Validation of the emergency surgery score (ESS) in a UK patient population and comparison with NELA scoring: a retrospective multicentre cohort study

INTRODUCTION

Accurate risk scoring in emergency general surgery (EGS) is vital for consent and resource allocation. The emergency surgery score (ESS) has been validated as a reliable preoperative predictor of postoperative outcomes in EGS but has been studied only in the US population. Our primary aim was to perform an external validation study of the ESS in a UK population. Our secondary aim was to compare the accuracy of ESS and National Emergency Laparotomy Audit (NELA) scores.

METHODS

We conducted an observational cohort study of adult patients undergoing emergency laparotomy over three years in two UK centres. ESS was calculated retrospectively. NELA scores and all other variables were obtained from the prospectively collected Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database. The primary and secondary outcomes were 30-day mortality and postoperative intensive care unit (ICU) admission, respectively.

RESULTS

A total of 609 patients were included. Median age was 65 years, 52.7% were female, the overall mortality was 9.9% and 23.8% were admitted to ICU. Both ESS and NELA were equally accurate in predicting 30-day mortality (c-statistic=0.78 (95% confidence interval (CI), 0.71-0.85) for ESS and c-statistic=0.83 (95% CI, 0.77-0.88) for NELA, p=0.196) and predicting postoperative ICU admission (c-statistic=0.76 (95% CI, 0.71-0.81) for ESS and 0.80 (95% CI, 0.76-0.85) for NELA, p=0.092).

CONCLUSIONS

In the UK population, ESS and NELA both predict 30-day mortality and ICU admission with no statistically significant difference but with higher c-statistics for NELA score. Both scores have certain advantages, with ESS being validated for a wider range of outcomes.

Identifying Implementation Determinants and Strategies for Long-Acting Injectable Cabotegravir-Rilpivirine in People with HIV Who Are Virally Unsuppressed

BACKGROUND

Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population.

SETTING

Ward 86, a clinic serving publicly insured PWH in San Francisco.

METHODS

We describe multi-level determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on pre-implementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process.

RESULTS

Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Provider-level determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers due to rapid and unconstrained inclusion of LA-CAB/RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication.

CONCLUSION

Multi-level strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed.

Strengthening Public Health Capacity to Address Infectious Diseases: Lessons From 3 Centers of Excellence in Public Health and Homelessness

People experiencing homelessness are disproportionately affected by infectious diseases and often face barriers to receiving appropriate medical treatment. Responding to the needs of people experiencing homelessness requires state and local health departments to integrate information sources and coordinate multisector efforts. From 2021 to 2023, the CDC Foundation, in cooperation with the Centers for Disease Control and Prevention, established pilot Centers of Excellence in Public Health and Homelessness in Seattle, Washington; San Francisco, California; and the state of Minnesota. These centers strengthened their capacity to address the needs of people experiencing homelessness by supporting cross-sector partnerships, assessing the interoperability of data systems, prioritizing infectious disease needs, and identifying health disparities. These programs demonstrated that health departments are heterogeneous entities with differing resources and priorities. They also showed the importance of employing dedicated public health staff focused on homelessness, establishing diverse partnerships and the need for support from local leaders to address homelessness.

Demonstration Project of Long-Acting Antiretroviral Therapy in a Diverse Population of People With HIV

BACKGROUND

Intramuscular cabotegravir (CAB) and rilpivirine (RPV) is the only long-acting antiretroviral therapy (LA-ART) regimen approved for people with HIV (PWH). Long-acting ART holds promise for improving outcomes among populations with barriers to adherence but is only approved for PWH who have virologic suppression with use of oral ART before initiating injectables.

OBJECTIVE

To examine LA-ART in a population of PWH that includes those with viremia.

DESIGN

Observational cohort study.

SETTING

Urban academic safety-net HIV clinic.

PATIENTS

Publicly insured adults living with HIV with and without viral suppression, high rates of unstable housing, mental illness, and substance use.

INTERVENTION

Demonstration project of long-acting injectable CAB-RPV.

MEASUREMENTS

Descriptive statistics summarizing cohort outcomes to date, based on pharmacy team logs and electronic medical record data.

RESULTS

Between June 2021 and November 2022, 133 PWH at the Ward 86 HIV Clinic were started on LA-ART, 76 of whom had virologic suppression while using oral ART and 57 of whom had viremia. The median age was 46 years (IQR, 25 to 68 years); 117 (88%) were cisgender men, 83 (62%) had non-White race, 56 (42%) were experiencing unstable housing or homelessness, and 45 (34%) had substance use. Among those with virologic suppression, 100% (95% CI, 94% to 100%) maintained suppression. Among PWH with viremia, at a median of 33 days, 54 of 57 had viral suppression, 1 showed the expected 2-log10 reduction in HIV RNA level, and 2 experienced early virologic failure. Overall, 97.5% (CI, 89.1% to 99.8%) were projected to achieve virologic suppression by a median of 33 weeks. The current virologic failure rate of 1.5% in the cohort is similar to that across registrational clinical trials at 48 weeks.

LIMITATION

Single-site study.

CONCLUSION

This project demonstrates the ability of LA-ART to achieve virologic suppression among PWH, including those with viremia and challenges to adherence. Further data on the ability of LA-ART to achieve viral suppression in people with barriers to adherence are needed.

PRIMARY FUNDING SOURCE

National Institutes of Health, City and County of San Francisco, and Health Resources and Services Administration.

