Monitoring SARS-CoV-2 incidence and seroconversion among university students and employees: a longitudinal cohort study in California, June-August 2020.

OBJECTIVES: To identify incident SARS-CoV-2 infections and inform effective mitigation strategies in university settings, we piloted an integrated symptom and exposure monitoring and testing system among a cohort of university students and employees. DESIGN: Prospective cohort study. SETTING: A public university in California from June to August 2020. PARTICIPANTS: 2180 university students and 738 university employees. PRIMARY OUTCOME MEASURES: At baseline and endline, we tested participants for active SARS-CoV-2 infection via quantitative PCR (qPCR) test and collected blood samples for antibody testing. Participants received notifications to complete additional qPCR tests throughout the study if they reported symptoms or exposures in daily surveys or were selected for surveillance testing. Viral whole genome sequencing was performed on positive qPCR samples, and phylogenetic trees were constructed with these genomes and external genomes. RESULTS: Over the study period, 57 students (2.6%) and 3 employees (0.4%) were diagnosed with SARS-CoV-2 infection via qPCR test. Phylogenetic analyses revealed that a super-spreader event among undergraduates in congregate housing accounted for at least 48% of cases among study participants but did not spread beyond campus. Test positivity was higher among participants who self-reported symptoms (incidence rate ratio (IRR) 12.7; 95% CI 7.4 to 21.8) or had household exposures (IRR 10.3; 95% CI 4.8 to 22.0) that triggered notifications to test. Most (91%) participants with newly identified antibodies at endline had been diagnosed with incident infection via qPCR test during the study. CONCLUSIONS: Our findings suggest that integrated monitoring systems can successfully identify and link at-risk students to SARS-CoV-2 testing. As the study took place before the evolution of highly transmissible variants and widespread availability of vaccines and rapid antigen tests, further research is necessary to adapt and evaluate similar systems in the present context.

Feasibility and effectiveness of daily temperature screening to detect COVID-19 in a prospective cohort at a large public university.

BACKGROUND: Many persons with active SARS-CoV-2 infection experience mild or no symptoms, presenting barriers to COVID-19 prevention. Regular temperature screening is nonetheless used in some settings, including university campuses, to reduce transmission potential. We evaluated the potential impact of this strategy using a prospective university-affiliated cohort. METHODS: Between June and August 2020, 2912 participants were enrolled and tested for SARS-CoV-2 by PCR at least once (median: 3, range: 1-9). Participants reported temperature and symptoms daily via electronic survey using a previously owned or study-provided thermometer. We assessed feasibility and acceptability of daily temperature monitoring, calculated sensitivity and specificity of various fever-based strategies for restricting campus access to reduce transmission, and estimated the association between measured temperature and SARS-CoV-2 test positivity using a longitudinal binomial mixed model. RESULTS: Most participants (70.2%) did not initially have a thermometer for taking their temperature daily. Across 5481 total person months, the average daily completion rate of temperature values was 61.6% (median: 67.6%, IQR: 41.8-86.2%). Sensitivity for SARS-CoV-2 ranged from 0% (95% CI 0-9.7%) to 40.5% (95% CI 25.6-56.7%) across all strategies for self-report of possible COVID-19 symptoms on day of specimen collection, with corresponding specificity of 99.9% (95% CI 99.8-100%) to 95.3% (95% CI 94.7-95.9%). An increase of 0.1 °F in individual mean body temperature on the same day as specimen collection was associated with 1.11 increased odds of SARS-CoV-2 positivity (95% CI 1.06-1.17). CONCLUSIONS: Our study is the first, to our knowledge, that examines the feasibility, acceptability, and effectiveness of daily temperature screening in a prospective cohort during an infectious disease outbreak, and the only study to assess these strategies in a university population. Daily temperature monitoring was feasible and acceptable; however, the majority of potentially infectious individuals were not detected by temperature monitoring, suggesting that temperature screening is insufficient as a primary means of detection to reduce transmission of SARS-CoV-2.

Psychometric Evaluation of a 10-Item Health Insurance Knowledge Scale.

