Pilot randomized controlled trial of biofeedback on reducing psychological and physiological stress among persons experiencing homelessness.

People experiencing homelessness report increased exposure to traumatic life events and higher rates of depression, anxiety, and post-traumatic stress disorder as compared with the general population. Heart rate variability-biofeedback (HRV-BF) has been shown to decrease symptoms of stress, anxiety, depression, and PTSD. However, HRV-BF has not been tested with the most vulnerable of populations, homeless adults. The purpose of this randomized controlled trial was to compare the effectiveness of an HRV-BF intervention versus a Health Promotion (HP) active control intervention focused on improving mental health symptoms among homeless adults. Guided by a community advisory board, homeless adults residing in Skid Row, Los Angeles (n = 40) were randomized to either the HRV-BF or an active HP control group and received eight weekly, 30-min sessions over two months, delivered by a nurse-led community health worker team. Dependent variables of HRV, mental health, anxiety, depression, and PTSD were measured at baseline, the 8-week session, and/or 2-month follow-up. All intervention sessions were completed by 90% (36/40) of participants. Both the HRV-BF and HP interventions showed significant increases in HRV from baseline to 2-month follow-up, with no significant difference between the intervention groups. The HRV-BF programme revealed a somewhat greater, although non-significant, improvement in anxiety, depression, and PTSD symptoms than the HP programme. The usefulness of both interventions, focused on emotional and physical health, warrants future studies to examine the value of a combined HRV-BF and HP intervention.

Exploratory assessment: Nurse-led community health worker delivered HCV intervention for people experiencing homelessness.

BACKGROUND: Getting and maintaining Hepatitis C Virus (HCV) cure is challenging among people experiencing homelessness (PEH) as a result of critical social determinants of health such as unstable housing, mental health disorders, and drug and alcohol use. OBJECTIVES: The purpose of this exploratory pilot study was to compare a registered nurse/community health worker (RN/CHW)-led HCV intervention tailored for PEH, "I am HCV Free," with a clinic-based standard of care (cbSOC) for treating HCV. Efficacy was measured by sustained virological response at 12 weeks after stopping antivirals (SVR12), and improvement in mental health, drug and alcohol use, and access to healthcare. METHODS: An exploratory randomized controlled trial design was used to assign PEH recruited from partner sites in the Skid Row Area of Los Angeles, California, to the RN/CHW or cbSOC programs. All received direct-acting antivirals. The RN/CHW group received directly observed therapy in community-based settings, incentives for taking HCV medications, and wrap-around services, including connection to additional healthcare services, housing support, and referral to other community services. For all PEH, drug and alcohol use and mental health symptoms were measured at month 2 or 3 and 5 or 6 follow-up, depending on HCV medication type, while SVR12 was measured at month 5 or 6 follow-up. RESULTS: Among PEH in the RN/CHW group, 75% (3 of 4) completed SVR12 and all three attained undetectable viral load. This was compared with 66.7% (n = 4 of 6) of the cbSOC group who completed SVR12; all four attained undetectable viral load. The RN/CHW group, as compared to the cbSOC, also showed greater improvements in mental health, and significant improvement in drug use, and access to healthcare services. DISCUSSION: While this study shows significant improvements in drug use and health service access among the RN/-CHW group, the sample size of the study limits the validity and generalizability of the results. Further studies using larger sample sizes are necessitated.

Comparison of In Situ Hybridization, Immunohistochemistry, and Reverse Transcription-Droplet Digital Polymerase Chain Reaction for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Testing in Tissue.

