Soft tissue infection and follow-up for an unsheltered patient: the role of Street Medicine providers in bridging gaps in care.

Street Medicine is a volunteer-run initiative for low-resource healthcare settings. Formed to bridge gaps in care for persons experiencing homelessness, these organisations work to provide preventative medicine through maintenance care and follow-up. However, there are limits to what Street Medicine can accomplish given the geographical radius covered, lack of available transportation options and vulnerable sleeping locations night to night for the patients served. The subject of this case report is a middle-aged Spanish-speaking unsheltered man who began his care with a Street Medicine team. He was unable to attend medical appointments due to relocation, complicating his disease course and resulting in hospital intervention for cellulitis. Post-discharge, he stayed within radius and was treated by the street team. Increased emphasis on the effects of housing insecurity and addressing social determinants of health could prevent deterioration of manageable diseases and should be an area of active interest for Street Medicine team expansion.

Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County.

Objective: To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population. Methods: Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2. Results: Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure. Conclusion: Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.

Wound Healing as an Unconventional Marker for Epilepsy Control in a Patient Experiencing Homelessness: A Case Report.

Post-traumatic epilepsy is a complicated disease that remains challenging to treat even for patients who are able to access care regularly. People experiencing homelessness (PEH) represent a vulnerable demographic for neurologic disorders, especially due to gaps in care, limited resources, and low health literacy. This is a case of a 53-year-old male experiencing homelessness who was encountered by low-resource medical providers in an extra-clinical setting. His medical history was pertinent for a traumatic brain injury at a construction site a few years prior. He was diagnosed with post-traumatic epilepsy but was lost to follow-up due to being homeless and lacking health insurance. He also had a history of multiple hospitalizations secondary to seizures and did not consistently take his anti-epileptic medications. He was noted to have multiple facial wounds of unclear etiology. Upon further investigation, he complained of episodes of waking up on the sidewalk with facial injuries. The high-risk characteristics of his seizures prompted street medicine providers to quickly arrange an appointment with a primary care doctor. The process was further expedited by petitioning other local charitable organizations. He was later connected to a physician and re-prescribed levetiracetam 1000 mg twice daily for his post-traumatic epilepsy. After taking his medication regularly, his facial wounds were noted to have dramatic improvement. In this way, his medication adherence was measured as a function of his healing wounds since a lack of fresh wounds implied a lack of spontaneous seizures and subsequent reinjury. Low-resource medical providers caring for PEH in extra-clinical settings may necessitate using unconventional indicators to assess disease status.

Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review.

Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.

Cutaneous Manifestation of Diabetes Mellitus in an Unsheltered Male Leading to Emergent Hospitalization.

Diabetes mellitus (DM) is one of the most common chronic diseases in the United States. It is characterized by increased patient morbidity and mortality due to the many complications that can arise. Certain dermatological findings can be indicative of poorly controlled DM and can be a useful clue to further management. Persons experiencing homelessness (PEH) with DM often have higher rates of diabetic complications than the general diabetic population. Medical providers caring for PEH in the setting of limited resources should carefully evaluate cutaneous disease as a potential indicator of underlying illness. This physical manifestation of illness can serve to guide the next appropriate steps in management. A 41-year-old unsheltered male with an extensive medical history of hypertension, seizures, chronic diarrhea, and cocaine use was seen at a "foot-washing" medical outreach event. He presented with fevers, chills, and multiple painless right lower extremity ulcerated lesions of unspecified origin. A finger-stick glucose measurement was found to be 650 mg/dL. After immediate administration of 10 units of insulin, he was transported immediately to the emergency department and admitted. His month-long hospital course was complicated and involved the amputation of multiple toes. Preemptive outreach and management could have prevented the marked deterioration of his disease and represents the importance of outreach and regular follow-up with the PEH community.

Onychotillomania in the Setting of Homelessness.

Onychotillomania is a psychodermatosis that involves repetitive, self-induced trauma to the nail and sometimes the periungual skin. It is generally seen as an overlapping psychiatric and dermatologic disorder, although there have not been any statistically significant associations with psychiatric illness. Some studies have noted an association with obsessive-compulsive disorder (OCD). Due to the relative lack of empirical data on this condition, treatments are often not evidence-based. As a result, there is no standardized method of treating onychotillomania, and patients suffering from this disease are susceptible to relapse. This report presents the case of a 32-year-old male experiencing homelessness and suffering from major depressive disorder and methamphetamine use disorder who developed onychotillomania two months after becoming homeless. He regularly used various instruments such as nail cutters, tweezers, and nail files to constantly pick at his nails, a few of which were noted to be bleeding with signs of infection. He was evaluated jointly by dermatology and psychiatry providers who confirmed the diagnosis. By thorough examination of the patient's history, he was provided tactile sensory equipment to reduce his repetitive picking behavior. A direct referral for substance use counseling was also provided. At follow-up, he was noted to have a subjective improvement in his picking symptoms, although there was no significant difference in the size of his nails. This case represents the twofold challenge of managing a difficult condition, onychotillomania, in the setting of the severe socio-personal stressor of homelessness.

