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1.
PLoS One ; 16(1): e0244819, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33444363

RESUMEN

BACKGROUND: The U.S. has experienced an unprecedented number of orders to shelter in place throughout the ongoing COVID-19 pandemic. We aimed to ascertain whether social distancing; difficulty with daily activities; and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of the nation's first shelter-in-place orders (SIPO) among individuals living in the seven affected counties in the San Francisco Bay Area. METHODS: We conducted an online, cross-sectional social media survey from March 14 -April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area versus elsewhere in the U.S. RESULTS: In this non-representative sample, the percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty obtaining hand sanitizer, medications, and in particular respondents reported increased difficulty obtaining food in the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the announcement. CONCLUSION: This study characterizes early changes in attitudes, behaviors, and difficulties. As states and localities implement, rollback, and reinstate shelter-in-place orders, ongoing efforts to more fully examine the social, economic, and health impacts of COVID-19, especially among vulnerable populations, are urgently needed.


Asunto(s)
Actividades Cotidianas/psicología , Aislamiento de Pacientes/psicología , Medios de Comunicación Sociales/estadística & datos numéricos , Adulto , /prevención & control , Estudios Transversales , Transmisión de Enfermedad Infecciosa/prevención & control , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Aislamiento de Pacientes/tendencias , San Francisco/epidemiología , Estados Unidos/epidemiología
2.
J Acquir Immune Defic Syndr ; 86(1): 19-21, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33044323

RESUMEN

INTRODUCTION: Studies to examine whether HIV predisposes to a higher incidence of COVID-19 or more severe disease are accumulating. Initial studies from New York City suggested more severe disease among people living with HIV (PLWH), but this was during a time when hospitals were over-capacity and health systems stretched. This report presents the incidence and outcomes among PLWH with COVID-19 in San Francisco over the first 6 months of the pandemic. METHODS: Community transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was first reported in San Francisco on March 5, 2020. This report examines the match of the San Francisco Department of Public Health COVID-19 testing database and the San Francisco Department of Public Health HIV Surveillance case registry from March 24, 2020, to September 3, 2020. RESULTS: Among 4252 COVID-19 tests performed among PLWH, 4.5% (N = 193) were positive for COVID-19, compared with a 3.5% (N = 9626) positivity rate among the 272,555 people without HIV tested for COVID-19 (P < 0.001). The mean age of those infected with HIV/COVID-19 was 48 years (20-76), 38.9% White, 38.3% Latinx, 11.9% Black, and 91.2% were men. Only 54.6% of coinfected PLWH were housed, with the remainder marginally housed. The rate of severe illness with COVID-19 was not increased among PLWH. DISCUSSION: In San Francisco, susceptibility to COVID-19 was increased among PLWH over the first 6 months of the pandemic, although clinical outcomes were similar to those without HIV. Homelessness and higher rates of congregate living situations among PLWH likely accounted for this disparity. Special efforts to house patients with marginal housing during the COVID-19 pandemic are needed.


Asunto(s)
/epidemiología , Susceptibilidad a Enfermedades/virología , Infecciones por VIH/epidemiología , Adolescente , Adulto , Anciano , Coinfección/epidemiología , Coinfección/virología , Femenino , Personas sin Hogar , Vivienda , Humanos , Incidencia , Masculino , Persona de Mediana Edad , San Francisco/epidemiología , Adulto Joven
3.
Nat Commun ; 11(1): 4698, 2020 09 17.
Artículo en Inglés | MEDLINE | ID: mdl-32943630

