Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco.

BACKGROUND: Illicitly manufactured fentanyls and stimulants are implicated in the escalating US mortality from drug overdose. San Francisco, California (SF) has seen declining fentanyl injection while smoking has increased. Beliefs and behaviors surrounding this development are not well understood. METHODS: The study used rapid ethnography to explore fentanyl and methamphetamine use in SF. The team conducted semi-structured interviews (n = 34) with participants recruited from syringe service programs. Video-recorded smoking sequences (n = 12), photography and daily field notes supplemented interview data. RESULTS: Difficulty injecting and fear of overdose motivated transitions from injecting to smoking. Fentanyl was extremely cheap-$10/gram-with variability in quality. Foil was the most commonly used smoking material but glass bubbles, bongs and dabbing devices were also popular. No reliable visible methods for determining fentanyl quality existed, however, participants could gauge potency upon inhalation, and developed techniques to regulate dosage. Several participants reported at least hourly use, some reporting one or more grams of daily fentanyl consumption. Smoking was also very social, with people sharing equipment, drugs and information. Participants raised concerns about hygiene and overdose risk to others arising from shared equipment. Reportedly potent fentanyl 'residue' accumulated on smoking materials and was commonly shared/traded/stolen or consumed accidentally with diverse preferences for its use. CONCLUSION: Our data highlight fentanyl residue as a new overdose risk with potential mismatch between the potency of the residual drug and the recipient's tolerance. Further, large doses of fentanyl are being consumed (estimated at approximately 50 mg of pure fentanyl/day). Smoking fentanyl has potential health benefits over injecting and may be protective against overdose, but substantial uncertainty exists. However, SF overdose mortality hit a record high in 2023. Recommendations to reduce fentanyl smoking overdose risks through pacing, greater awareness of dosages consumed and checking tolerance of residue recipients are potentially viable interventions deserving further exploration.

Evaluating a Targeted Minimum Loss-Based Estimator for Capture-Recapture Analysis: An Application to HIV Surveillance in San Francisco, California.

The capture-recapture method is a common tool used in epidemiology to estimate the size of "hidden" populations and correct the underascertainment of cases, based on incomplete and overlapping lists of the target population. Log-linear models are often used to estimate the population size yet may produce implausible and unreliable estimates due to model misspecification and small cell sizes. A novel targeted minimum loss-based estimation (TMLE) model developed for capture-recapture makes several notable improvements to conventional modeling: "targeting" the parameter of interest, flexibly fitting the data to alternative functional forms, and limiting bias from small cell sizes. Using simulations and empirical data from the San Francisco, California, Department of Public Health's human immunodeficiency virus (HIV) surveillance registry, we evaluated the performance of the TMLE model and compared results with those of other common models. Based on 2,584 people observed on 3 lists reportable to the surveillance registry, the TMLE model estimated the number of San Francisco residents living with HIV as of December 31, 2019, to be 13,523 (95% confidence interval: 12,222, 14,824). This estimate, compared with a "ground truth" of 12,507, was the most accurate and precise of all models examined. The TMLE model is a significant advancement in capture-recapture studies, leveraging modern statistical methods to improve estimation of the sizes of hidden populations.

Changes in Breast Cancer Risk and Risk Factor Profiles among U.S.-Born and Immigrant Asian American Women Residing in the San Francisco Bay Area.

