Assessing the coverage and timeliness of coronavirus vaccination among people experiencing homelessness in Wales, UK: a population-level data-linkage study.

BACKGROUND: People experiencing homelessness have elevated morbidity, increasing their risk of COVID-19 related complications and mortality. Achieving high vaccination coverage in a timely manner among homeless populations was therefore important during the mass vaccination programme in Wales to limit adverse outcomes. However, no systematic monitoring of vaccinations among people experiencing homelessness in Wales has been undertaken. METHODS: Retrospective cohort analysis was conducted using de-identified administrative data. Study cohort members were adults (≥ 18 years old) living in Wales on the 2 December 2020 and who had recently experienced homelessness, defined as experiencing homelessness between 1 July 2020 and 2 December 2020. The outcome of interest was first coronavirus vaccine dose. Follow-up started on 2 December 2020, and ended if the participant died, had a break in address history > 30 days, reached the end of follow up (30 November 2021), or had the outcome of interest. Median-time-to-vaccination was used as a crude measure of 'timeliness' of vaccine uptake. To account for competing risk of death prior to vaccination, vaccine coverage was described using cumulative incidence at 350-days, and at 50-day increments over follow-up (2 December 2020 to 17 November 2021). As a benchmark, all time-to-event measures were generated for the adult population in Wales with similar baseline individual and residential characteristics as the study cohort. RESULTS: 1,595 people with recent experiences of homelessness were identified and included in analysis. The study cohort were disproportionately male (68.8%) and concentrated in the most deprived areas in Wales. Median time-to-vaccination for the study cohort was 196 days (95% CI.: 184-209 days), compared to 141 days (95% CI.: 141-141 days) among the matched adult population in Wales. Cumulative incidence of vaccination after 350-days of follow-up was 60.4% (95% CI.: 57.8-62.8%) among the study cohort, compared to 81.4% (95% CI.: 81.3-81.5%) among the matched adult population. Visual analysis of cumulative incidence over time suggests that vaccine inequality, i.e., difference between study cohort and matched adult population, peaked after 200-days of follow-up, and declined slightly until last follow-up at 350-days. CONCLUSIONS: Despite being prioritised for vaccination, people experiencing homelessness in Wales appear to have been under-engaged, leading to lower vaccination coverage and greater time unvaccinated, potentially increasing their risk of COVID-19 complications and mortality.

Moving on trial: protocol for a pilot randomised controlled trial of models of housing and support to reduce risks of COVID-19 infection and homelessness.

BACKGROUND: It is estimated that around 160,000 households in Britain experience homelessness each year, although no definitive statistics exist. Between March and September 2020, as part of the initial 'Everyone In' government response to COVID-19 in England, 10,566 people were living in emergency accommodation and nearly 18,911 people had been moved into settled accommodation. However, some forms of temporary accommodation may not be suitable as shared facilities make it impossible for people to adhere to government guidelines to reduce the spread of COVID-19. METHODS: This is parallel group, pilot randomised controlled trial. The target is to recruit three local authorities, each of which will recruit 50 participants (thus a total of approximately 150 participants). Individuals are eligible if they are aged 18 and over, in a single-person homeless household, temporarily accommodated by the LA with recourse to public funds. Participants will be randomised to receive settled accommodation (intervention group) or temporary accommodation (control group). The intervention group includes settled housing such as Private Rented Sector (low and medium support), Social Housing (low and medium support), and Housing First (High support). The control group will maintain treatment as usual. The follow-up period will last 6 months. The primary outcome is to assess the feasibility of recruitment, retention, and acceptability of trial processes against progression criteria laid out in a traffic light system (green: all criteria are met, the trial should progress as designed in this pilot; amber: the majority of criteria are met and with adaptations to methods all criteria could be met; red: the minority of criteria are met and the pilot RCT should not proceed). Secondary outcomes include assessment of completeness of data collection at 3 and 6 months and percentage of participants consenting to data linkage, as well as a process evaluation and economic evaluation. DISCUSSION: This trial will address feasibility questions associated with progression to a fully powered effectiveness trial of models of housing to reduce risk of COVID-19 infection and homelessness. TRIAL REGISTRATION: ISRCTN69564614 . Registered on December 16, 2020.

Accommodation-based interventions for individuals experiencing, or at risk of experiencing, homelessness.