RESUMEN

Given the limited availability of serological testing to date, the seroprevalence of SARS-CoV-2-specific antibodies in different populations has remained unclear. Here, we report very low SARS-CoV-2 seroprevalence in two San Francisco Bay Area populations. Seroreactivity was 0.26% in 387 hospitalized patients admitted for non-respiratory indications and 0.1% in 1,000 blood donors in early April 2020. We additionally describe the longitudinal dynamics of immunoglobulin-G (IgG), immunoglobulin-M (IgM), and in vitro neutralizing antibody titers in COVID-19 patients. The median time to seroconversion ranged from 10.3-11.0 days for these 3 assays. Neutralizing antibodies rose in tandem with immunoglobulin titers following symptom onset, and positive percent agreement between detection of IgG and neutralizing titers was >93%. These findings emphasize the importance of using highly accurate tests for surveillance studies in low-prevalence populations, and provide evidence that seroreactivity using SARS-CoV-2 anti-nucleocapsid protein IgG and anti-spike IgM assays are generally predictive of in vitro neutralizing capacity.


Asunto(s)
Anticuerpos Neutralizantes/sangre , Betacoronavirus/inmunología , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Anticuerpos Antivirales/inmunología , Técnicas de Laboratorio Clínico , Infecciones por Coronavirus/sangre , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/inmunología , Humanos , Inmunoglobulina G/inmunología , Inmunoglobulina M/inmunología , Pandemias , Neumonía Viral/sangre , Neumonía Viral/inmunología , San Francisco/epidemiología , Sensibilidad y Especificidad , Estudios Seroepidemiológicos , Pruebas Serológicas/métodos
4.
PLoS One ; 15(8): e0237241, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32764800

RESUMEN

BACKGROUND: Despite being one of the wealthiest nations, disparities in adverse birth outcomes persist across racial and ethnic lines in the United States. We studied the association between historical redlining and preterm birth, low birth weight (LBW), small-for-gestational age (SGA), and perinatal mortality over a ten-year period (2006-2015) in Los Angeles, Oakland, and San Francisco, California. METHODS: We used birth outcomes data from the California Office of Statewide Health Planning and Development between January 1, 2006 and December 31, 2015. Home Owners' Loan Corporation (HOLC) Security Maps developed in the 1930s assigned neighborhoods one of four grades that pertained to perceived investment risk of borrowers from that neighborhood: green (grade A) were considered "Best", blue (grade B) "Still Desirable", yellow (grade C) "Definitely Declining", and red (grade D, hence the term "redlining") "Hazardous". Geocoded residential addresses at the time of birth were superimposed on HOLC Security Maps to assign each birth a HOLC grade. We adjusted for potential confounders present at the time of Security Map creation by assigning HOLC polygons areal-weighted 1940s Census measures. We then employed propensity score matching methods to estimate the association of historical HOLC grades on current birth outcomes. Because tracts graded A had almost no propensity of receiving grade C or D and because grade B tracts had low propensity of receiving grade D, we examined birth outcomes in the three following comparisons: B vs. A, C vs. B, and D vs. C. RESULTS: The prevalence of preterm birth, SGA and mortality tended to be higher in worse HOLC grades, while the prevalence of LBW varied across grades. Overall odds of mortality and preterm birth increased as HOLC grade worsened. Propensity score matching balanced 1940s census measures across contrasting groups. Logistic regression models revealed significantly elevated odds of preterm birth (odds ratio (OR): 1.02, 95% confidence interval (CI): 1.00-1.05), and SGA (OR: 1.03, 95% CI: 1.00-1.05) in the C vs. B comparison and significantly reduced odds of preterm birth (OR: 0.93, 95% CI: 0.91-0.95), LBW (OR: 0.94-95% CI: 0.92-0.97), and SGA (OR: 0.94, 95% CI: 0.92-0.96) in the D vs. C comparison. Results differed by metropolitan area and maternal race. CONCLUSION: Similar to prior studies on redlining, we found that worsening HOLC grade was associated with adverse birth outcomes, although this relationship was less clear after propensity score matching and stratifying by metropolitan area. Higher odds of preterm birth and SGA in grade C versus grade B neighborhoods may be caused by higher-stress environments, racial segregation, and lack of access to resources, while lower odds of preterm birth, SGA, and LBW in grade D versus grade C neighborhoods may due to population shifts in those neighborhoods related to gentrification.