Urine Tenofovir Levels Strongly Correlate With Virologic Suppression in Patients With Human Immunodeficiency Virus on Tenofovir Alafenamide-Based Antiretroviral Therapy

We found that urine tenofovir (TFV) levels >1500 ng/mL strongly predict virologic suppression among people with human immunodeficiency virus taking tenofovir alafenamide (odds ratio, 5.66; 95% confidence interval, 1.59-20.14; P = .007). This suggests an existing point-of-care assay developed for tenofovir disoproxil fumarate will support adherence monitoring for patients on all TFV-based antiretrovirals.

First Demonstration Project of Long-Acting Injectable Antiretroviral Therapy for Persons With and Without Detectable Human Immunodeficiency Virus (HIV) Viremia in an Urban HIV Clinic

BACKGROUND

Long-acting injectable antiretroviral therapy (LAI-ART) is approved for treatment-naive or experienced people with human immunodeficiency virus (HIV; PWH) based on trials that only included participants with viral suppression. We performed the first LAI-ART demonstration project to include PWH unable to achieve or maintain viral suppression due to challenges adhering to oral ART.

METHODS

Ward 86 is a large HIV clinic in San Francisco that serves publicly insured and underinsured patients. We started patients on LAI-ART via a structured process of provider referral, multidisciplinary review (MD, RN, pharmacist), and monitoring for on-time injections. Inclusion criteria were willingness to receive monthly injections and a reliable contact method.

RESULTS

Between June 2021 and April 2022, 51 patients initiated LAI-ART, with 39 receiving at least 2 follow-up injections by database closure (median age, 46 years; 90% cisgender men, 61% non-White, 41% marginally housed, 54% currently using stimulants). Of 24 patients who initiated injections with viral suppression (median CD4 cell count, 706 cells/mm3), 100% (95% confidence interval [CI], 86%-100%) maintained viral suppression. Of 15 patients who initiated injections with detectable viremia (median CD4 cell count, 99 cells/mm3; mean log10 viral load, 4.67; standard deviation, 1.16), 12 (80%; 95% CI, 55%-93%) achieved viral suppression, and the other 3 had a 2-log viral load decline by a median of 22 days.

CONCLUSIONS

This small demonstration project of LAI-ART in a diverse group of patients with high levels of substance use and marginal housing demonstrated promising early treatment outcomes, including in those with detectable viremia due to adherence challenges. More data on LAI-ART in hard-to-reach populations are needed.

HIV treatment outcomes in POP-UP: drop-in HIV primary care model for people experiencing homelessness

INTRODUCTION

People living with HIV experiencing homelessness have low rates of viral suppression, driven by socio-structural barriers and limitations of traditional care systems. Informed by the Capability-Opportunity-Motivation-Behavior (COM-B) model and patient preference research, we developed "POP-UP", an integrated drop-in (non-appointment-based) HIV clinic with wrap-around services (substance use, mental health, case management, financial incentives) for persons with housing instability and viral-non suppression.

METHODS

We report HIV viral suppression (VS; <200 copies/mL), care engagement (≥90 day gaps in care and ≥1 clinical visit each 4-month period) and mortality at 12-months post-enrollment. We used logistic regression to determine participant characteristics associated with VS and care engagement.

RESULTS

We enrolled 112 patients with viral non-suppression and housing instability: 52% experiencing street-homelessness, 100% with a substance use disorder, and 70% with mental health diagnoses. At 12-months post-enrollment, 70% had ≥1 visit each 4-month period, although 59% had a 90-day care gap. In addition, 44% had VS, 24% had viral non-suppression, 23% missing, and 9% died (6 overdose, 2 AIDS-associated, 2 other). No baseline characteristics were associated with VS; baseline mental health diagnosis was associated with lower odds of a 90-day care gap (53% vs 74%; odds ratio 0.4, 95% CI 0.17-0.96).

CONCLUSIONS

The POP-UP low-barrier HIV care model successfully reached and retained some of the clinic's highest-risk patients. It was associated with improvement in VS from 0% to 44% at 12-months among people with housing instability. Gaps in care and high mortality from overdose remain major challenges to achieving optimal HIV treatment outcomes in this population.

Brief Report: Heterogeneous Preferences for Care Engagement Among People With HIV Experiencing Homelessness or Unstable Housing During the COVID-19 Pandemic

BACKGROUND/SETTING

In San Francisco, HIV viral suppression is 71% among housed individuals but only 20% among unhoused individuals. We conducted a discrete choice experiment at a San Francisco public HIV clinic to evaluate care preferences among people living with HIV (PLH) experiencing homelessness/unstable housing during the COVID-19 pandemic.

METHODS

From July to November 2020, we conducted a discrete choice experiment among PLH experiencing homelessness/unstable housing who accessed care through (1) an incentivized, drop-in program (POP-UP) or (2) traditional primary care. We investigated 5 program features: single provider vs team of providers; visit incentives ($0, $10, and $20); location (current site vs current + additional site); drop-in vs scheduled visits; in-person only vs optional telehealth visits; and navigator assistance. We estimated relative preferences using mixed-effects logistic regression and conducted latent class analysis to evaluate preference heterogeneity.

RESULTS

We enrolled 115 PLH experiencing homelessness/unstable housing, 40% of whom lived outdoors. The strongest preferences were for the same provider (β = 0.94, 95% CI: 0.48 to 1.41), visit incentives (β = 0.56 per $5; 95% CI: 0.47 to 0.66), and drop-in visits (β = 0.47, 95% CI: 0.12 to 0.82). Telehealth was not preferred. Latent class analysis revealed 2 distinct groups: 78 (68%) preferred a flexible care model, whereas 37 (32%) preferred a single provider.