BACKGROUND: Breast cancer incidence rates in women of Asian descent have been increasing in the United States and Asia. METHODS: In a case-control study of Asian American women from the San Francisco Bay Area, we assessed associations with birthplace and migration-related characteristics and compared risk factors between Asian American and non-Hispanic White women by birthplace and birth cohort. RESULTS: Birthplace and migration-related characteristics were associated with breast cancer risk only among women in the younger birth cohort (1951-1984) that comprised 355 cases diagnosed at age ≤55 years and 276 sister and population controls. Breast cancer risk was marginally increased among foreign-born women [OR = 1.40; 95% confidence interval (CI), 0.97-2.03] and two-fold among foreign-born Chinese women (OR = 2.16; 95% CI, 1.21-3.88). Two-fold increased risks were associated with migration at age ≥40 years and longer U.S. residence (≥30 years or ≥75% of life). The education level was high among both cases and controls. Differences in the prevalence of risk factors by birthplace and birth cohort suggest temporal changes in reproductive and lifestyle-related factors. The prevalence in risk factors was similar between foreign-born and U.S.-born women in the younger birth cohort, and did not fully explain the observed associations with birthplace and other migration characteristics. CONCLUSIONS: In contrast to studies from earlier decades, younger foreign-born Asian American women had a higher risk of breast cancer than U.S.-born Asian American women. IMPACT: It is important and urgent to understand what factors drive the increasing burden of breast cancer in women of Asian descent and implement effective prevention programs.

Qualitative exploration of melanoma awareness in black people in the USA.

OBJECTIVE: Although black patients are more likely to have advanced melanomas at diagnosis, with a 5-year survival rate among black patients of 70% compared with 92% for white patients, black people are generally not the focus of melanoma public health campaigns. We sought to explore awareness and perspectives of melanoma among black people to inform the development of relevant and valued public health messages to promote early detection of melanoma. DESIGN: Inductive thematic analysis of in-depth semistructured interviews. SETTING: Interviews were conducted with participants via video software or telephone in the USA. PARTICIPANTS: Participants were adults from the USA who self-identified as African American or black. Recruitment flyers were posted around the San Francisco Bay Area and shared on our team Facebook page, with further participants identified through snowball sampling. RESULTS: We interviewed 26 participants from 10 different states. Overall, 12 were men and 14 were women, with a mean age of 43 years (range 18-85). We identified five key themes regarding melanoma awareness in black people: (1) lack of understanding of term 'melanoma' and features of skin cancer; (2) do not feel at risk of melanoma skin cancer; (3) surprise that melanoma can occur on palms, soles and nails; (4) skin cancer awareness messages do not apply to or include black people; and (5) Importance of relationship with healthcare and habits of utilisation. CONCLUSIONS: Analysis of these in-depth semistructured interviews illuminate the pressing need for health information on melanoma designed specifically for black people. We highlight two key points for focused public health messaging: (1) melanoma skin cancer does occur in black people and (2) high-risk sites for melanoma in black people include the palms, soles and nail beds. Therefore, public health messages for black people and their healthcare providers may involve productively checking these body surface areas.

Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California.

The tobacco industry has used recent findings from the Youth Risk Behavior Surveillance System Survey (YRBSS) to claim that a sales restriction on flavoured tobacco products might increase youth combustible cigarette use. In this special communication, we examined YRBSS data and reached the opposite conclusion. We observed the patterns in youth cigarette smoking in Oakland, California following its 2017 convenience store flavoured tobacco sales restriction. We also found that 2019 YRBSS data from San Francisco, California cannot be used to evaluate the effect of the sales restriction on all flavoured tobacco products in San Francisco as the YRBSS data for this city were collected prior to enforcement of the sales restriction. For future studies, we suggest triangulating with corroborating sales, behavioural and qualitative data over time to assess the effects of tobacco control policies on youth tobacco use. We recommend that policy enactment and enforcement dates, as well as the exact data collection periods for population health surveys, be published to facilitate more rigorous policy evaluation.

Prevalence and factors associated with neck injection among people who inject drugs in San Francisco, California.

BACKGROUND: Groin and neck injections are generally a last resort for people who inject drugs (PWID) who do not have easy access to functioning veins. These alternative injection practices can lead to an increased likelihood of adverse health outcomes. There is still much we do not know about groin and neck injections among PWID in the US, as the literature to-date comes from studies primarily focused on groin injections outside the US. We assessed prevalence, predictors, and associated behaviors of neck injection through a survey fielded in San Francisco, California, US. METHODS: The sample comes from a longitudinal observational study that used targeted sampling to recruit PWID in San Francisco. The current study sample includes 239 PWID who completed their 12-month survey between June 2019 and June 2020. RESULTS: About a third of the sample reported injecting in their neck in the past 30 days, with the most common reason being lack of available veins. Age, past 6-month abscess / soft tissue infection, and past 30-day use of opioids mixed with cocaine were significantly associated with past 30-day neck injection in the final multivariate model. Past 30-day neck injection was also significantly associated with being injected by another person in the past 30 days. CONCLUSIONS: PWID at higher risk for vein deterioration were more likely to inject into their neck. Harm reduction strategies such as safer injection counseling, safe smoking supplies, use of "street doctors," and safe consumption sites may reduce instances of neck injection and/or associated health risks.