Asunto(s)
Resultado del Embarazo , Nacimiento Prematuro/epidemiología , Adulto , Femenino , Humanos , Recién Nacido de Bajo Peso , Recién Nacido Pequeño para la Edad Gestacional , Los Angeles/epidemiología , Masculino , Embarazo , Puntaje de Propensión , Características de la Residencia , Estudios Retrospectivos , San Francisco/epidemiología , Segregación Social , Factores Socioeconómicos , Adulto Joven
8.
Environ Health ; 19(1): 61, 2020 06 03.
Artículo en Inglés | MEDLINE | ID: mdl-32493340

RESUMEN

BACKGROUND: Polybrominated diphenyl ether (PBDE) exposures have been associated with adverse pregnancy outcomes. A hypothesized mechanism is via alterations in placental development and function. However, we lack biomarkers that can be used as early indicators of maternal/fetal response to PBDE exposures and/or perturbations in placental development or function. METHODS: To evaluate the relationship between PBDE levels and placental biomarkers during mid-gestation of human pregnancy (n = 62), we immunolocalized three molecules that play key roles in cytotrophoblast (CTB) differentiation and interstitial/endovascular uterine invasion-integrin alpha-1 (ITGA1), vascular endothelial-cadherin (CDH5), and metalloproteinase-1 (MMP1)-and assessed three morphological parameters as potential indicators of pathological alterations using H&E-stained tissues-leukocyte infiltration, fibrinoid deposition, and CTB endovascular invasion. We evaluated associations between placental PBDE levels and of biomarkers of placental development and disease using censored Kendall's tau correlation and linear regression methods. RESULTS: PBDEs were detected in all placental samples. We observed substantial variation in antigen expression and morphological endpoints across placental regions. We observed an association between PBDE concentrations and immunoreactivity of endovascular CTB staining with anti-ITGA1 (inverse) or interstitial CTBs staining with anti-CDH5 (positive). CONCLUSIONS: We found several molecular markers that may be sensitive placental indicators of PBDE exposure. Further, this indicates that placental biomarkers of development and disease could be useful barometers of exposure to PBDEs, a paradigm that could be extended to other environmental chemicals and placental stage-specific antigens.


Asunto(s)
Biomarcadores/metabolismo , Éteres Difenilos Halogenados/efectos adversos , Exposición Materna/efectos adversos , Placenta/química , Placentación/efectos de los fármacos , Complicaciones del Embarazo/epidemiología , Resultado del Embarazo/epidemiología , Adulto , Biomarcadores/sangre , Femenino , Feto/química , Humanos , Hígado/química , Embarazo , Complicaciones del Embarazo/inducido químicamente , San Francisco/epidemiología , Adulto Joven
9.
PLoS One ; 15(6): e0233904, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32479509

RESUMEN

Racial and ethnic minorities are at higher risk for a variety of diseases. While sociodemographic and lifestyle factors contribute to racial/ethnic health disparities, the biological processes underlying these associations remain poorly understood. Stress and its biological consequences through the glucocorticoid receptor (GR) have been hypothesized to mediate adverse disease outcomes. In fasting morning samples of 503 control women from the San Francisco Bay Area Breast Cancer Study, we used a sensitive Chemical-Activated LUciferase gene eXpression (CALUX) assay to examine the association of sociodemographic and lifestyle factors with plasma glucocorticogenic (G) activity in three racial/ethnic groups. The G activity is a sensitive measure that reflects biological activity of total plasma glucocorticoids including cortisol and glucocorticoid-like compounds. Associations between G activity and sociodemographic and lifestyle factors were examined using multivariable linear regression models. Latina and non-Latina Black (NLB) women had 9% (P = 0.053) and 14% (P = 0.008) lower morning G activity than non-Latina White (NLW) women, respectively. Additionally, we replicated a previously reported association between G activity and alcohol intake (women who drank >10gms had 19% higher G activity than non-drinkers, P = 0.004) in Latina and NLB women. Further research should assess the association between G activity and health outcomes in a prospective cohort so as to characterize the relationship between total plasma G activity in pre-disease state and disease outcomes across different racial/ethnic populations.