CONCLUSIONS

We identified heterogeneous care preferences among PLH experiencing homelessness/unstable housing during the COVID-19 pandemic, with two-thirds preferring greater flexibility and one-third preferring provider continuity. Telehealth was not preferred, even with navigator facilitation. Including patient choice in service delivery design can improve care engagement, particularly for marginalized populations, and is an essential tool for ending the HIV epidemic.

Implementation of rapid and frequent SARS-CoV2 antigen testing and response in congregate homeless shelters

Background

People experiencing homelessness who live in congregate shelters are at high risk of SARS-CoV2 transmission and severe COVID-19. Current screening and response protocols using rRT-PCR in homeless shelters are expensive, require specialized staff and have delays in returning results and implementing responses.

Methods

We piloted a program to offer frequent, rapid antigen-based tests (BinaxNOW) to residents and staff of congregate-living shelters in San Francisco, California, from January 15^th to February 19^th, 2021. We used the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework to evaluate the implementation.

Results

Reach: We offered testing at ten of twelve eligible shelters. Shelter residents and staff had variable participation across shelters; approximately half of eligible individuals tested at least once; few tested consistently during the study.

Effectiveness: 2.2% of participants tested positive. We identified three outbreaks, but none exceeded 5 cases. All BinaxNOW-positive participants were isolated or left the shelters.

Adoption: We offered testing to all eligible participants within weeks of the project’s initiation.

Implementation: Adaptations made to increase reach and improve consistency were promptly implemented.

Maintenance: San Francisco Department of Public Health expanded and maintained testing with minimal support after the end of the pilot.

Conclusion

Rapid and frequent antigen testing for SARS-CoV2 in homeless shelters is a viable alternative to rRT-PCR testing that can lead to immediate isolation of infectious individuals. Using the RE-AIM framework, we evaluated and adapted interventions to enable the expansion and maintenance of protocols.

Impact of Multicomponent Support Strategies on Human Immunodeficiency Virus Virologic Suppression Rates During Coronavirus Disease 2019: An Interrupted Time Series Analysis

BACKGROUND

After coronavirus disease 2019 (COVID-19) shelter-in-place (SIP) orders, viral suppression (VS) rates initially decreased within a safety-net human immunodeficiency virus (HIV) clinic in San Francisco, particularly among people living with HIV (PLWH) who are experiencing homelessness. We sought to determine if proactive outreach to provide social services, scaling up of in-person visits, and expansion of housing programs could reverse this decline.

METHODS

We assessed VS 24 months before and 13 months after SIP using mixed-effects logistic regression followed by interrupted time series (ITS) analysis to examine changes in the rate of VS per month. Loss to follow-up (LTFU) was assessed via active clinic tracing.

RESULTS

Data from 1816 patients were included; the median age was 51 years, 12% were female, and 14% were experiencing unstable housing/homelessness. The adjusted odds of VS increased 1.34 fold following institution of the multicomponent strategies (95% confidence interval [CI], 1.21-1.46). In the ITS analysis, the odds of VS continuously increased 1.05 fold per month over the post-intervention period (95% CI, 1.01-1.08). Among PLWH who previously experienced homelessness and successfully received housing support, the odds of VS were 1.94-fold higher (95% CI, 1.05-3.59). The 1-year LTFU rate was 2.8 per 100 person-years (95% CI, 2.2-3.5).

CONCLUSIONS

The VS rate increased following institution of the multicomponent strategies, with a lower LFTU rate compared with prior years. Maintaining in-person care for underserved patients, with flexible telemedicine options, along with provision of social services and permanent expansion of housing programs, will be needed to support VS among underserved populations during the COVID-19 pandemic.

COVID-19 Testing and Vaccine Acceptability Among Homeless-Experienced Adults: Qualitative Data from Two Samples

BACKGROUND

Homeless-experienced populations are at increased risk of exposure to SARS-CoV-2 due to their living environments and face an increased risk of severe COVID-19 disease due to underlying health conditions. Little is known about COVID-19 testing and vaccination acceptability among homeless-experienced populations.

OBJECTIVE

To understand the facilitators and barriers to COVID-19 testing and vaccine acceptability among homeless-experienced adults.

DESIGN

We conducted in-depth interviews with participants from July to October 2020. We purposively recruited participants from (1) a longitudinal cohort of homeless-experienced older adults in Oakland, CA (n=37) and (2) a convenience sample of people (n=57) during a mobile outreach COVID-19 testing event in San Francisco.

PARTICIPANTS

Adults with current or past experience of homelessness.

APPROACH

We asked participants about their experiences with and attitudes towards COVID-19 testing and their perceptions of COVID-19 vaccinations. We used participant observation techniques to document the interactions between testing teams and those approached for testing. We audio-recorded, transcribed, and content analyzed all interviews and identified major themes and subthemes.

KEY RESULTS

Participants found incentivized COVID-19 testing administered in unsheltered settings and supported by community health outreach workers (CHOWs) to be acceptable. The majority of participants expressed a positive inclination toward vaccine acceptability, citing a desire to return to routine life and civic responsibility. Those who expressed hesitancy cited a desire to see trial data, concerns that vaccines included infectious materials, and mistrust of the government.

CONCLUSIONS

Participants expressed positive evaluations of the incentivized, mobile COVID-19 testing supported by CHOWs in unsheltered settings. The majority of participants expressed a positive inclination toward vaccination. Vaccine hesitancy concerns must be addressed when designing vaccine delivery strategies that overcome access challenges. Based on the successful implementation of COVID-19 testing, we recommend mobile delivery of vaccines using trusted CHOWs to address concerns and facilitate wider access to and uptake of the COVID vaccine.