HIV prevalence, engagement in care, and risk behavior among trans women, San Francisco: Evidence of recent successes and remaining challenges.

BACKGROUND: Trans women have high HIV prevalence and lag behind 90-90-90 targets for HIV care. In San Francisco in 2017, 96% of trans women were aware of their status, 75% were on antiretroviral therapy, 88% had viral suppression. Initiatives to address gaps include peer navigators, free gender-affirming surgery, and housing. Our study updates HIV prevalence and engagement in care among trans women. METHODS: Cross-sectional community-based survey of trans women living in San Francisco sampled by respondent-driven sampling, 7/2019-2/2020 (N = 201). Eligibility was: self-identified trans women or other gender and assigned male at birth; living in San Francisco; English/Spanish-speaking; and 18 years or older. RESULTS: HIV prevalence was 42.3% (95%CI 35.4.-49.4) and associated with having a partner who injected drugs (adjusted odds ratio [AOR] 3.30, 95%CI 1.58-6.90), ever injected drugs (AOR 2.28, 95%CI 1.06-4.89), cost not a barrier to healthcare (AOR 2.63, 95%CI 1.02-6.67), emotional support from family (AOR 2.85, 95%CI 1.43-5.65), and Black/African-American (AOR 2.59, 95%CI 1.16-5.79). Of trans women with HIV, 92.9% were previously diagnosed, 89.9% were on ART, 91.5% reported viral suppression. CONCLUSIONS: Trans women met 90-90-90 targets in 2020, at 93-90-92. Interventions need to reach Black/African-American trans women, trans women who inject drugs, and partners of trans women.

Urinary Biomarkers of Polycyclic Aromatic Hydrocarbons and Timing of Pubertal Development: The California PAH Study.

BACKGROUND: Polycyclic aromatic hydrocarbons (PAHs) are endocrine-disrupting chemicals. Few studies have evaluated the association between pubertal development in girls and PAH exposures quantified by urinary biomarkers. METHODS: We examined associations of urinary PAH metabolites with pubertal development in 358 girls 6-16 years of age from the San Francisco Bay Area enrolled in a prospective cohort from 2011 to 2013 and followed until 2020. Using baseline data, we assessed associations of urinary PAH metabolites with pubertal development stage. In prospective analyses limited to girls who at baseline had not yet started breast (N = 176) or pubic hair (N = 179) development or menstruation (N = 267), we used multivariable Cox proportional hazards regression to assess associations of urinary PAH metabolites with the onset of breast and pubic hair development, menstruation, and pubertal tempo (interval between the onset of breast development and menstruation). RESULTS: We detected PAH metabolites in >98% of girls. In cross-sectional analyses using baseline data, PAH metabolites were not associated with the pubertal development stage. In prospective analyses, higher concentrations (≥ median) of some PAH metabolites were associated with two-fold higher odds of earlier breast development (2-hydroxy naphthalene, 1-hydroxy phenanthrene, summed hydroxy phenanthrenes) or pubic hair development (1-hydroxy naphthalene) among girls overweight at baseline (body mass index-for-age percentile ≥85) compared with nonoverweight girls with lower metabolites concentrations. PAH metabolites were not associated with age at menarche or pubertal tempo. CONCLUSIONS: PAH exposures were widespread in our sample. Our results support the hypothesis that, in overweight girls, PAHs impact the timing of pubertal development, an important risk factor for breast cancer.