Asunto(s)
Consumo de Bebidas Alcohólicas/epidemiología , Disparidades en el Estado de Salud , Estilo de Vida/etnología , Receptores de Glucocorticoides/sangre , Salud de la Mujer/estadística & datos numéricos , Afroamericanos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Hispanoamericanos/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Grupos Minoritarios/estadística & datos numéricos , Estudios Prospectivos , San Francisco/epidemiología , Factores Socioeconómicos , Encuestas y Cuestionarios/estadística & datos numéricos
10.
Acad Med ; 95(7): 1057-1065, 2020 07.
Artículo en Inglés | MEDLINE | ID: mdl-32576764

RESUMEN

PURPOSE: Feedback is important for medical students' development. Recent conceptualizations of feedback as a dialogue between feedback provider and recipient point to longitudinal relationships as a facilitator of effective feedback discussions. This study illuminates how medical students experience feedback within a longitudinal relationship with a physician coach. METHOD: In this qualitative study, second-year medical students from the University of California, San Francisco, School of Medicine participated in semistructured interviews that explored their experiences discussing feedback within longitudinal, nonevaluative coaching relationships. Interviews occurred between May and October 2018. Interview questions addressed students' experiences receiving feedback from their coach, how and when they used this feedback, and how their relationship with their coach influenced engagement in feedback discussions. Interviews were analyzed using constructivist grounded theory. RESULTS: Seventeen students participated. The authors identified 3 major themes. First, students' development of a feedback mindset: Over time, students came to view feedback as an invaluable component of their training. Second, setting the stage for feedback: Establishing feedback routines and a low-stakes environment for developing clinical skills were important facilitators of effective feedback discussions. Third, interpreting and acting upon feedback: Students described identifying, receiving, and implementing tailored and individualized feedback in an iterative fashion. As students gained comfort and trust in their coaches' feedback, they reported increasingly engaging in feedback conversations for learning. CONCLUSIONS: Through recurring feedback opportunities and iterative feedback discussions with coaches, students came to view feedback as essential for growth and learning. Longitudinal coaching relationships can positively influence how students conceptualize and engage in feedback discussions.


Asunto(s)
Retroalimentación , Aprendizaje/fisiología , Tutoría/métodos , Aprendizaje Basado en Problemas/estadística & datos numéricos , Estudiantes de Medicina/psicología , Adulto , Competencia Clínica/estadística & datos numéricos , Comunicación , Educación de Pregrado en Medicina/métodos , Femenino , Humanos , Entrevistas como Asunto , Masculino , Tutoría/estadística & datos numéricos , Investigación Cualitativa , San Francisco/epidemiología , Universidades/estadística & datos numéricos
11.
MMWR Morb Mortal Wkly Rep ; 69(17): 521-522, 2020 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-32352957

RESUMEN

In the United States, approximately 1.4 million persons access emergency shelter or transitional housing each year (1). These settings can pose risks for communicable disease spread. In late March and early April 2020, public health teams responded to clusters (two or more cases in the preceding 2 weeks) of coronavirus disease 2019 (COVID-19) in residents and staff members from five homeless shelters in Boston, Massachusetts (one shelter); San Francisco, California (one); and Seattle, Washington (three). The investigations were performed in coordination with academic partners, health care providers, and homeless service providers. Investigations included reverse transcription-polymerase chain reaction testing at commercial and public health laboratories for SARS-CoV-2, the virus that causes COVID-19, over approximately 1-2 weeks for residents and staff members at the five shelters. During the same period, the team in Seattle, Washington, also tested residents and staff members at 12 shelters where a single case in each had been identified. In Atlanta, Georgia, a team proactively tested residents and staff members at two shelters with no known COVID-19 cases in the preceding 2 weeks. In each city, the objective was to test all shelter residents and staff members at each assessed facility, irrespective of symptoms. Persons who tested positive were transported to hospitals or predesignated community isolation areas.


Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/epidemiología , Personas sin Hogar/estadística & datos numéricos , Vivienda/estadística & datos numéricos , Neumonía Viral/epidemiología , Boston/epidemiología , Ciudades , Georgia/epidemiología , Humanos , Pandemias , Prevalencia , San Francisco/epidemiología , Washingtón/epidemiología
12.
JAMA ; 323(19): 1978, 2020 05 19.
Artículo en Inglés | MEDLINE | ID: mdl-32427296
13.
BMC Infect Dis ; 20(1): 386, 2020 May 29.
Artículo en Inglés | MEDLINE | ID: mdl-32471376

RESUMEN

BACKGROUND: Hepatitis C virus (HCV) is highly prevalent among homeless persons, yet barriers continue to impede HCV testing and treatment in this population. We studied the experiences of homeless individuals related to accessing HCV care to inform the design of a shelter-based HCV prevention and treatment program. METHODS: Homeless shelter clients (10 women and 10 men) of a large shelter in San Francisco participated in gender segregated focus groups. Focus groups followed a semi-structured interview format, which assessed individual, program/system, and societal-level barriers and facilitators to universal HCV testing and linkage to HCV care. Focus group interviews were transcribed, coded, and analyzed using thematic analysis. RESULTS: We identified key barriers to HCV testing and treatment at the individual level (limited knowledge and misconceptions about HCV infection, mistrust of health care providers, co-morbid conditions of substance use, psychiatric and chronic medical conditions), system level (limited advocacy for HCV services by shelter staff), and social level (stigma of homelessness). Individual, system, and social facilitators to HCV care described by participants included internal motivation, financial incentives, prior experiences with rapid HCV testing, and availability of affordable direct acting antiviral (DAA) treatment, respectively. CONCLUSIONS: Interrelated individual- and social-level factors were the predominant barriers affecting homeless persons' decisions to engage in HCV prevention and treatment. Integrated models of care for homeless persons at risk for or living with HCV address many of these factors, and should include interventions to improve patient knowledge of HCV and the availability of effective treatments.


Asunto(s)
Implementación de Plan de Salud , Hepacivirus/inmunología , Hepatitis C/epidemiología , Hepatitis C/psicología , Personas sin Hogar , Adulto , Anciano , Antivirales/uso terapéutico , Femenino , Personal de Salud , Hepatitis C/complicaciones , Hepatitis C/prevención & control , Anticuerpos contra la Hepatitis C/sangre , Vivienda , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , San Francisco/epidemiología , Estigma Social , Trastornos Relacionados con Sustancias/complicaciones
14.
J Int AIDS Soc ; 23(4): e25472, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32294338

RESUMEN

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in-depth interviews with people who HIV seroconverted after using PrEP. METHODS: We identified individuals who initiated PrEP in an integrated safety-net public health system and performed in-depth chart review to determine person-time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention's Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in-depth interviews with those who seroconverted. RESULTS: Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person-years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5-fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on-demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP's benefit versus self-perceived risk; and entering a primary partnership. The individual who developed HIV using on-demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. CONCLUSIONS: HIV incidence during gaps in PrEP use was nearly eight-fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non-daily PrEP may require additional education and support in the United States.