Using a "Big Events" framework to understand emergency department use among women experiencing homelessness or housing instability in San Francisco during the COVID-19 pandemic

Background

The COVID-19 pandemic created a major public health crisis that disrupted economic systems, social networks and individual behaviors, which led to changes in patterns of health care use. Factors associated with emergency department (ED) visits during the pandemic among especially high-risk individuals are unknown. We used a “Big Events” approach, which considers major disruptions that create social instability, to investigate ED use in people experiencing homelessness or housing instability, many of whom use drugs.

Methods

Between July and December 2020, we conducted a community-based San Francisco study to compare homeless and unstably housed (HUH) women who did and did not use an ED during the first 10 months of the pandemic.

Results

Among 128 study participants, 34% had ≥1 ED visit during the pandemic. In adjusted analysis, factors significantly associated with ED use included experiencing homelessness, cocaine use and increased difficulties receiving drug use treatment during the pandemic.

Conclusion

These findings build on the “Big Events” approach to considering risk pathways among people who use drugs. They suggest the importance of ensuring access to housing and low-barrier non-COVID health services, including drug treatment, alongside crisis management activities, to reduce the health impacts of public health crises.

Coronavirus Disease 2019 Outbreak in a San Francisco Homeless Shelter

We report the public health response to a COVID-19 outbreak in a San Francisco shelter where 67% of residents and 17% of staff tested positive for SARS-CoV-2. We describe the limited utility of case investigation, person-based contact tracing and symptom screening, and the benefits of mass testing in outbreak response.

Evaluation of the POP-UP programme: a multicomponent model of care for people living with HIV with homelessness or unstable housing

OBJECTIVE

Homelessness is the greatest risk factor for HIV viremia in San Francisco. Innovative care models for people with HIV (PWH) with homelessness or unstable housing (HUH) are needed to address this inequity. We developed a novel low-barrier clinic-based program for PWH-HUH in an urban safety-net clinic ('POP-UP') and report outcomes on care engagement and viral suppression.

DESIGN

A prospective cohort study.

SETTING

San Francisco General Hospital HIV Clinic (Ward 86).

PARTICIPANTS

We enrolled PWH who are HUH, viraemic and for whom usual care is not working (at least one missed primary care appointment and at least two drop-in visits at Ward 86 in the last year).

INTERVENTION

POP-UP provides drop-in comprehensive primary care, housing assistance and case management, financial incentives and patient navigation with frequent contact.

MAIN OUTCOME MEASURES

We describe uptake of eligible patients into POP-UP, and cumulative incidence of antiretroviral therapy (ART) initiation, return to care and virologic suppression 6 months post-enrolment, estimated via Kaplan--Meier.

RESULTS

Out of 192 referred patients, 152 were eligible, and 75 enrolled. All 75 were off ART and viraemic; 100% had a substance use disorder; and 77% had a mental health diagnosis. Over three-quarters restarted ART within 7 days of enrolment, and 91% returned for follow-up within 90 days. The cumulative incidence of viral suppression at 6 months was 55% (95% confidence interval 43-68).

CONCLUSION

A novel care model for PWH-HUH demonstrates early success in engaging viraemic patients in care and improving viral suppression. Low-barrier, high-contact primary care programmes offering comprehensive services and incentives may improve outcomes for this vulnerable population.

Coronavirus Disease 2019 (COVID-19) and HIV Spotlight the United States Imperative for Permanent Affordable Housing

Job loss and evictions tied to the COVID-19 pandemic are expected to significantly increase homelessness in the coming months. Reciprocally, homelessness and the many vulnerabilities that inevitably accompany it are driving COVID-19 outbreaks in U.S. shelters and other congregate living situations. Unless we intervene to address homelessness, these co-existing and synergistic situations will make the current public health crisis even worse.

Preventing homelessness and providing permanent affordable housing has reduced the ravages of the HIV epidemic. We must take the lessons learned in 40 years of fighting HIV to respond effectively to the COVID-19 crisis. Housing is an investment that will curb the spread of COVID-19 and help protect all of us from future pandemics.

Comparison of infection control strategies to reduce COVID-19 outbreaks in homeless shelters in the United States: a simulation study

BACKGROUND

COVID-19 outbreaks have occurred in homeless shelters across the US, highlighting an urgent need to identify the most effective infection control strategy to prevent future outbreaks.

METHODS

We developed a microsimulation model of SARS-CoV-2 transmission in a homeless shelter and calibrated it to data from cross-sectional polymerase chain reaction (PCR) surveys conducted during COVID-19 outbreaks in five homeless shelters in three US cities from March 28 to April 10, 2020. We estimated the probability of averting a COVID-19 outbreak when an exposed individual is introduced into a representative homeless shelter of 250 residents and 50 staff over 30 days under different infection control strategies, including daily symptom-based screening, twice-weekly PCR testing, and universal mask wearing.

RESULTS

The proportion of PCR-positive residents and staff at the shelters with observed outbreaks ranged from 2.6 to 51.6%, which translated to the basic reproduction number (R₀) estimates of 2.9-6.2. With moderate community incidence (~ 30 confirmed cases/1,000,000 people/day), the estimated probabilities of averting an outbreak in a low-risk (R₀ = 1.5), moderate-risk (R₀ = 2.9), and high-risk (R₀ = 6.2) shelter were respectively 0.35, 0.13, and 0.04 for daily symptom-based screening; 0.53, 0.20, and 0.09 for twice-weekly PCR testing; 0.62, 0.27, and 0.08 for universal masking; and 0.74, 0.42, and 0.19 for these strategies in combination. The probability of averting an outbreak diminished with higher transmissibility (R₀) within the simulated shelter and increasing incidence in the local community.