BACKGROUND: College students are a priority population for health insurance literacy interventions. Yet, there are few psychometric studies on measuring health insurance knowledge - a core construct of health insurance literacy. METHODS: We administered a health insurance survey to 2,250 college students. We applied Classical Test Theory and Item Response Theory methods to estimate psychometric properties of the Kaiser Family Foundation's 10-item health insurance knowledge quiz. RESULTS: The scale is unidimensional, and a two-parameter logistic model best fit the data. IRT estimates indicated varying item discriminations (a range: 0.717-2.578) and difficulties (b range: -0.913-1.790). Precision of measurement was maximized for students half a standard deviation below the mean (θ = -0.686) health insurance knowledge ability. CONCLUSIONS: This scale can be used to identify gaps in health insurance knowledge among college students and be applied in clinical and community health education practice.

Launching a saliva-based SARS-CoV-2 surveillance testing program on a university campus.

Regular surveillance testing of asymptomatic individuals for SARS-CoV-2 has been center to SARS-CoV-2 outbreak prevention on college and university campuses. Here we describe the voluntary saliva testing program instituted at the University of California, Berkeley during an early period of the SARS-CoV-2 pandemic in 2020. The program was administered as a research study ahead of clinical implementation, enabling us to launch surveillance testing while continuing to optimize the assay. Results of both the testing protocol itself and the study participants' experience show how the program succeeded in providing routine, robust testing capable of contributing to outbreak prevention within a campus community and offer strategies for encouraging participation and a sense of civic responsibility.

Piloting an integrated SARS-CoV-2 testing and data system for outbreak containment among college students: A prospective cohort study.

BACKGROUND: Colleges and universities across the country are struggling to develop strategies for effective control of COVID-19 transmission as students return to campus. METHODS AND FINDINGS: We conducted a prospective cohort study with students living on or near the UC Berkeley campus from June 1st through August 18th, 2020 with the goal of providing guidance for campus reopening in the safest possible manner. In this cohort, we piloted an alternative testing model to provide access to low-barrier, high-touch testing and augment student-driven testing with data-driven adaptive surveillance that targets higher-risk students and triggers testing notifications based on reported symptoms, exposures, or other relevant information. A total of 2,180 students enrolled in the study, 51% of them undergraduates. Overall, 6,247 PCR tests were administered to 2,178 students over the two-month period. Overall test positivity rate was 0.9%; 2.6% of students tested positive. Uptake and acceptability of regular symptom and exposure surveys was high; 98% of students completed at least one survey, and average completion rate was 67% (Median: 74%, IQR: 39%) for daily reporting of symptoms and 68% (Median: 75%, IQR: 40%) for weekly reporting of exposures. Of symptom-triggered tests, 5% were PCR-positive; of exposure-triggered tests, 10% were PCR-positive. The integrated study database augmented traditional contact tracing during an outbreak; 17 potentially exposed students were contacted the following day and sent testing notifications. At study end, 81% of students selected their desire "to contribute to UC Berkeley's response to COVID-19" as a reason for their participation in the Safe Campus study. CONCLUSIONS: Our results illustrate the synergy created by bringing together a student-friendly, harm reduction approach to COVID-19 testing with an integrated data system and analytics. We recommend the use of a confidential, consequence-free, incentive-based daily symptom and exposure reporting system, coupled with low-barrier, easy access, no stigma testing. Testing should be implemented alongside a system that integrates multiple data sources to effectively trigger testing notifications to those at higher risk of infection and encourages students to come in for low-barrier testing when needed.

Health insurance literacy and health service utilization among college students.

Objective: Health literacy and health insurance literacy affect healthcare utilization. The purpose of this study was to determine the relation between health insurance knowledge, self-efficacy, and student healthcare utilization in the past year. Participants: A random sample of 1,450 respondents, over the age of 18, attending a public university in the southeastern United States completed a survey in March 2017. Methods: A model was constructed to test the effect of health insurance self-efficacy on the relation between knowledge and healthcare utilization in the past year. Results: Health insurance knowledge (M = 5.8, range 0-10) and self-efficacy (M = 2.48, range 1-4) were low. Self-efficacy was a significant moderator when explaining healthcare utilization in the past year. Conclusions: College students have low knowledge and self-efficacy regarding health insurance. These findings can be used for developing policies and self-efficacy-based health education programs that may increase student healthcare utilization.

