Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Disproportionately Affects the Latinx Population During Shelter-in-Place in San Francisco.

BACKGROUND: There is an urgent need to understand the dynamics and risk factors driving ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during shelter-in-place mandates. METHODS: We offered SARS-CoV-2 reverse-transcription polymerase chain reaction (PCR) and antibody (Abbott ARCHITECT IgG) testing, regardless of symptoms, to all residents (aged ≥4 years) and workers in a San Francisco census tract (population: 5174) at outdoor, community-mobilized events over 4 days. We estimated SARS-CoV-2 point prevalence (PCR positive) and cumulative incidence (antibody or PCR positive) in the census tract and evaluated risk factors for recent (PCR positive/antibody negative) vs prior infection (antibody positive/PCR negative). SARS-CoV-2 genome recovery and phylogenetics were used to measure viral strain diversity, establish viral lineages present, and estimate number of introductions. RESULTS: We tested 3953 persons (40% Latinx; 41% White; 9% Asian/Pacific Islander; and 2% Black). Overall, 2.1% (83/3871) tested PCR positive: 95% were Latinx and 52% were asymptomatic when tested; 1.7% of census tract residents and 6.0% of workers (non-census tract residents) were PCR positive. Among 2598 tract residents, estimated point prevalence of PCR positives was 2.3% (95% confidence interval [CI], 1.2%-3.8%): 3.9% (95% CI, 2.0%-6.4%) among Latinx persons vs 0.2% (95% CI, .0-.4%) among non-Latinx persons. Estimated cumulative incidence among residents was 6.1% (95% CI, 4.0%-8.6%). Prior infections were 67% Latinx, 16% White, and 17% other ethnicities. Among recent infections, 96% were Latinx. Risk factors for recent infection were Latinx ethnicity, inability to shelter in place and maintain income, frontline service work, unemployment, and household income <$50 000/year. Five SARS-CoV-2 phylogenetic lineages were detected. CONCLUSIONS: SARS-CoV-2 infections from diverse lineages continued circulating among low-income, Latinx persons unable to work from home and maintain income during San Francisco's shelter-in-place ordinance.

Implementing a Trauma-Informed Approach at a Student-Run Clinic for Individuals Seeking Asylum.

PROBLEM: Health care professionals complete forensic medical evaluations (FMEs) to corroborate evidence of persecution among individuals seeking asylum. Many FMEs are conducted at student-run clinics for individuals seeking asylum (or student-run asylum clinics; SRACs). Trauma-informed care (TIC) recognizes that trauma is pervasive and seeks to mitigate reexposure to trauma in health care interactions. Given that FMEs involve recalling trauma, TIC is an ideal model for supporting the individuals involved in an FME. APPROACH: The authors operationalized TIC principles in an SRAC model (the Human Rights Cooperative) at the University of California, San Francisco. Between April 2019 and April 2022, the SRAC provided 3 to 10 pro bono FMEs per month, as well as community referrals for individuals seeking asylum, clinician and medical student training on FMEs and TIC, and research on FMEs. This report describes the SRAC operations, organized by the 10 implementation domains of the Substance Abuse and Mental Health Services Administration guidance to organizations for implementing a trauma-informed approach. OUTCOMES: Between April 2019 and April 2022, the SRAC completed 160 FMEs. Sixty-nine clinicians performed FMEs, and 119 first-year medical students participated in the accompanying elective. Qualitative survey responses by clinicians, lawyers, students, and clients (individuals seeking asylum) highlighted the trauma-informed principles of safety; trustworthiness and transparency; empowerment, voice, and choice; peer support; collaboration and mutuality; and cultural, historical, and gender issues. All students who acted as leaders sustained their engagement with the SRAC over time. NEXT STEPS: Future research should use validated tools to assess secondary trauma and resilience within SRACs. The SRAC concept, which engages medical students and experienced clinicians in learning skills that can be used in the pursuit of health justice and equity, should be expanded and supported in U.S. medical schools across the country, which is facing unprecedented levels of migration.

Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV.

INTRODUCTION: The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine. METHODS: We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance. RESULTS: Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03-0.48), CD4 < 200 (OR 0.24, 95% CI 0.07-0.85), or were homeless (OR 0.24, 95% CI 0.07-0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67-2.81). CONCLUSIONS: A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.

Forearm Fracture Nonunion with and without Bone Loss: An Overview of Adult and Child Populations.

Nonunion occurs in 2-10% of all forearm fractures due to different mechanical and biological factors, patient characteristics, and surgeon-dependent causes. It is a condition that causes functional and psychosocial disability for the patient because it is a unique anatomical segment in which all the bones and structures involved embody a complex functional unit; therefore, it is a challenge for the orthopedic surgeon. The ultimate goal of the care of these patients is the restoration of function and limitations related to impairment and disability. The aim of this review is to provide an extended description of nonunion forearm fractures, related risk factors, diagnosis, classification systems, and the available evidence for different types of treatment as a tool to better manage this pathology.

Filler Use Among Trans Women: Correlates of Feminizing Subcutaneous Injections and Their Health Consequences.

Purpose: Subcutaneous injections, or "fillers," are used illicitly and in large quantities by trans women for feminization. They are associated with severe complications, but data on their use are limited, especially in places with widespread access to safe gender-affirming care. Our analysis seeks to assess the prevalence, correlates, and complications of filler use to inform prevention and treatment. Methods: A secondary analysis of cross-sectional survey data from the Trans* National Study conducted from May 2016 to December 2017 of 631 adult trans women in the San Francisco Bay Area, California, recruited using respondent-driven sampling. Results: Around 65/631 participants (10.3%) reported filler use. Filler use was highest among Latinas (21.3% vs. 3.8% among whites, p<0.001), high school graduates (22.6% vs. 1.7% among college graduates, p<0.001), and those with a history of being undocumented (31.7% vs. 16.3% among documented immigrants and 6.4% among U.S. natives, p<0.001). Filler users had higher odds of engaging in sex work ever (odds ratio [OR] 3.3, p<0.001) and in the last 6 months (OR 2.00, p=0.049). The majority of filler users (78.5%) reported a physical complication, including infectious and inflammatory responses, coagulopathies, and neuropathies. Conclusion: Filler use was high among participants, despite availability of gender-affirming care and prevalence of complications. Filler use was highest among those with social, economic, and political vulnerabilities. Thus, filler use might be associated with structural factors that reduce access to safer methods of feminization. Addressing these factors, increasing access to safe gender-affirming care, and developing protocols for filler-related complications are needed.