CONCLUSIONS

In high-risk homeless shelter environments and locations with high community incidence of COVID-19, even intensive infection control strategies (incorporating daily symptom screening, frequent PCR testing, and universal mask wearing) are unlikely to prevent outbreaks, suggesting a need for non-congregate housing arrangements for people experiencing homelessness. In lower-risk environments, combined interventions should be employed to reduce outbreak risk.

Drug Overdose Deaths Before and After Shelter-in-Place Orders During the COVID-19 Pandemic in San Francisco

This cross-sectional study evaluates the association of the shelter-in-place order with fatal drug overdoses in San Francisco, California.

Shelter Characteristics, Infection Prevention Practices, and Universal Testing for SARS-CoV-2 at Homeless Shelters in 7 US Urban Areas

Objectives. To examine shelter characteristics and infection prevention practices in relation to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection point prevalence during universal testing at homeless shelters in the United States.Methods. SARS-CoV-2 testing was offered to clients and staff at homeless shelters, irrespective of symptoms. Site assessments were conducted from March 30 to June 1, 2020, to collect information on shelter characteristics and infection prevention practices. We assessed the association between SARS-CoV-2 infection prevalence and shelter characteristics, including 20 infection prevention practices by using crude risk ratios (RRs) and exact unconditional 95% confidence intervals (CIs).Results. Site assessments and SARS-CoV-2 testing results were reported for 63 homeless shelters in 7 US urban areas. Median infection prevalence was 2.9% (range = 0%-71.4%). Shelters implementing head-to-toe sleeping and excluding symptomatic staff from working were less likely to have high infection prevalence (RR = 0.5; 95% CI = 0.3, 0.8; and RR = 0.5; 95% CI = 0.4, 0.6; respectively); shelters with medical services available were less likely to have very high infection prevalence (RR = 0.5; 95% CI = 0.2, 1.0).Conclusions. Sleeping arrangements and staffing policies are modifiable factors that might be associated with SARS-CoV-2 infection prevalence in homeless shelters. Shelters should follow recommended practices to reduce the risk of SARS-CoV-2 transmission.

Assessment of a Hotel-Based COVID-19 Isolation and Quarantine Strategy for Persons Experiencing Homelessness

Importance

Several jurisdictions in the United States have secured hotels to temporarily house people experiencing homelessness who require isolation or quarantine for confirmed or suspected coronavirus disease 2019 (COVID-19). To our knowledge, little is known about how these programs serve this vulnerable population outside the hospital setting.

Objective

To assess the safety of a hotel-based isolation and quarantine (I/Q) care system and its association with inpatient hospital capacity.

Design, Setting, and Participants

This retrospective cohort study of a hotel-based I/Q care system for homeless and unstably housed individuals in San Francisco, California, was conducted from March 19 to May 31, 2020. Individuals unable to safely isolate or quarantine at home with mild to moderate COVID-19, persons under investigation, or close contacts were referred from hospitals, outpatient settings, and public health surveillance to 5 I/Q hotels. Of 1009 I/Q hotel guests, 346 were transferred from a large county public hospital serving patients experiencing homelessness.

Exposure

A physician-supervised team of nurses and health workers provided around-the-clock support, including symptom monitoring, wellness checks, meals, harm-reduction services, and medications for opioid use disorder.

Main Outcomes and Measures

Characteristics of I/Q hotel guests, program retention, county hospital readmissions, and mean length of stay.

Results

Overall, the 1009 I/Q hotel guests had a median age of 44 years (interquartile range, 33-55 years), 756 (75%) were men, 454 (45%) were Latinx, and 501 (50%) were persons experiencing sheltered (n = 295) or unsheltered (n = 206) homelessness. Overall, 463 (46%) received a diagnosis of COVID-19; 303 of 907 (33%) had comorbid medical disorders, 225 of 907 (25%) had comorbid mental health disorders, and 236 of 907 (26%) had comorbid substance use disorders. A total of 776 of 955 guests (81%) completed their I/Q hotel stay; factors most strongly associated with premature discontinuation were unsheltered homelessness (adjusted odds ratio, 4.5; 95% CI, 2.3-8.6; P < .001) and quarantine status (adjusted odds ratio, 2.6; 95% CI, 1.5-4.6; P = .001). In total, 346 of 549 patients (63%) were transferred from the county hospital; of 113 ineligible referrals, 48 patients (42%) had behavioral health needs exceeding I/Q hotel capabilities. Thirteen of the 346 patients transferred from the county hospital (4%) were readmitted for worsening COVID-19. Overall, direct transfers to I/Q hotels from emergency and outpatient departments were associated with averting many hospital admissions. There was a nonsignificant decrease in the mean hospital length of stay for inpatients with confirmed or suspected COVID-19 from 5.5 to 2.7 days from March to May 2020 (P = .11).

Conclusions and Relevance

To support persons experiencing homelessness during the COVID-19 pandemic, San Francisco rapidly and safely scaled a hotel-based model of I/Q that was associated with reduced strain on inpatient capacity. Strategies to improve guest retention and address behavioral health needs not met in hotel settings are intervention priorities.

Viral suppression during COVID-19 among people with HIV experiencing homelessness in a low-barrier clinic-based program

Coronavirus disease-2019 (COVID-19) threatens to further worsen HIV outcomes among people experiencing homelessness. We conducted an interrupted time-series analysis of care engagement and viral suppression among unhoused individuals in the 'POP-UP' low-barrier, high-intensity HIV primary care program during COVID-19. Among 85 patients, care engagement and viral suppression did not decrease in the 5 months following implementation of San Francisco's 'shelter-in-place' ordinance. Low-barrier, in-person HIV care for homeless individuals may be important for maintaining HIV outcomes during COVID-19.