Organophosphate and Organohalogen Flame-Retardant Exposure and Thyroid Hormone Disruption in a Cross-Sectional Study of Female Firefighters and Office Workers from San Francisco.

Occupational exposures to flame retardants (FRs), a class of suspected endocrine-disrupting compounds, are of health concern for firefighters. We sought to characterize exposure to FR compounds and evaluate their association with thyroid hormone levels, a biomarker of early effect, in female firefighters and office workers in San Francisco. In a cross-sectional study, we measured replacement organophosphate and organohalogen FRs in spot urine samples from firefighters (N = 86) and office workers (N = 84), as well as total thyroxine (T4) and thyroid-stimulating hormone in plasma for 84 firefighters and 81 office workers. Median bis(1,3-dichloro-2-propyl)phosphate (BDCPP) levels were 5 times higher in firefighters than office workers. Among firefighters, a doubling of BDCPP was associated with a 2.88% decrease (95% confidence interval -5.28, -0.42) in T4. We did not observe significant associations between FRs and T4 among office workers. In the full group, intermediate body mass index and a college education were associated with higher FR levels. The inverse association observed between FRs and T4 coupled with the lack of studies on women workers and evidence of adverse health effects from FR exposure─including endocrine disruption and breast cancer risk─warrant further research on occupational exposures and identification of opportunities for exposure reduction.

Transition from injecting opioids to smoking fentanyl in San Francisco, California.

BACKGROUND: The introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco. METHODS: We used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018-2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids. RESULTS: The median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID's motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma. CONCLUSION: Between 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.

Surviving traumatic injury, only to die of acute drug poisoning: Should trauma centers be a path for intervention?

BACKGROUND: Although death from drug overdose is a leading cause of injury-related death in the United States, its incidence after traumatic incident is unknown. Moreover, little is known about related risk factors. We sought to determine the incidence and characteristics of and risk factors for trauma patients suffering death by acute drug poisoning ("overdose") after hospitalization for a traumatic incident. METHODS: We conducted a retrospective chart review of all admitted trauma patients ≥18 y of age at the only level-1 trauma center in our region from 2012 to 2019, matched with unintentional overdose decedents from the California death registry. We assessed associations between demographic and clinical characteristics with risk of overdose death, using cumulative incidence functions and Fine-Gray subdistribution hazard models. RESULTS: Of 9,860 patients residing in San Francisco, CA, USA, at the time of their trauma activation or admission during the study period, 1,418 died (4.3 per 100 person-years), 107 from unintentional overdose (0.3 per 100 person-years). Overdose decedents were 84% male, 50% white, with a mean age of 48 years at the time of presentation; 20% of deaths occurred within 3 months of hospitalization, and 40% were attributed to a prescription opioid. In multivariate analysis, younger age, male sex, white race, and having undergone a urine drug screening were all associated with subsequent death from overdose. CONCLUSION: During a mean 3.4-year follow-up, the mortality rate from overdose among adult patients with traumatic incidents was 0.3/100 person-years. Trauma hospitalization may serve as an opportunity to screen and initiate prevention, harm reduction, and treatment interventions.

E-Cigarette Use among Current Smokers Experiencing Homelessness.

Two-thirds of cigarette smokers experiencing homelessness report using alternative tobacco products, including blunts, cigarillos (little cigars) or roll-your-own tobacco or electronic nicotine delivery systems such as e-cigarettes. We examined attitudes toward e-cigarette use and explored whether e-cigarette use patterns were associated with past-year cigarette quit attempts among current smokers experiencing homelessness. Among the 470 current cigarette smokers recruited from homeless service sites in San Francisco, 22.1% (n = 65) reported the use of e-cigarettes in the past 30 days ('dual users'). Compared to cigarette-only smokers, dual users considered e-cigarettes to be safer than cigarettes. Patterns of e-cigarette use, including the number of times used per day, duration of use during the day, manner of use and nicotine concentration were not associated with past-year cigarette quit attempts. Studies that examine the motivations for use of e-cigarettes, particularly for their use as smoking cessation aids, could inform interventions for tobacco use among people experiencing homelessness.

