from contact precautions-Is less more?

BACKGROUND Guidelines recommend that health care personnel (HCP) wear gloves for all interactions with patients on contact precautions. We aimed to assess hand hygiene (HH) compliance during contact precautions before and after eliminating mandatory glove use. METHODS We assessed HH compliance of HCP in the care of patients on contact precautions in 50 series before (2009) and 6 months after (2012) eliminating mandatory glove use and compared these results with the hospital-wide HH compliance. RESULTS We assessed 426 HH indications before and 492 indications after the policy change. Compared with 2009, we observed a significantly higher HH compliance in patients on contact precautions in 2012 (52%; 95% confidence interval [95% CI], 47-57) vs 85%; 95% CI, 82-88; P < .001). During the same period, hospital-wide HH compliance also increased from 63% (95% CI, 61-65) to 81% (95% CI 80-83) (P < .001). However, the relative improvement (RI) of HH compliance during contact precautions was significantly higher than the hospital-wide relative improvement (RI, 1.6; 95% CI, 1.49-1.81 vs 1.29; 95% CI, 1.25-1.34), with a relative improvement ratio of 1.27 (95% CI, 1.15-1.41). CONCLUSION Eliminating mandatory glove use in the care of patients on contact precautions increased HH compliance in our institution, particularly before invasive procedures and before patient contacts. Further studies on the effect on pathogen transmission are needed before revisiting the current official guidelines on the topic.

Gender differences in tuberculosis notification in Pakistan

Worldwide the male:female ratio of new smear-positive TB cases is estimated to be roughly 2:1. However in Pakistan this is not the case. Rates of notified TB cases are 20–30% higher in young females compared with males and female rates remain high regardless of increasing age. This is in stark contrast to neighboring India which is characterized by a huge excess of male TB cases. It is currently unknown why rates of notified TB are so high in females in Pakistan, but it is clear this epidemiology is a public health issue of great importance that impacts transmission dynamics and disease control initiatives.^

E-Flow: A communication system for user notification in dynamic evacuation scenarios

Most of the current evacuation plans are based on static signaling, fixed monitoring infrastructure, and limited user notification and feedback mechanisms. These facts lead to lower situation awareness, in the case event of an emergency, such as blocked emergency exits, while delaying the reaction time of individuals. In this context, we introduce the E-Flow communication system, which improves the user awareness by integrating personal, mobile and fixed devices with the existing monitoring infrastructure. Our system broadens the notification and monitoring alternatives, in real time, among, safety staff, end-users and evacuation related devices, such as sensors and actuators.