Start the Way You Want to Finish: An Intensive Diversity, Equity, Inclusion Orientation Curriculum in Undergraduate Medical Education

PROBLEM

Medical students often feel unprepared to care for patients whose cultural backgrounds differ from their own. Programs in medical schools have begun to address health: inequities; however, interventions vary in intensity, effectiveness, and student experience.

INTERVENTION

The authors describe an intensive 2-day diversity, equity, and inclusion curriculum for medical students in their orientation week prior to starting formal classes. Rather than using solely a knowledge-based "cultural competence" or a reflective "cultural humility" approach, an experiential curriculum was employed that links directly to fundamental communication skills vital to interactions with patients and teams, and critically important to addressing interpersonal disparities. Specifically, personal narratives were incorporated to promote individuation and decrease implicit bias, relationship-centered skills practice to improve communication across differences, and mindfulness skills to help respond to bias when it occurs. Brief didactics highlighting student and faculty narratives of difference were followed by small group sessions run by faculty trained to facilitate sessions on equity and inclusion.

CONTEXT

Orientation week for matriculating first-year students at a US medical school.

IMPACT

Matriculating students highly regarded an innovative 2-day diversity, equity, and inclusion orientation curriculum that emphasized significant relationship-building with peers, in addition to core concepts and skills in diversity, equity, and inclusion.

LESSONS LEARNED

This orientation represented an important primer to concepts, skills, and literature that reinforce the necessity of training in diversity, equity, and inclusion. The design team found that intensive faculty development and incorporating diversity concepts into fundamental communication skills training were necessary to perpetuate this learning. Two areas of further work emerged: (1) the emphasis on addressing racism and racial equity as paradigmatic belies further essential understanding of intersectionality, and (2) uncomfortable conversations about privilege and marginalization arose, requiring expert facilitation.

Brief Report: Understanding Preferences for HIV Care Among Patients Experiencing Homelessness or Unstable Housing: A Discrete Choice Experiment

BACKGROUND

Homelessness and unstable housing (HUH) negatively impact care outcomes for people living with HIV (PLWH). To inform the design of a clinic program for PLWH experiencing HUH, we quantified patient preferences and trade-offs across multiple HIV-service domains using a discrete choice experiment (DCE).

METHODS

We sequentially sampled PLWH experiencing HUH presenting at an urban HIV clinic with ≥1 missed primary care visit and viremia in the last year to conduct a DCE. Participants chose between 2 hypothetical clinics varying across 5 service attributes: care team "get to know me as a person" versus not; receiving $10, $15, or $20 gift cards for clinic visits; drop-in versus scheduled visits; direct phone communication to care team versus front-desk staff; and staying 2 versus 20 blocks from the clinic. We estimated attribute relative utility (ie, preference) using mixed-effects logistic regression and calculated the monetary trade-off of preferred options.

RESULTS

Among 65 individuals interviewed, 61% were >40 years old, 45% White, 77% men, 25% heterosexual, 56% lived outdoors/emergency housing, and 44% in temporary housing. Strongest preferences were for patient-centered care team [β = 3.80; 95% confidence interval (CI): 2.57 to 5.02] and drop-in clinic appointments (β = 1.33; 95% CI: 0.85 to 1.80), with a willingness to trade $32.79 (95% CI: 14.75 to 50.81) and $11.45 (95% CI: 2.95 to 19.95) in gift cards/visit, respectively.

CONCLUSIONS

In this DCE, PLWH experiencing HUH were willing to trade significant financial gain to have a personal relationship with and drop-in access to their care team rather than more resource-intensive services. These findings informed Ward 86's "POP-UP" program for PLWH-HUH and can inform "ending the HIV epidemic" efforts.

Flower colour polymorphism in the Mediterranean Basin: occurrence, maintenance and implications for speciation

Flower colour polymorphism (FCP) is the occurrence of at least two discrete flower colour variants in the same population. Despite a vast body of research concerning the maintenance and evolutionary consequences of FCP, only recently has the spatial variation in morph frequencies among populations been explored. Here we summarise the biochemical and genetic basis of FCP, the factors that have been proposed to explain their maintenance, and the importance of FCP and its geographic variation in the speciation process. We also review the incidence of FCP in the environmentally heterogeneous Mediterranean Basin. Nearly 88% of Mediterranean FCP species showed anthocyanin-based polymorphisms. Concerning the evolutionary mechanisms that contribute to maintain FCP, selection by pollinators is suggested in some species, but in others, selection by non-pollinator agents, genetic drift or gene flow are also found; in some cases different processes interact in the maintenance of FCP. We emphasise the role of both autonomous selfing and clonal reproduction in FCP maintenance. Mediterranean polymorphic species show mainly monomorphic populations with only a few polymorphic ones, which generate clinal or mosaic patterns of variation in FCP. No cases of species with only polymorphic populations were found. We posit that different evolutionary processes maintaining polymorphism the Mediterranean Basin will result in a continuum of geographic patterns in morph compositions and relative frequencies of FCP species.