CONTEXT.­: Small case series have evaluated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection in formalin-fixed, paraffin-embedded tissue using reverse transcription-polymerase chain reaction, immunohistochemistry (IHC), and/or RNA in situ hybridization (RNAish). OBJECTIVE.­: To compare droplet digital polymerase chain reaction, IHC, and RNAish to detect SARS-CoV-2 in formalin-fixed, paraffin-embedded tissue in a large series of lung specimens from coronavirus disease 2019 (COVID-19) patients. DESIGN.­: Droplet digital polymerase chain reaction and RNAish used commercially available probes; IHC used clone 1A9. Twenty-six autopsies of COVID-19 patients with formalin-fixed, paraffin-embedded tissue blocks of 62 lung specimens, 22 heart specimens, 2 brain specimens, and 1 liver, and 1 umbilical cord were included. Control cases included 9 autopsy lungs from patients with other infections/inflammation and virus-infected tissue or cell lines. RESULTS.­: Droplet digital polymerase chain reaction had the highest sensitivity for SARS-CoV-2 (96%) when compared with IHC (31%) and RNAish (36%). All 3 tests had a specificity of 100%. Agreement between droplet digital polymerase chain reaction and IHC or RNAish was fair (κ = 0.23 and κ = 0.35, respectively). Agreement between IHC and in situ hybridization was substantial (κ = 0.75). Interobserver reliability was almost perfect for IHC (κ = 0.91) and fair to moderate for RNAish (κ = 0.38-0.59). Lung tissues from patients who died earlier after onset of symptoms revealed higher copy numbers by droplet digital polymerase chain reaction (P = .03, Pearson correlation = -0.65) and were more likely to be positive by RNAish (P = .02) than lungs from patients who died later. We identified SARS-CoV-2 in hyaline membranes, in pneumocytes, and rarely in respiratory epithelium. Droplet digital polymerase chain reaction showed low copy numbers in 7 autopsy hearts from ProteoGenex Inc. All other extrapulmonary tissues were negative. CONCLUSIONS.­: Droplet digital polymerase chain reaction was the most sensitive and highly specific test to identify SARS-CoV-2 in lung specimens from COVID-19 patients.

Performance Characteristics of a High-Throughput Automated Transcription-Mediated Amplification Test for SARS-CoV-2 Detection.

The COVID-19 pandemic caused by the new SARS-CoV-2 coronavirus has imposed severe challenges on laboratories in their effort to achieve sufficient diagnostic testing capability for identifying infected individuals. In this study, we report the analytical and clinical performance characteristics of a new, high-throughput, fully automated nucleic acid amplification test system for the detection of SARS-CoV-2. The assay utilizes target capture, transcription-mediated amplification, and acridinium ester-labeled probe chemistry on the automated Panther system to directly amplify and detect two separate target sequences in the open reading frame 1ab (ORF1ab) region of the SARS-CoV-2 RNA genome. The probit 95% limit of detection of the assay was determined to be 0.004 50% tissue culture infective dose (TCID50)/ml using inactivated virus and 25 copies/ml (c/ml) using synthetic in vitro transcript RNA targets. Analytical sensitivity (100% detection) was confirmed to be 83 to 194 c/ml using three commercially available SARS-CoV-2 nucleic acid controls. No cross-reactivity or interference was observed with testing of six related human coronaviruses, as well as 24 other viral, fungal, and bacterial pathogens, at high titers. Clinical nasopharyngeal swab specimen testing (n = 140) showed 100%, 98.7%, and 99.3% positive, negative, and overall agreement, respectively, with a validated reverse transcription-PCR nucleic acid amplification test (NAAT) for SARS-CoV-2 RNA. These results provide validation evidence for a sensitive and specific method for pandemic-scale automated molecular diagnostic testing for SARS-CoV-2.

Correlates of Posttraumatic Stress Symptoms among Formerly Incarcerated, Homeless Women.

Posttraumatic stress symptoms are a pressing issue among women experiencing incarceration and homelessness. Baseline data were collected among formerly incarcerated homeless women (N = 130) who were on average 38.9 (SD = 11.36, range 19-64) years of age and recruited into a pilot randomized control trial (RCT) intervention program. A logistic regression was used to assess correlates of PTSD symptoms. The majority of the sample self-reported witnessing violence (85%) and had moderate PTSD symptoms (M = 1.61, SD = 1.62, range: 0-4). No past month drug use (p = 0.006), higher anger scores (p = 0.002), greater emotional support (p = 0.009), and psychological frailty (p = 0.02) were significantly associated with higher odds of PTSD symptoms. Moreover, women who experienced minor family conflicts had lower odds of PTSD symptoms relative to those that had family conflicts most of the time (p = 0.02). Similarly, controlling for all other variables, women who had a higher positive social interaction score also had lower odds of PTSD symptoms (p = 0.006). These findings are a call to action for academicians, service providers, and health practitioners to develop an intervention which integrates comprehensive PTSD screening, and discussion of ways to build coping skills, relationships with family and social networks, and utilizes a trauma-informed approach during reentry.

Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India.

We conducted a cross-sectional examination of the physical and psychological factors related to ART adherence among a sample of 400 women living with HIV/AIDS in rural India. Interviewer-administered measures assessed adherence, internalized stigma, depressive symptoms, quality of life, food insecurity, health history and sociodemographic information. CD4 counts were measured using blood collected at screening. Findings revealed that adherence to ART was generally low, with 94% of women taking 50% or less of prescribed medication in past month. Multivariate analyses showed a non-linear association between numbers of self-reported opportunistic infections (OIs) in past 6 months (p = 0.016) and adherence, with adherence decreasing with each additional OI for 0-5 OIs. For those reporting more than 5 OIs, the association reversed direction, with increasing OIs beyond 5 associated with greater adherence.

Career mentoring needs of youths in foster care: voices for change.

PROBLEM: Adolescents with a history of foster care placement are more likely to become homeless, have mental illness, become parents too early in life, or become incarcerated within the juvenile justice/prison system. In addition, a low percentage of young adults, who formerly were in foster care, complete vocational training or higher education. METHODS: This was a qualitative study, using focus group methodology. Four focus group sessions were conducted with youth living in foster care. The purpose was to obtain their perceptions about mentoring. Focus groups comprised six to eight youths per group and were guided by a semi-structured interview guide. FINDINGS: A total of 27 youth in foster care participated in focus group interviews. Mean age was 16.4 (SD = 0.68) years. Youth participants were very knowledgeable about mentoring programs for at-risk youth, along with negative psychosocial outcomes experienced by former foster youth. However, they remarked that they are given few opportunities for career mentoring. The overall themes that emerged from narrative data were needing and finding authority figures, hooking up with a career mentor, and deserving the good life. CONCLUSION: Career mentoring is an affordable and feasible intervention for child welfare agencies. This could lead to more motivated and prepared youth living in foster care for vocational training or higher education. Learning opportunities from a career mentor may be a lifeline for preventing negative psychosocial outcomes for foster youth, reward achievement goals, and improve overall quality of life in emerging adulthood.

Comparisons of substance abuse, high-risk sexual behavior and depressive symptoms among homeless youth with and without a history of foster care placement.

AIMS AND OBJECTIVES: The purpose of this study was to compare prevalence of substance use, high-risk sexual behaviors, and depression symptoms between homeless youth with and without a history of foster care placement. BACKGROUND: Approximately 26,000 young persons exit foster care annually in the United States. Once they 'age out' of foster care, however, many young persons do not have access to comprehensive health care. They also are at risk for substance abuse, homelessness, or mental illness. Because persons with a history of foster care are at risk for negative psycho-social outcomes, it is unclear if these young people might be different than homeless youth without this history. DESIGN: The design is descriptive and cross-sectional. METHODS: A total of 156 homeless young persons, of whom 44 had a history of foster care placement, were recruited from a drop-in center that caters to homeless youth and young adults. RESULTS: The sample was majority male and white; ages were 16-25. Significantly higher proportion of homeless former foster youth used methamphetamine within the last six months compared to non-fostered homeless youth p = 0.03). Homeless former foster youth were significantly older (p = 0.02) and less educated (p = 0.02) than their homeless counterparts without a history of foster care placement. Prevalence of using tobacco, marijuana, alcohol, crack cocaine, and powder cocaine were similar for both groups. Although not significant, a higher proportion of homeless former foster youth reported trading sex for money or drugs compared to non-fostered, homeless youth (19% versus 12% [trading sex for money], and 26% versus 14% [trading sex for drugs], respectively. CONCLUSIONS: Findings from this study show that, in general, homelessness is a negative outcome, irrespective of having a foster care history. However, those with that history need continued support when transitioning to independent living, such as access to health care, and encouragement to further their education. RELEVANCE TO CLINICAL PRACTICE: It is important that nurses, who serve homeless youth populations, conduct a risk assessment profile, in order to ascertain a history of foster care placement, link former foster youth to social service agencies that provide risk reduction/health promotion education, and advocate for stable housing.