High hepatitis C virus seropositivity, viremia, and associated risk factors among trans women living in San Francisco, California.

Trans women have been understudied in the Hepatitis C virus (HCV) epidemic, yet data suggest they may be at elevated risk of the disease. Using data collected from the Centers for Disease Control and Prevention's (CDC) National HIV Behavioral Surveillance (NHBS) survey, we measured HCV seropositivity, viremia, and associated risk factors for HCV infection among trans women in San Francisco from June 2019 to February 2020. Respondent-driven sampling (RDS) was used to obtain a diverse, community-based sample of 201 trans women, of whom 48 (23.9%, 95% CI 17.9% - 30.0%) were HCV seropositive. HCV seropositivity significantly increased with increasing age (adjusted prevalence ratio [APR] 1.04 per year, 95% CI 1.01-1.07) and history of injection drug use (APR 4.44, 95% CI 2.15-9.18). We also found that many had HCV viremia as twelve (6.0% of the total sample, 95% CI 2.7% - 9.3%) were RNA-positive for HCV. Trans women are highly impacted by HCV and could benefit from access to regular and frequent HCV screening and treatment access. HCV screening could be offered regularly in trans-specific health services, in the community, in jails and prisons, and integrated syringe exchange programs where treatment access or referral are also available.

Unmet Health and Social Welfare Needs of Women Who Inject Drugs in San Francisco.

We characterize social welfare and health care needs of women who inject drugs in a community-based survey in San Francisco. A total of 139 women were enrolled; 74.8% were homeless, and 67.6% earned below poverty level. Indicators of health care and prevention program access included: 95.7% with health insurance, 90.6% used a needle exchange program, and 58.2% tested for HIV two or more times. However, only 8.6% received HPV vaccination and there was unmet contraception need for 79.0% of women. Only 28.7% of those testing positive for HCV infection had received treatment. Physical and sexual violence in the last year were common (41.0% and 18.0%, respectively). Women who inject drugs would benefit from integrated health and social services including addressing interpersonal violence, sexual and reproductive health, and HIV and HCV prevention needs. Women-only needle exchange programs and safe injection sites may be effective delivery points for these services.

Hepatic Toxicity After Selective Chemoembolization Is Associated With Decreased Survival Among Patients With Hepatocellular Carcinoma.

OBJECTIVE. The purpose of this study was to identify risk factors for and outcomes of hepatotoxicity after selective chemoembolization of hepatocellular carcinoma. MATERIALS AND METHODS. This retrospective study included 182 patients (136 men and 46 women; median age, 63 years [interquartile range, 57-70 years]) who underwent 338 consecutive doxorubicin drug-eluting bead (DEB) chemoembolization procedures between 2011 and 2014. Outcomes were assessed until November 2019. In 97% of procedures, two or fewer segments were targeted. The Barcelona Clinic Liver Cancer (BCLC) stage was 0 or A for 77 procedures (22.8%), B for 75 (22.2%), C for 122 (36.1%), and D for 64 (18.9%). Hepatotoxicity was defined as worsened ascites or encephalopathy or as grade 3 or 4 elevations in liver function test results, creatinine levels, or the international normalized ratio within 30 days. Risk factors were assessed by univariate and multivariable generalized estimating equations. Transplant-free survival was assessed using Cox proportional hazard models. RESULTS. Hepatotoxicity was observed after 84 of 338 procedures (24.9%) performed for 70 of 182 patients (38.5%) and was irreversible for 40 procedures (11.8%). On multivariable analysis, risk factors for irreversible toxicity included Child-Pugh class C liver function (odds ratio [OR], 4.4; 95% CI, 1.0-19.0; p = .04), BCLC stage C (OR, 5.0; 95% CI, 1.6-16.0; p = .006) or D (OR, 7.4; 95% CI, 2.1-25.5; p = .002) disease, TIPS or hepatofugal portal venous flow (OR, 6.3; 95% CI, 2.3-17.0; p < .001), and a serum α-fetoprotein level of 200 ng/mL or greater (OR, 2.6; 95% CI, 1.1-6.1; p = .03). Irreversible toxicity was associated with reduced transplant-free survival among patients who were ineligible for liver transplant (hazard ratio, 2.5; standard error, 0.42; p = .03). CONCLUSION. Irreversible hepatotoxicity was common after selective chemoembolization in patients with advanced stage disease, an elevated serum α-fetoprotein level, or reduced hepatic portal venous perfusion, and it may hasten death among patients who are ineligible for liver transplant.