Diagnostic sequence of cocaine use disorder in relation to other mental health conditions among college students.

Objective: Cocaine use is increasing. Comorbidities and diagnostic sequencing are needed among college students to inform treatment of cocaine use disorder (CUD). Method: Using electronic medical records from the psychiatric clinic at the student health care center of a large, public university from 2005 to 2015, patients diagnosed with CUD were identified. Their top mental health conditions were identified and assessed to see whether the first diagnosis of these conditions was made (1) before, (2) at the same time as, or (3) after the first diagnosis of CUD. Results: Among the 50 CUD patients, their most common mental health comorbidities were alcohol use disorder, anxiety, depression, and cannabis use disorder. Anxiety and depression were likely to be diagnosed before CUD; alcohol and cannabis use disorders were likely to be diagnosed concurrently with CUD. Conclusion: Diagnostic sequencing can be used to inform screening, workup, and treatment for patients with CUD.

Systematically collected information at encounters with HIV-positive students: A review of 10 years of electronic medical records.

Objective: The objective of this study was to examine clinical and epidemiological information collected by Student Health Center (SHC) providers on HIV-positive students, and benchmark this information against Infectious Disease Society of America guidelines. Participants: Students who utilized the SHC and had an ICD-9 code indicating positive HIV status between 2005 and 2015 (3 = 7). Methods: In June 2016, we accessed the free-form provider notes of the SHC's electronic medical records to identify specific, recorded epidemiological and clinical information. Results: Seven unique students sought care at the SHC during the study period. Current sexual risk taking and other known behavioral risk factors were absent from all records, along with CD4 count and viral load. ART status was only available for one patient, and he was not on ART. The information collected failed to meet IDSA benchmarks. Conclusion: Clinically- and epidemiologically-relevant information is not systematically collected from HIV-positive students at SHCs.

Ulnar collateral ligament injuries of the elbow in female division I collegiate gymnasts: a report of five cases.

INTRODUCTION: Elbow ulnar collateral ligament (UCL) injuries in gymnastics have not been well documented in the literature, in comparison to UCL injuries in baseball. Few studies have examined the mechanism and nonoperative management of this injury, and no studies to date have been published on incidence of injury and return to play recommendations in gymnastics. PATIENT CASE REVIEW: A literature search was performed using PubMed to review articles from 1980 to 2016 that addressed the biomechanics of UCL injury in baseball and gymnastics, the anatomy of the elbow, injury rates, surgical vs non-surgical management, rehabilitation, and return to play recommendations for the sport of gymnastics. Five female collegiate gymnasts sustained UCL injury over a 3-year period. Electronic medical records for each case were thoroughly reviewed including imaging, surgical and non-surgical management, rehabilitation, and the progressive return to gymnastics. DISCUSSION: Four UCL injuries were confirmed by MRI to be avulsions at the distal insertion of the UCL and one was an avulsion at the proximal origin. While less than half of baseball players can return to competition with conservative management of these types of injuries, four out of five gymnasts were able to return to competition with nonoperative management. One gymnast opted to have reconstruction after a successful competition season. Time to return to play varied seemingly dependent on the severity of UCL injury and event. CONCLUSION: In our case series, collegiate female gymnasts were able to return to participation with nonoperative treatment of the UCL. Their success in returning to competitive gymnastics may also depend on the event(s) in which they are trying to participate. STRENGTH OF RECOMMENDATION TAXONOMY: C.

Foot and Ankle Conditions: Plantar Fasciitis.