Missed Opportunities for Universal HIV Screening in Primary Care Clinics.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) has reported that the number of new cases of HIV infection has been underreported annually by at least 40,000 cases. In 2006, the CDC recommended that voluntary HIV counseling and testing (VCT) was given to all patients aged 13 to 64 years in ambulatory care settings. The purpose of this qualitative study was to explore primary care providers' (PCP) perspectives on and experiences of facilitators and barriers to offering VCT as part of annual screening. METHODS: This was a descriptive, exploratory study where fifteen primary care providers were individually interviewed. Only community-based primary care providers were interviewed, and no obstetrician/gynecologists were enrolled, as VCT is standard of care in that specialty. RESULTS: Barriers included doubts about the CDC recommendation, time constraints, fear, and assumptions about age and marital status. Facilitators included normalizing HIV testing and the availability of resources and training. PCPs' role as an advocate and their professional style had the paradoxical potential of being both a barrier and a facilitator to VCT. Providers' ability to connect patients to community resources was linked to their persistence and experience. CONCLUSIONS: Findings suggest more effort is needed by PCPs to facilitate HIV counseling and testing more frequently to their ambulatory care patients.

Characteristics of homeless youth who use cocaine and methamphetamine.

This cross-sectional hepatitis health promotion study (N = 156) was designed to identify correlates of cocaine and methamphetamine use among young, homeless persons living in Los Angeles County. Structured questionnaires were administered at baseline to assess sociodemographic characteristics, drug history, and social support. Unadjusted analysis showed that older age, having a history of incarceration, injection drug use (IDU), 10 or more sexual partners, and sex for money were associated with both cocaine and methamphetamine use. Logistic regression results showed that injection drug users had over seven times greater odds of using each stimulant compared with nonusers of injection drugs; those reporting at least 10 sexual partners and alcohol use in the past 6 months were more likely to use cocaine than their respective counterparts. African Americans were also less likely than Whites to report cocaine use. Understanding of these relationships can guide interventions targeting the multiple challenges faced by this population.

Where do youth in foster care receive information about preventing unplanned pregnancy and sexually transmitted infections?

Adolescents in foster care are at risk for unplanned pregnancy and sexually transmitted infections, including HIV infection. A study using a qualitative method was conducted to describe how and where foster youth receive reproductive health and risk reduction information to prevent pregnancy and sexually transmitted infections. Participants also were asked to describe their relationship with their primary health care provider while they were in foster care. Nineteen young adults, recently emancipated from foster care, participated in individual interviews. Using grounded theory as the method of analysis, three thematic categories were generated: discomfort visiting and disclosing, receiving and not receiving the bare essentials, and learning prevention from community others. Recommendations include primary health care providers providing a confidential space for foster youth to disclose sexual activity and more opportunities for foster youth to receive reproductive and risk prevention information in the school setting.

Art messaging to engage homeless young adults.

BACKGROUND: Art has been shown to be an empowering and engaging entity with numerous benefits to vulnerable populations, including the homeless persons and young adults. However, little is known how homeless young adults perceive the use of art as messages that can communicate the danger of initiating or continuing drug and alcohol use. OBJECTIVES: The purpose of this study was to solicit perspectives of homeless, drug-using young adults as to how art can be used to design messages for their peers about the danger of initiating or continuing drug and alcohol use. METHODS: Qualitative methodology via focus group discussions was utilized to engage 24 homeless young adults enrolled from a drop-in site in Santa Monica, California. RESULTS: The findings revealed support for a myriad of delivery styles, including in-person communication, flyers, music, documentary film, and creative writing. The young adults also provided insight into the importance of the thematic framework of messages. Such themes ranged from empowering and hopeful messages to those designed to scare young homeless adults into not experimenting with drugs. CONCLUSION: The findings indicate that in addition to messages communicating the need to prevent or reduce drug and alcohol use, homeless young adults respond to messages that remind them of goals and dreams they once had for their future, and to content that is personal, real, and truthful. Our research indicates that messages that reinforce protective factors such as hope for the future and self-esteem may be as important to homeless young adults as information about the risks and consequences of drug use.

Impact of prison status on HIV-related risk behaviors.