Background: Globally, almost 1.6 billion individuals lack adequate housing. Many accommodation-based approaches have evolved across the globe to incorporate additional support and services beyond delivery of housing. Objectives: This review examines the effectiveness of accommodation-based approaches on outcomes including housing stability, health, employment, crime, wellbeing, and cost for individuals experiencing or at risk of experiencing homelessness. Search Methods: The systematic review is based on evidence already identified in two existing EGMs commissioned by the Centre for Homelessness Impact (CHI) and built by White et al. The maps were constructed using a comprehensive three stage search and mapping process. Stage one mapped included studies in an existing systematic review on homelessness, stage two was an extensive search of 17 academic databases, three EGM databases, and eight systematic review databases. Finally stage three included web searches for grey literature, scanning reference lists of included studies and consultation with experts to identify additional literature. We identified 223 unique studies across 551 articles from the effectiveness map on 12th April 2019. Selection Criteria: We include research on all individuals currently experiencing, or at risk of experiencing homelessness irrespective of age or gender, in high-income countries. The Network Meta-Analysis (NMA) contains all study designs where a comparison group was used. This includes randomised controlled trials (RCTs), quasi-experimental designs, matched comparisons and other study designs that attempt to isolate the impact of the intervention on homelessness. The NMA primarily addresses how interventions can reduce homelessness and increase housing stability for those individuals experiencing, or at risk of experiencing, homelessness. Additional outcomes are examined and narratively described. These include: access to mainstream healthcare; crime and justice; employment and income; capabilities and wellbeing; and cost of intervention. These outcomes reflect the domains used in the EGM, with the addition of cost. Data Collection and Analysis: Due to the diverse nature of the literature on accommodation-based approaches, the way in which the approaches are implemented in practice, and the disordered descriptions of the categories, the review team created a novel typology to allow meaningful categorisations for functional and useful comparison between the various intervention types. Once these eligible categories were identified, we undertook dual data extraction, where two authors completed data extraction and risk of bias (ROB) assessments independently for each study. NMA was conducted across outcomes related to housing stability and health.Qualitative data from process evaluations is included using a "Best Fit" Framework synthesis. The purpose of this synthesis is to complement the quantitative evidence and provide a better understanding of what factors influenced programme effectiveness. All included Qualitative data followed the initial framework provided by the five main analytical categories of factors of influence (reflected in the EGM), namely: contextual factors, policy makers/funders, programme administrators/managers/implementing agencies, staff/case workers and recipients of the programme. Main Results: There was a total of 13,128 people included in the review, across 51 reports of 28 studies. Most of the included studies were carried out in the United States of America (25/28), with other locations including Canada and the UK. Sixteen studies were RCTs (57%) and 12 were nonrandomised (quasi-experimental) designs (43%). Assessment of methodological quality and potential for bias was conducted using the second version of the Cochrane Risk of Bias tool for Randomised controlled trials. Nonrandomised studies were coded using the ROBINS- I tool. Out of the 28 studies, three had sufficiently low ROB (11%), 11 (39%) had moderate ROB, and five (18%) presented serious problems with ROB, and nine (32%) demonstrated high, critical problems with their methodology. A NMA on housing stability outcomes demonstrates that interventions offering the highest levels of support alongside unconditional accommodation (High/Unconditional) were more effective in improving housing stability compared to basic support alongside unconditional housing (Basic/Unconditional) (ES=1.10, 95% confidence interval [CI] [0.39, 1.82]), and in comparison to a no-intervention control group (ES=0.62, 95% CI [0.19, 1.06]). A second NMA on health outcomes demonstrates that interventions categorised as offering Moderate/Conditional (ES= 0.36, 95% CI [0.03, 0.69]) and High/Unconditional (ES = 0.22, 95% CI [0.01, 0.43]) support were effective in improving health outcomes compared to no intervention. These effects were smaller than those observed for housing stability. The quality of the evidence was relatively low but varied across the 28 included studies. Depending on the context, finding accommodation for those who need it can be hindered by supply and affordability in the market. The social welfare approach in each jurisdiction can impact heavily on support available and can influence some of the prejudice and stigma surrounding homelessness. The evaluations emphasised the need for collaboration and a shared commitment between policymakers, funders and practitioners which creates community and buy in across sectors and agencies. However, co-ordinating this is difficult and requires sustainability to work. For those implementing programmes, it was important to invest time in developing a culture together to build trust and solid relationships. Additionally, identifying sufficient resources and appropriate referral routes allows for better implementation planning. Involving staff and case workers in creating processes helps drive enthusiasm and energy for the service. Time should be allocated for staff to develop key skills and communicate engage effectively with service users. Finally, staff need time to develop trust and relationships with service users; this goes hand in hand with providing information that is up to date and useful as well making themselves accessible in terms of location and time. Authors' Conclusions: The network meta-analysis suggests that all types of accommodation which provided support are more effective than no intervention or Basic/Unconditional accommodation in terms of housing stability and health. The qualitative evidence synthesis raised a primary issue in relation to context: which was the lack of stable, affordable accommodation and the variability in the rental market, such that actually sourcing accommodation to provide for individuals who are homeless is extremely challenging. Collaboration between stakeholders and practitioners can be fruitful but difficult to coordinate across different agencies and organisations.