Past and current gene flow in the selfing, wind-dispersed species Mycelis muralis in western Europe

The distribution of genetic diversity in Mycelis muralis, or wall lettuce, was investigated at a European scale using 12 microsatellite markers to infer historical and contemporary forces from genetic patterns. Mycelis muralis has the potential for long-distance seed dispersal by wind, is mainly self-pollinated, and has patchily distributed populations, some of which may show metapopulation dynamics. A total of 359 individuals were sampled from 17 populations located in three regions, designated southern Europe (Spain and France), the Netherlands, and Sweden. At this within-region scale, contemporary evolutionary forces (selfing and metapopulation dynamics) are responsible for high differentiation between populations (0.34 < F(ST) < 0.60) but, contrary to expectation, levels of within-population diversity, estimated by Nei's unbiased expected heterozygosity (H(E)) (0.24 < H(E) < 0.68) or analyses of molecular variance (50% of the variation found within-populations), were not low. We suggest that the latter results, which are unusual in selfing species, arise from efficient seed dispersal that counteracts population turnover and thus maintains genetic diversity within populations. At the European scale, northern regions showed lower allelic richness (A = 2.38) than populations from southern Europe (A = 3.34). In light of postglacial colonization hypotheses, these results suggest that rare alleles may have been lost during recolonization northwards. Our results further suggest that mutation has contributed to genetic differentiation between southern and northern Europe, and that Sweden may have been colonized by dispersers originating from at least two different refugia.

[Changes in pharmacists practices (1996 - 2000) related to harm reduction policy (condoms, injecting equipment, methylmorphine) and maintenance therapy delivery (buprenorphine, methadone)]

AIMS

To measure pharmacists involvement in harm reduction programs and in delivery of maintenance therapies in order to estimate their contribution to the new public health policy.

METHOD

A longitudinal study was conducted among 327 pharmacies located in the southern suburban area of Paris (28 communities) using a standardized questionnaire.

RESULTS

The response rate was 95% in 1996 and 92% in 2000. The number of condoms offered to intravenous drug users (IDU) decreased dramatically from 99% to 24% while delivered units decreased from 857 to 566 per day for needles and from 1200 to 760 per month per pharmacy for methylmorphine tablets (14.93 mg/tablet). Pharmacists delivered injecting equipment to some of their patients under opiate treatment: methylmorphine 19%, buprenorphine 35%, methadone 14%. Their contribution to the local healthcare network on addiction decreased from 38% to 20%. Nevertheless, the pharmacists attitude towards the IDU and public health policy was found to be improving with problems being mentioned for 62% of the cases in 1996 and for 16% in 2000.

CONCLUSION

Pharmacists are rapidly and intensively changing their practices and are discovering a new comprehensive relationship with IDU. Better pharmacist involvement is associated with a shift in local healthcare network concentration, reinforcing the general practitioner-pharmacist partnership.

Expression of leukocyte adhesion molecules by endothelial cells seeded on various polymer surfaces

Although endothelial cell seeding in small-diameter vascular prostheses significantly improves graft survival, the detachment of adherent endothelial cells after the restoration of circulation remains one of the major obstacles. Because in vivo experiments indicate that leukocyte infiltration is involved in endothelial cell loss, we hypothesize that seeded endothelial cells become activated and express leukocyte adhesion molecules and cytokines because of an interaction with the underlying polymer surface. The aim of this study was to investigate the expression of the leukocyte adhesion molecules ICAM-1, VCAM-1, PECAM-1, and E-selectin by cultured human umbilical vein endothelial cells (HUVECs) and human adipose microvascular endothelial cells (HAMVECs). The cells were seeded on tissue culture poly(styrene) and the vascular graft materials Dacron and Teflon. The results of this study indicate that the expression of leukocyte adhesion molecules by cultured endothelial cells is mainly affected by the endothelial cell origin, that is, umbilical vein or adipose tissue. Expressions of both ICAM-1 and E-selectin by HUVECs and HAMVECs are characterized by the presence of two cell populations with distinct levels of expression. With respect to endothelial cell seeding in vascular prostheses, the increased expression of E-selectin by microvascular endothelial cells deserves further attention.

Capitulum characters in a seed heteromorphic plant, Crepis sancta (Asteraceae): variance partitioning and inference for the evolution of dispersal rate

In Crepis sancta (Asteraceae), achenes produced in the periphery of the flower head have reduced dispersal ability and are larger than achenes produced in the centre of the head, which disperse farther. The proportion of central achenes produced by a single individual represents the potential dispersal rate of its progeny. Seed variation in dispersal ability may be important where there is spatio-temporal variability of habitats, but its evolutionary significance mainly depends on the heritability of the relative proportions of each achene morph. However, the number of peripheral achenes in a capitulum, and that of involucral bracts are suggested to depend on the number of parastichies, a canalized character. From a diallel cross design, phenotypic variance for several capitulum traits was partitioned among six variance components, including the additive variance. The phenotypic values of some head traits reflected the expected frequency due to ontogeny, in particular the number of involucral bracts. Yet, this character also had a significant heritability, suggesting that variation around the mode of the distribution was not only due to developmental noise. The additive variance for number of peripheral and central achenes was not significantly different from zero. In contrast, their respective proportion had a narrow sense heritability greater than 0.20. The present results suggest that the percentage of central achenes per individual, and thus the potential dispersal rate in Crepis sancta, is under quantitative genetic control, and could undergo microevolutionary changes in natural populations.

Different growth behaviour of human umbilical vein endothelial cells and an endothelial cell line seeded on various polymer surfaces

Major obstacles for successful application of endothelial cell seeding in synthetic vascular grafts include the source of autologous endothelial cells, the efficiency of cell seeding and detachment of adherent endothelial cells from the graft surface after restoration of circulation. Human umbilical vein endothelial cells (HUVECs) are frequently used to investigate the in vitro adhesion and proliferation of endothelial cells on polymer surfaces. In order to minimize the biological variation of HUVECs isolated from different umbilical veins, it would be advantageous to use an endothelial cell line in in vitro proliferation experiments. Aim of the present study was to compare the proliferation of primary HUVECs and the endothelial cell line EC-RF24 on several polymer surfaces coated with various concentrations of the adhesive protein fibronectin. EC-RF24 cells grow to a higher density than primary HUVECs. Moreover, the EC-RF24 cell line is able to proliferate on surfaces with sub-optimal adhesive properties. Therefore, it is concluded that the EC-RF24 cell line is less suitable for evaluation of the in vitro proliferation of endothelial cells on polymer surfaces.