A Novel Approach to Context-Aware Content-Based Middleware

La computación ubicua está extendiendo su aplicación desde entornos específicos hacia el uso cotidiano; el Internet de las cosas (IoT, en inglés) es el ejemplo más brillante de su aplicación y de la complejidad intrínseca que tiene, en comparación con el clásico desarrollo de aplicaciones. La principal característica que diferencia la computación ubicua de los otros tipos está en como se emplea la información de contexto. Las aplicaciones clásicas no usan en absoluto la información de contexto o usan sólo una pequeña parte de ella, integrándola de una forma ad hoc con una implementación específica para la aplicación. La motivación de este tratamiento particular se tiene que buscar en la dificultad de compartir el contexto con otras aplicaciones. En realidad lo que es información de contexto depende del tipo de aplicación: por poner un ejemplo, para un editor de imágenes, la imagen es la información y sus metadatos, tales como la hora de grabación o los ajustes de la cámara, son el contexto, mientras que para el sistema de ficheros la imagen junto con los ajustes de cámara son la información, y el contexto es representado por los metadatos externos al fichero como la fecha de modificación o la de último acceso. Esto significa que es difícil compartir la información de contexto, y la presencia de un middleware de comunicación que soporte el contexto de forma explícita simplifica el desarrollo de aplicaciones para computación ubicua. Al mismo tiempo el uso del contexto no tiene que ser obligatorio, porque si no se perdería la compatibilidad con las aplicaciones que no lo usan, convirtiendo así dicho middleware en un middleware de contexto. SilboPS, que es nuestra implementación de un sistema publicador/subscriptor basado en contenido e inspirado en SIENA [11, 9], resuelve dicho problema extendiendo el paradigma con dos elementos: el Contexto y la Función de Contexto. El contexto representa la información contextual propiamente dicha del mensaje por enviar o aquella requerida por el subscriptor para recibir notificaciones, mientras la función de contexto se evalúa usando el contexto del publicador y del subscriptor. Esto permite desacoplar la lógica de gestión del contexto de aquella de la función de contexto, incrementando de esta forma la flexibilidad de la comunicación entre varias aplicaciones. De hecho, al utilizar por defecto un contexto vacío, las aplicaciones clásicas y las que manejan el contexto pueden usar el mismo SilboPS, resolviendo de esta forma la incompatibilidad entre las dos categorías. En cualquier caso la posible incompatibilidad semántica sigue existiendo ya que depende de la interpretación que cada aplicación hace de los datos y no puede ser solucionada por una tercera parte agnóstica. El entorno IoT conlleva retos no sólo de contexto, sino también de escalabilidad. La cantidad de sensores, el volumen de datos que producen y la cantidad de aplicaciones que podrían estar interesadas en manipular esos datos está en continuo aumento. Hoy en día la respuesta a esa necesidad es la computación en la nube, pero requiere que las aplicaciones sean no sólo capaces de escalar, sino de hacerlo de forma elástica [22]. Desgraciadamente no hay ninguna primitiva de sistema distribuido de slicing que soporte un particionamiento del estado interno [33] junto con un cambio en caliente, además de que los sistemas cloud actuales como OpenStack u OpenNebula no ofrecen directamente una monitorización elástica. Esto implica que hay un problema bilateral: cómo puede una aplicación escalar de forma elástica y cómo monitorizar esa aplicación para saber cuándo escalarla horizontalmente. E-SilboPS es la versión elástica de SilboPS y se adapta perfectamente como solución para el problema de monitorización, gracias al paradigma publicador/subscriptor basado en contenido y, a diferencia de otras soluciones [5], permite escalar eficientemente, para cumplir con la carga de trabajo sin sobre-provisionar o sub-provisionar recursos. Además está basado en un algoritmo recientemente diseñado que muestra como añadir elasticidad a una aplicación con distintas restricciones sobre el estado: sin estado, estado aislado con coordinación externa y estado compartido con coordinación general. Su evaluación enseña como se pueden conseguir notables speedups, siendo el nivel de red el principal factor limitante: de hecho la eficiencia calculada (ver Figura 5.8) demuestra cómo se comporta cada configuración en comparación con las adyacentes. Esto permite conocer la tendencia actual de todo el sistema, para saber si la siguiente configuración compensará el coste que tiene con la ganancia que lleva en el throughput de notificaciones. Se tiene que prestar especial atención en la evaluación de los despliegues con igual coste, para ver cuál es la mejor solución en relación a una carga de trabajo dada. Como último análisis se ha estimado el overhead introducido por las distintas configuraciones a fin de identificar el principal factor limitante del throughput. Esto ayuda a determinar la parte secuencial y el overhead de base [26] en un despliegue óptimo en comparación con uno subóptimo. Efectivamente, según el tipo de carga de trabajo, la estimación puede ser tan baja como el 10 % para un óptimo local o tan alta como el 60 %: esto ocurre cuando se despliega una configuración sobredimensionada para la carga de trabajo. Esta estimación de la métrica de Karp-Flatt es importante para el sistema de gestión porque le permite conocer en que dirección (ampliar o reducir) es necesario cambiar el despliegue para mejorar sus prestaciones, en lugar que usar simplemente una política de ampliación. ABSTRACT The