A population level study of SARS-CoV-2 prevalence amongst people experiencing homelessness in Wales, UK.

Introduction: Prior research into the prevalence of SARS-CoV-2 infection amongst people experiencing homelessness (PEH) largely relates to people in communal forms of temporary accommodation in contexts where this type of accommodation remained a major part of the response to homelessness during the COVID-19 pandemic. Little is known about the prevalence of SARS-CoV-2 amongst PEH more broadly, and in a policy and practice context that favoured self-contained accommodation, such as Wales, UK. Objective: Describe the prevalence of SARS-CoV-2 amongst PEH in Wales, UK, using routinely collected administrative data from the Secure Anonymised Information Linkage Databank. Methods: Routinely collected data were used to identify PEH in Wales between 1st March 2020 and 1st March 2021. Using SARS-CoV-2 pathology testing data, prevalence rates were generated for PEH and three comparator groups: (1) the not-homeless population; (2) a cohort 'exact matched' for age, sex, local authority and area deprivation; and (3) a matched comparison group created using these same variables and Propensity Score Matching (PSM). Three logistic regressions were run on samples containing each of the comparator groups to explore the effect of experiencing homelessness on testing positive for SARS-CoV-2. Results: The prevalence of SARS-CoV-2 infection amongst PEH was 5.0%, compared to the not-homeless population at 5.6%. For the exact matched and PSM match comparator groups, prevalence was 6.9% and 6.7%, respectively. Logistic regression found that SARS-CoV-2 infection was 0.9 times less likely amongst PEH compared to people not experiencing homelessness from the general population. The odds of SARS-CoV-2 infection for PEH was 0.75 and 0.73 where the 'not-homeless' comparators were from the exact match and PSM samples, respectively. Conclusion: Our analysis revealed that a year into the COVID-19 pandemic, the prevalence of SARS-CoV-2 amongst PEH in Wales was lower than the general population. A policy response to homelessness that moved away from communal accommodation may be partly responsible for the reduced SAR-CoV-2 infection amongst PEH.

Osteosarcoma in a Child Below 2 Years of Age: Case Report and Review of the Literature.

BACKGROUND: Osteosarcoma in children below the age of 5 is extremely rare. OBSERVATION: We report on a previously well 14-month-old male infant, who presented with a reluctance to weight-bear on his right leg and had an associated limp. Plain imaging and a magnetic resonance imaging scan demonstrated a lytic lesion in the right distal femur. An open surgical biopsy confirmed the diagnosis of osteosarcoma. There was no significant family history of cancer and genetic screening for Li-Fraumeni syndrome was negative. CONCLUSIONS: This case highlights the importance of timely consideration of osteosarcoma in an infant, when the clinical presentation and medical imaging are consistent with that diagnosis.

High dose methylprednisolone can induce remissions in CLL patients with p53 abnormalities.

Abnormalities of the p53 gene are known to confer detrimental effects in chronic lymphocytic leukaemia (CLL) and are associated with short survival. We have used high dose methylprednisolone (HDMP) to treat 25 patients with advanced refractory CLL of whom 45% had p53 abnormalities shown by one or more methods: flow cytometry, fluorescent in situ hybridisation and direct DNA sequencing. Fifteen were resistant to fludarabine and 16 were non-responders to their most recent therapy. Methylprednisolone had a cytotoxic effect on lymphocytes from 95% of cases assessed by an ex vivo apoptotic drug sensitivity index (DSI). HDMP was given alone or in combination with other drugs: vincristine, CCNU, Ara-C, doxorubicin, mitoxantrone and chlorambucil, according to the results of DSI. Three patients were treated twice and each treatment was analysed separately. The overall response rate was 77% with a median duration of 12 months (range 7 -23+). Responders included 5/10 with abnormal p53, of which two achieved nodular PR. Patients with p53 abnormalities fared worse than those with normal p53. There were no differences in response according to whether HDMP was used alone or in combination. Nine of the 22 evaluable patients (3 NR and 6 PR) have died from progressive disease or transformation. Main toxicity was infection in 7/25 patients. Event free and overall survival were significantly better in responders vs non-responders ( P>0.0001 and P=0.04 respectively). Patients with a DSI of 100% to steroids had a better overall and event free survival, but this was not statistically significant. This study demonstrates that HDMP alone or in combination with other agents is a useful treatment strategy in refractory CLL including patients with p53 abnormalities.

In and out of nursing.

When I was asked to write about my reasons for choosing nursing as a career, and why I subsequently left the profession after only eight months of training, I don't think I had fully resolved the issue in my own mind. But preparing to write this piece has proved cathartic.