Fractionation of RNA polymerase II transcription factors from HeLa cell nuclear extracts by affinity chromatography on "DNA-like" phosphorylated polystyrene

It was previously shown that phosphorylated cross-linked polystyrene derivatives specifically interacted with anti-DNA antibodies and anti-phospholipid antibodies present in the sera of systemic lupus erythematosus patients. These resins are potential candidates as stationary phases in affinity chromatography. We wondered whether these biospecific resins might allow the fractionation of DNA binding proteins such as RNA polymerase II transcription factors from HeLa cell nuclear extracts. Indeed, these proteins play a major role in gene regulation in mammalian cells and their purification still requires numerous steps. To study the biospecificity of DNA-like phosphorylated polystyrene derivatives, ethanolamine sulfamide crosslinked polystyrene derivatives were phosphorylated at various rates and HeLa cell nuclear extracts were adsorbed on these resins. Adsorbed proteins were eluted with increasing concentrations of aqueous potassium chloride. Collected fractions were characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and the biological activities of the eluted transcription factors were tested by in vitro transcription assay. Results showed that the elution of transcription factors depended on the substitution rate in phosphoester groups of the resins. It appears that specific interactions were developed between the polymers and the transcription factors. Moreover, the eluted transcription factors kept their biological activity. These results lead us to propose the purification of RNA polymerase II transcription factors using the phosphorylated polystyrene resins as stationary phases.

Randomly phosphorylated polystyrene derivatives interact with RNA polymerase II transcription factors: part I

Insoluble functional synthetic random copolymers are able to develop at their surfaces specific interactions with biologic components. Crosslinked phosphorylated polystyrene derivatives were previously shown to mimic DNA antigen because they interacted with anti-DNA antibodies found in the sera of systemic lupus erythematosus patients. These biospecific surfaces were postulated to be able to bind other DNA-binding proteins such as RNA polymerase II transcription factors. Indeed, these proteins play a major role in gene regulation in mammalian cells. This hypothesis was checked by adsorption and elution of HeLa cell nuclear extracts on a 72% phosphorylated resin. The composition of the eluted fractions were analyzed by electrophoresis, and the biologic activity of the transcription factors was tested using an in vitro transcription assay. The results showed that USF, TATA-binding protein (TBP), and TFIIB were specifically adsorbed on the polymer and that all eluted factors kept their biologic activity. Therefore, randomly phosphorylated polystyrene derivatives may be useful for the fractionation of RNA polymerase II transcription factors.

Clinical and microbiological evaluation of a postdilutional hemofiltration system with in-line production of substitution fluid

Safety and efficacy of a recently developed hemofiltration (HF) system with in-line production of substitution fluid (GHS-10; Gambro, Lund, Sweden) based on a sterilizing filtration of acetate buffered dialysate has been evaluated in 4 patients over a 6-month period. Two patients were prematurely excluded from the study: 1 because of acetate intolerance and the other because of kidney transplantation. Two patients completed the study (240 HF sessions). Treatment adequacy was maintained in the 2 medium term treated patients according to the usual clinical and biochemical criteria and a mean exchange volume of 100-105 liters/week (30-35 liters/session three times weekly). Urea kinetic modeling analysis performed over all HF cycles gave the following results: dialysis index (urea clearance.time-on HF/urea volume space) (KT/V) approximately 1-1.1, urea time averaged concentration (UREA TAC) approximately 15-20 mmol/l, and protein catabolic rate (PCR) approximately 1.1-1.2 g/kg/day. Rare clinical adverse symptoms observed during the course of sessions were attributed to acetate intolerance. Microbiological safety was confirmed in vivo by the absence of pyrogenic reactions after 240 HF sessions (approximately 7 m3 substitution fluid infused intravenously) and in vitro by the constant absence of bacteria and/or endotoxin content limulus amaebocyte lysate (LAL) sensibility threshold 10 pg/l within the infusate produced during the sham HF sessions. The fluid mass balance obtained with the GHS-10 monitor was excellent. The electrolyte composition as judged by Na variation remained in a range of 2-3%. GHS-10 used in this study for postdilutional HF confirms that a large quantity of intravenous quality fluid may be safely produced by ultrafiltration from dialysate. It also introduced a new dimension in biocompatibility of dialysis by demonstrating that sterile dialysate may be routinely produced and used for routine dialysis.

Cytolytically active murine T-lymphocyte/polyoma virus-transformed fibroblast hybrids

It would be of great interest to obtain permanent T-cell lines retaining specific activity without either allogeneic or xenogeneic stimulation. Functionally active hybrids between cytolytic T cells and thymoma were previously reported, but they had to be selected in a TCGF-containing medium. This study contains new results and reports the preparation of a hybrid cell from a cytolytic T cell and a polyoma virus-infected fibroblast, in which the T-cell characteristics dominate over the polyoma-transformed characteristics. A differentiated T-cell function (i.e., cytolysis) persists and the differentiated line does not require TCGF. The loss of cytolytic activity during in vitro evolution may be due to a selection favouring transformed cells, as suggested by concomitant enhancement of the transformed phenotype and chromosome loss.