Plantar fasciitis is the most common cause of heel pain in adults. It involves painful symptoms occurring along the plantar fascia with or without the presence of a bony heel spur. Heel pain that occurs on standing after a prolonged non-weight-bearing period is a prominent symptom of plantar fasciitis. On physical examination, palpation along the medial plantar calcaneal region reproduces the painful symptoms. Routine imaging studies usually are not necessary but can be used to rule out pathologies or confirm chronic or recalcitrant plantar fasciitis. The presence of a heel spur on x-ray is not thought to be an underlying cause of symptoms and indicates the condition has been present for at least 6 to 12 months. Conservative therapies such as rest, ice massage, nonsteroidal anti-inflammatory drugs, specific plantar fascia stretching exercises, and orthoses are the preferred initial treatments. Injection therapies using a corticosteroid or platelet-rich plasma typically provide short-term relief. If conservative treatment is ineffective, extracorporeal shock wave therapy and surgery may be considered.

Foot and Ankle Conditions: Pes Planus.

Pes planus or pes planovalgus (ie, flatfoot) is a common condition among young children and also is encountered in adults. In children, congenital pes planus typically resolves with age as the foot musculature strengthens. Flexible pes planus is defined as a normal arch during non-weight-bearing activity or tiptoeing, with a flattening arch on standing. In rigid pes planus, the arch remains stiff and collapsed with or without weight bearing. Patients with rigid pes planus should be referred for subspecialist treatment. Patients with flexible pes planus, in the absence of signs of rheumatologic, neuromuscular, genetic, or collagen conditions, should be treated conservatively. Asymptomatic children should be monitored and maintenance of a healthy weight should be encouraged. Surgical intervention for refractory symptomatic pediatric pes planus may be considered but there is little evidence to support it. Several etiologies of acquired pes planus in adults have been identified. The most common is posterior tibial tendon dysfunction. Clinical and x-ray evaluation can assist in staging the condition and guiding treatment decisions.

Foot and Ankle Conditions: Midfoot and Forefoot Conditions.

The midfoot and forefoot are the regions of the foot distal to the talus and calcaneus and are critical to weight bearing and movement. They help support the arch of the foot, provide shock absorption, and convert vertically oriented forces into horizontal forward and propulsive movement. A spectrum of acute, subacute, and chronic conditions in these regions can cause pain and decreased function. A thorough history and physical examination should include foot and leg biomechanics, alignment, and posture in addition to palpation of painful areas. All patients with traumatic or overuse midfoot and forefoot injuries should be evaluated with x-rays, with the need for advanced imaging determined based on initial findings. Appropriate diagnosis and management of Lisfranc joint injuries and navicular and base of the fifth metatarsal stress fractures can prevent adverse outcomes. Management of these injuries commonly includes a period of non-weight-bearing immobilization and referral to an orthopedic surgeon. Turf toe, hallux rigidus, metatarsalgia, and Morton neuroma are common causes of forefoot pain. Treatment should be individualized and may include shoe and orthotic adjustments, injections, and, occasionally, surgical intervention.

Foot and Ankle Conditions: Chronic Lateral Ankle Pain.

Chronic ankle pain is relatively common in family medicine. Sequelae from lateral ankle sprains are the most common cause. Other etiologies include peroneal tendinopathy or subluxation, osteochondral injury, lateral ankle impingement, sinus tarsi syndrome, cuboid syndrome, bony stress injury, and other unusual factors. A thorough history focusing on the mechanism of injury (if traumatic) and the nature of the pain along with a targeted physical examination typically will provide the information needed to make the diagnosis. Imaging might be necessary for diagnosis or confirmation of the diagnosis. Early functional bracing, physical therapy for strengthening, and proprioceptive exercises are the preferred treatments for most patients. Daily pain drugs or full immobilization devices rarely are necessary.

"Motionyms": activity-related musculoskeletal and medical problems (or "not an eponym!!").

Many common conditions in sports medicine are eponymous; that is, they are named for the person first describing or popularizing the diagnosis. But other medical conditions are named for the action or activity that is associated with the pathology. This article lists and references these conditions, and suggests that this group of conditions should be called "motionyms".