Baseline data were collected to evaluate the effectiveness of interventions on completion of the hepatitis A and B vaccine series among 664 sheltered and street-based homeless adults who were: (a) homeless; (b) recently (<1 year) discharged from prison; (c) discharged 1 year or more; and (d) never incarcerated. Group differences at baseline were assessed for socio-demographic characteristics, drug and alcohol use, sexual activity, mental health and public assistance. More than one-third of homeless persons (38%) reported prison time and 16% of the sample had been recently discharged from prison. Almost half of persons who were discharged from prison at least 1 year ago reported daily use of drugs and alcohol over the past 6 months compared to about 1 in 5 among those who were recently released from prison. As risk for HCV and HIV co-infection continues among homeless ex-offenders, HIV/HCV prevention efforts are needed for this population.

Correlates of substance use severity among homeless youth.

PROBLEM: this cross-sectional study identified a number of factors that were correlated with drug-use severity among homeless youth. METHODS: to examine a commonly used measure of substance-use severity, the TCU Drug Screen II, in a convenience sample of 156 homeless youth, ages 15-25 from a drop-in site in Santa Monica, California. FINDINGS: higher drug-use severity scores were independently related to low levels of perceived health and maladaptive coping strategies. CONCLUSIONS: the findings from this study are particularly relevant in that they support previous results showing that psychosocial variables are related to substance use behavior among young populations.

Correlates of adult assault among homeless women.

The purpose of this study was to assess predictors of sexual and physical assault among homeless women. A multivariate, correlation design was utilized to identify independent correlates of adult physical and sexual assault. The sample consisted of 202 homeless women residing in shelters or living on the street in the Skid Row area of Los Angeles. Respondents reporting a history of child sexual abuse were almost four times more likely to report being sexually assaulted as adults and were almost two and one third times more likely to report being physically assaulted as adults. A range of factors increase homeless women's risk of adult physical and sexual victimization, including child sexual abuse, substance use, lifetime sex trade activity, and previous incarceration. It is important for homeless service providers to develop an individual risk profile for homeless women and to intervene in order to decrease their risk of re-victimization.

Health-seeking challenges among homeless youth.

BACKGROUND: Approximately 1.5 to 2 million homeless young persons live on the streets in the United States. With the current economic situation, research is needed on quality of services geared toward homeless young adults. OBJECTIVES: The objective of this study was to explore homeless young adults' perspectives on barriers and facilitators of health-care-seeking behavior and their perspectives on improving existing programs for homeless persons. METHODS: This article is a descriptive qualitative study using focus groups, with a purposeful sample of 24 homeless drug-using young adults. RESULTS: Identified themes were failing access to care based on perceived structural barriers (limited clinic sites, limited hours of operation, priority health conditions, and long wait times) and social barriers (perception of discrimination by uncaring professionals, law enforcement, and society in general). DISCUSSION: Results provide insight into programmatic and agency resources that facilitate health-seeking behaviors among homeless young adults and include implications for more research with providers of homeless health and social services.

Analytical performance of the Investigational Use Only Cervista HPV HR test as determined by a multi-center study.

BACKGROUND: Any HPV test designed to be utilized in cervical cancer screening programs should be highly validated both analytically and clinically. OBJECTIVES: The Investigational Use Only (IUO) Cervista HPV HR test is designed to detect 14 high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68). The analytical performance of the Cervista HPV HR test was characterized in a multi-center study. RESULTS: Analytical sensitivity for the 14 high-risk HPV types that the test is designed to detect ranged from 1,250 copies to 7,500 copies per reaction depending on HPV type. Accuracy compared to PCR with bi-directional sequencing was 91.4% [95% CI: 86.5 95.0%]. The reproducibility, when tested at three different testing centers, resulted in an overall inter-run reproducibility (between day/within site) agreement of 98.8% [1-sided 95% Confidence Lower Limit = 96.9%] and an overall inter-site reproducibility (between site) agreement of 98.7% [1-sided 95% Confidence Lower Limit = 97.9%]. The Cervista HPV HR test showed no cross-reactivity with DNA from seven non-oncogenic HPV types or 17 different infectious agents at up to 10(7) copies per reaction. CONCLUSIONS: The analytical performance of the Cervista HPV HR test demonstrates sufficient analytical performance for use in cervical cancer screening. As with any clinical laboratory test, analytical characteristics must be evaluated in light of the clinical performance of this assay.