Resource-Limited Management of Presumptive Pyoderma Gangrenosum in an Unsheltered Patient.

Pyoderma gangrenosum (PG) is an ulcerating dermatosis associated with various chronic medical conditions. Its exact etiology is unknown but likely a function of inflammation and immune dysregulation. Treatment of PG generally follows a stepwise approach which involves extensive testing, biopsies, and potentially systemic therapy. However, patients with presumptive PG in an unsheltered homeless (USH) environment require a different approach, especially in a resource-limited setting. Our 65-year-old USH patient with an extensive medical history presented with an initial, irregular salmon-colored plaque measuring approximately 10 cm × 6 cm that eventually ulcerated with pain and purulent discharge. The consistent and judicious management of his wound in terms of gentle irrigation and appropriate dressing was performed over the course of seven months starting in April 2021. In November 2021, his wound margins shrunk by roughly 1 cm circumferentially, and the ulcer had scant serosanguinous discharge, a noticeable improvement from baseline. The previously impaired wound healing may have been due to pathergy, which was indirectly addressed by protective wound dressings. Management of chronic wounds and ulcers in patients otherwise lacking access to reliable care should avoid systemic immunosuppressants due to the inherently high-risk conditions on unsheltered streets.

Melanoma Identification and Management in an Unsheltered Male Using Teledermatology: Street Medicine Perspective.

Skin cancers are concerning for unsheltered people experiencing homelessness because of their high levels of sun exposure. Currently, there is little data on the prevalence of skin cancers in people experiencing homelessness. Skin diseases are often untreated in people experiencing homelessness due to a lack of access to specialized care. Miami Street Medicine (MSM) is an organization that provides people experiencing homelessness in the Miami Health District with medical care in a nonclinical street setting, near overpasses, sidewalks, and encampments. We present a case of an unsheltered 59-year-old male with a pigmented, 2 cm × 2 cm facial lesion that developed over several years. Through a teledermatology consultation, his lesion was highly suspicious of melanoma and further evaluation was recommended. Due to a lack of insurance, he could not be treated at any dermatology clinic. Coincidentally, 2 weeks later, he developed cellulitis of his lower extremity and was admitted to the local safety-net hospital through the emergency department. By coordinating with his primary inpatient team, MSM was able to include a biopsy of the lesion as part of his hospital stay. The results demonstrated melanoma in situ. The vital course of action was to ensure treatment before metastasis. After registration for insurance and follow-up with a surgical oncology team, he is weeks away from excision and reconstruction surgery. His unsheltered status made follow-up difficult, but MSM bridged the gap from the street to the clinical setting by incorporating teledermatology into patient evaluations and leveraging connections with community shareholders such as charitable clinics and volunteer physicians. This case also represents the barriers to care for cancer-based dermatologic outreach among people experiencing homelessness.

The Potential Cutaneous Effects of Pornography Addiction: A Narrative Review.

Pornography addiction is an area of increasing concern, particularly due to the ubiquitous nature of pornographic material on the Internet. Even so, there is no formal Diagnostic and Statistical Manual of Mental Disorders (DSM-5) inclusion of compulsive pornography use as a behavioral addiction. Although the psychosocial impacts of pornography addiction have been studied, the risk of direct skin injuries and behavioral changes brought about by excessive pornography usage remain to be seen. Adult males constitute the majority of cases of engaging in risky and violent sexual behaviors with an unclear association with pornography consumption. Adult females may be likely to copy pubic hair trimming patterns analogous to those seen in pornographic content, even though attitudes towards labiaplasty are unclear. Finally, adolescents regularly exposed to pornography have been found to replicate sexual activity seen in pornographic material and have earlier sexual activity. In the literature evaluated, an association between pornographic material and direct cutaneous disease remains a major area of further research.

A translatable, closed recirculation system for AAV6 vector-mediated myocardial gene delivery in the large animal.

Current strategies for managing congestive heart failure are limited, validating the search for an alternative treatment modality. Gene therapy holds tremendous promise as both a practical and translatable technology platform. Its effectiveness is evidenced by the improvements in cardiac function observed in vector-mediated therapeutic transgene delivery to the murine myocardium. A large animal model validating these results is the likely segue into clinical application. However, controversy still exists regarding a suitable method of vector-mediated cardiac gene delivery that provides for efficient, global gene transfer to the large animal myocardium that is also clinically translatable and practical. Intramyocardial injection and catheter-based coronary delivery techniques are attractive alternatives with respect to their clinical applicability; yet, they are fraught with numerous challenges, including concerns regarding collateral gene expression in other organs, low efficiency of vector delivery to the myocardium, inhomogeneous expression, and untoward immune response secondary to gene delivery. Cardiopulmonary bypass (CPB) delivery with dual systemic and isolated cardiac circuitry precludes these drawbacks and has the added advantage of allowing for control of the pharmacological milieu, multiple pass recirculation through the coronary circulation, the selective addition of endothelial permeabilizing agents, and an increase in vector residence time. Collectively, these mechanics significantly improve the efficiency of global, vector-mediated cardiac gene delivery to the large animal myocardium, highlighting a potential therapeutic strategy to be extended to some heart failure patients.