Sensitivity and Specificity of the National Death Index for Multiple Causes of Death in People With HIV.

OBJECTIVES: Inaccuracies in cause-of-death information in death certificates can reduce the validity of national death statistics and result in poor targeting of resources to reduce morbidity and mortality in people with HIV. Our objective was to measure the sensitivity, specificity, and agreement between multiple causes of deaths from death certificates obtained from the National Death Index (NDI) and causes determined by expert physician review. METHODS: Physician specialists determined the cause of death using information collected from the medical records of 50 randomly selected HIV-infected people who died in San Francisco from July 1, 2016, through May 31, 2017. Using expert review as the gold standard, we measured sensitivity, specificity, and agreement. RESULTS: The NDI had a sensitivity of 53.9% and a specificity of 66.7% for HIV deaths. The NDI had a moderate sensitivity for non-AIDS-related infectious diseases and non-AIDS-related cancers (70.6% and 75.0%, respectively) and high specificity for these causes (100.0% and 94.7%, respectively). The NDI had low sensitivity and high specificity for substance abuse (27.3% and 100.0%, respectively), heart disease (58.3% and 86.8%, respectively), hepatitis B/C (33.3% and 97.7%, respectively), and mental illness (50.0% and 97.8%, respectively). The measure of agreement between expert review and the NDI was lowest for HIV (κ = 0.20); moderate for heart disease (κ = 0.45) and hepatitis B/C (κ = 0.40); high for non-AIDS-related infectious diseases (κ = 0.76) and non-AIDS-related cancers (κ = 0.72); and low for all other causes of death (κ < 0.35). CONCLUSIONS: Our findings support education and training of health care providers to improve the accuracy of cause-of-death information on death certificates.

Smoke-Free Home Intervention in Permanent Supportive Housing: A Multifaceted Intervention Pilot.

INTRODUCTION: Smoke-free homes (SFHs), the voluntary adoption of home smoking restrictions, are associated with reduced secondhand smoke exposure. However, SFHs are uncommon in permanent supportive housing (PSH) for formerly homeless adults, who have fivefold higher smoking rates than the general population. We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. AIMS AND METHODS: We pilot-tested a brief intervention to increase voluntary adoption of SFHs among PSH residents in the San Francisco Bay Area. Rest of the methods, PSH residents (n = 100) and staff (n = 62) from 15 PSH sites participated in the intervention between October 2017 and February 2018. Research staff provided counseling to PSH residents on how to adopt an SFH and trained PSH staff on how to counsel residents on smoking cessation. The primary outcome was self-reported voluntary adoption of an SFH for ≥90 days, and the secondary outcome was carbon monoxide-verified PPA at 6-month follow-up. PSH staff completed the Smoking Knowledge, Attitudes, and Practices survey at baseline and 3-month follow-up. RESULTS: At 6 months, 31.3% of PSH residents had adopted an SFH (vs. 13.0% at baseline) and 16.9% reported carbon monoxide-verified PPA. A positive attitude toward an SFH policy was associated with increased odds of SFH adoption (adjusted odds ratio = 8.68, 95% confidence interval: 2.42, 31.17). Voluntary SFH adoption was associated with increased PPA (adjusted odds ratio = 26.27, 95% confidence interval: 3.43, 201.30). PSH staff reported improved attitudes toward and self-efficacy in delivering cessation care, and decreased barriers to discussing smoking cessation among PSH residents between baseline and 3-month follow-up. CONCLUSIONS: In this single-arm study, a brief intervention increased SFH adoption and PPA among PSH residents. IMPLICATIONS: To date, few interventions have addressed SFHs and their association with tobacco use among PSH residents. A "ground-up" approach that relies on buy-in from residents and that promotes voluntary SFHs is an innovative way to increase smoke-free living environments in PSH. This approach could pave a pathway for smoke-free policy implementation in these sites. PSH can play a role in reducing the burden of tobacco use by empowering its residents to adopt voluntary SFHs, which could increase smoking cessation among residents.