application of pervasive computing is extending from field-specific to everyday use. The Internet of Things (IoT) is the shiniest example of its application and of its intrinsic complexity compared with classical application development. The main characteristic that differentiates pervasive from other forms of computing lies in the use of contextual information. Some classical applications do not use any contextual information whatsoever. Others, on the other hand, use only part of the contextual information, which is integrated in an ad hoc fashion using an application-specific implementation. This information is handled in a one-off manner because of the difficulty of sharing context across applications. As a matter of fact, the application type determines what the contextual information is. For instance, for an imaging editor, the image is the information and its meta-data, like the time of the shot or camera settings, are the context, whereas, for a file-system application, the image, including its camera settings, is the information and the meta-data external to the file, like the modification date or the last accessed timestamps, constitute the context. This means that contextual information is hard to share. A communication middleware that supports context decidedly eases application development in pervasive computing. However, the use of context should not be mandatory; otherwise, the communication middleware would be reduced to a context middleware and no longer be compatible with non-context-aware applications. SilboPS, our implementation of content-based publish/subscribe inspired by SIENA [11, 9], solves this problem by adding two new elements to the paradigm: the context and the context function. Context represents the actual contextual information specific to the message to be sent or that needs to be notified to the subscriber, whereas the context function is evaluated using the publisher’s context and the subscriber’s context to decide whether the current message and context are useful for the subscriber. In this manner, context logic management is decoupled from context management, increasing the flexibility of communication and usage across different applications. Since the default context is empty, context-aware and classical applications can use the same SilboPS, resolving the syntactic mismatch that there is between the two categories. In any case, the possible semantic mismatch is still present because it depends on how each application interprets the data, and it cannot be resolved by an agnostic third party. The IoT environment introduces not only context but scaling challenges too. The number of sensors, the volume of the data that they produce and the number of applications that could be interested in harvesting such data are growing all the time. Today’s response to the above need is cloud computing. However, cloud computing applications need to be able to scale elastically [22]. Unfortunately there is no slicing, as distributed system primitives that support internal state partitioning [33] and hot swapping and current cloud systems like OpenStack or OpenNebula do not provide elastic monitoring out of the box. This means there is a two-sided problem: 1) how to scale an application elastically and 2) how to monitor the application and know when it should scale in or out. E-SilboPS is the elastic version of SilboPS. I t is the solution for the monitoring problem thanks to its content-based publish/subscribe nature and, unlike other solutions [5], it scales efficiently so as to meet workload demand without overprovisioning or underprovisioning. Additionally, it is based on a newly designed algorithm that shows how to add elasticity in an application with different state constraints: stateless, isolated stateful with external coordination and shared stateful with general coordination. Its evaluation shows that it is able to achieve remarkable speedups where the network layer is the main limiting factor: the calculated efficiency (see Figure 5.8) shows how each configuration performs with respect to adjacent configurations. This provides insight into the actual trending of the whole system in order to predict if the next configuration would offset its cost against the resulting gain in notification throughput. Particular attention has been paid to the evaluation of same-cost deployments in order to find out which one is the best for the given workload demand. Finally, the overhead introduced by the different configurations has been estimated to identify the primary limiting factor for throughput. This helps to determine the intrinsic sequential part and base overhead [26] of an optimal versus a suboptimal deployment. Depending on the type of workload, this can be as low as 10% in a local optimum or as high as 60% when an overprovisioned configuration is deployed for a given workload demand. This Karp-Flatt metric estimation is important for system management because it indicates the direction (scale in or out) in which the deployment has to be changed in order to improve its performance instead of simply using a scale-out policy.

Notification to Loammi Baldwin, 1795 June 25

One-page brief handwritten letter requesting Baldwin attend an examination and committee meeting.

Notification of a committee meeting, 1835 October 13

One-page printed notification of a meeting on October 20, 1835 of the Committee appointed by the Board of Overseers for the purpose of visiting the University, signed by President Josiah Quincy.

Notification of an Overseers meeting, 1835 July 6

One-page printed notification of a meeting of the Overseers of Harvard College on July 16, 1835 signed by Secretary John Pierce.