Stress and the Surgical Resident in the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has drastically transformed the healthcare community and medical education across the United States. The aim of this study was to evaluate the impact of COVID-19 on the surgical resident training experience, assess possible sources of stress or anxiety among surgery residents, and examine how patterns of anxiety vary by resident rank. DESIGN: We developed and disseminated a survey, which included the Generalized Anxiety Disorder 7-Item Scale (GAD-7), to all general and integrated plastic surgery residents in their clinical years of training at the University of California, San Francisco. Statistical analysis of the survey responses was performed using the Kruskal-Wallis or Wilcoxon rank sum test. Post-hoc analysis was performed using the Bonferroni-corrected Dunn test. Survey data were combined with aggregated duty hour information and operative case numbers from select hospitals for March and April of 2019 (historical baseline) and 2020. RESULTS: The overall survey response rate was 73.7% (n = 73). With an estimated operative volume reduction of 63.3% for general surgery cases, over 90% of residents expressed concern about the decline in operative exposure. While the senior residents tended to work more shifts, they were not more likely to have higher risk perception scores for contracting COVID-19 nor higher anxiety levels about the possibility of contracting COVID-19. They were, however, significantly more likely to have high GAD-7 scores (≥ 10) when compared to interns (z = -2.82, p-adj = 0.014). Overall, residents were more concerned about the general health of loved ones than about their own risk of contracting COVID-19 (U = 3897.5, p < 0.01). CONCLUSIONS: While the work-related experiences of residents varied across a number of factors during the pandemic, residents tended to report similar sources of anxiety. Moving forward, surgical residency training programs will need to develop ways to optimize available surgical experiences and address the unique resident anxieties that an infectious pandemic presents.

Is Preimplantation Genetic Testing Associated with Increased Risk of Abnormal Placentation After Frozen Embryo Transfer?

OBJECTIVE: This study aimed to assess the association of preimplantation genetic testing (PGT) with abnormal placentation among a cohort of pregnancies conceived after frozen embryo transfer (FET). STUDY DESIGN: This is a retrospective cohort study of women who conceived via FET at the University of California, San Francisco from 2012 to 2016 with resultant delivery at the same institution. The primary outcome was abnormal placentation, including placenta accreta, retained placenta, abruption, placenta previa, vasa previa, marginal or velamentous cord insertion, circumvallate placenta, circummarginate placenta, placenta membranacea, bipartite placenta, and placenta succenturiata. Diagnosis was confirmed by reviewing imaging, delivery, and pathology reports. Our secondary outcome was hypertensive disease of pregnancy. RESULTS: A total of 311 pregnancies were included in analysis; 158 (50.8%) underwent PGT. Baseline demographic characteristics were similar between groups except for age at conception and infertility diagnosis. Women with PGT were more likely to undergo single embryo transfer (82.3 vs. 64.1%, p < 0.001). There were no statistically significant differences in the rate of the primary outcome (26.6 vs. 27.4%, p = 0.86) or hypertensive disorders of pregnancy (33.5 vs. 33.3%, p = 0.97), which remained true after multivariate analysis was performed. CONCLUSION: Among pregnancies conceived after FET, PGT is not associated with a statistically significant increased risk of abnormal placentation or hypertensive disorders of pregnancy. KEY POINTS: · In pregnancies conceived by FET, PGT is not associated with increased risk of abnormal placentation.. · In pregnancies conceived by FET, PGT is not associated with increased risk of hypertensive disorders.. · Differences in outcomes of PGT pregnancies may be related to FET rather than trophectoderm biopsy..