Asunto(s)
Infecciones por VIH/prevención & control , Profilaxis Pre-Exposición , Adulto , Anciano , Fármacos Anti-VIH/uso terapéutico , Estudios de Cohortes , Femenino , Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , Homosexualidad Masculina , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Profilaxis Pre-Exposición/métodos , San Francisco/epidemiología , Trastornos Relacionados con Sustancias , Estados Unidos , Adulto Joven
15.
PLoS One ; 15(3): e0230408, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32210442

RESUMEN

BACKGROUND: Opioid overdose mortality continues to increase in the United States despite significant investments to reverse the epidemic. The national response to-date has focused primarily on reducing opioid prescribing, yet reductions in prescribing have been associated with patients reporting uncontrolled pain, psychological distress, and transition to illicit substances. The aim of this study is to qualitatively explore chronic pain management experiences among PLWH with a history of illicit substance use after long-term opioid therapy reductions or discontinuations. METHODS: We analyzed 18 interviews, stopping upon reaching thematic saturation, with HIV-positive participants with a history of substance use who were enrolled in a longitudinal cohort study to assess the impact of prescribing changes among patients with chronic pain. Participants in this nested qualitative study had been reduced/discontinued from opioid pain relievers (OPRs) within the 12 months prior to interview. Interviews were audio-recorded and transcribed verbatim. Two analysts coded all interviews, interrater reliability was measured, and coding discrepancies discussed. The study took place in San Francisco, California in 2018. RESULTS: Eleven participants were male with a mean age of 55; 8 were African American and 8 were White. All participants were HIV-positive, actively engaged in primary care, and had a lifetime history of illicit substance use. Twelve reported using illicit substances within the past year, including non-prescription opioids/heroin (10), and stimulant use (10). After being reduced/discontinued from their long-term opioid therapy, patients reported developing complex multimodal pain management systems that often included both nonpharmacological approaches and illicit substance use. Participants encountered a range of barriers to nonpharmacological therapies including issues related to accessibility and availability. Participants often reported attempts to replicate their prior OPR prescription by seeking out the same medication and dose from illicit sources and reported transitioning to heroin after exhausting other options. CONCLUSION: After being reduced/discontinued from OPRs, HIV-positive patients with a history of substance use reported experimenting with a range of pain management modalities including nonpharmacological therapies and illicit substance use to manage symptoms of opioid withdrawal and pain. Providers should consider that any change to a patients' long-term opioid therapy may result in experimentation with pain management outside of the medical setting and may want to employ patient-centered, holistic approaches when managing patients' opioid prescriptions and chronic pain.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Dolor/tratamiento farmacológico , Acupuntura , Analgésicos Opioides/efectos adversos , Prescripciones de Medicamentos , Femenino , Infecciones por VIH/patología , Infecciones por VIH/virología , Heroína/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Trastornos Relacionados con Opioides/patología , Trastornos Relacionados con Opioides/virología , Dolor/patología , Dolor/virología , Manejo del Dolor , San Francisco/epidemiología , Personas Transgénero
17.
Acad Med ; 95(7): 1038-1042, 2020 07.
Artículo en Inglés | MEDLINE | ID: mdl-32101932

RESUMEN

PROBLEM: Improving well-being in residency requires solutions that focus on organizational factors and the individual needs of residents, yet there are few examples of successful strategies to address this challenge. Design thinking (DT), or human-centered design, is an approach to problem-solving that focuses on understanding emotions and human dynamics and may be ideally suited to tackling well-being as a complex problem. The authors taught residents to use DT techniques to identify, analyze, and address organizational well-being challenges. APPROACH: Internal medicine residents at the University of California, San Francisco completed an 8-month DT program in 2016-2017. The program consisted of four 2-hour workshops with small group project work between sessions. In each session, resident teams shared their progress and analyzed emerging themes to solve well-being problems. At the conclusion of the program, they summarized the final design principles and recommendations that emerged from their work and were interviewed about DT as a strategy for developing well-being interventions for residents. OUTCOMES: Eighteen residents worked in teams to design solutions to improve: community and connection, space for reflection, peer support, and availability of individualized wellness. The resulting recommendations led to new interventions to improve well-being through near-peer communities. Residents emphasized how DT enhanced their creative thinking and trust in the residency program. They reported that not having enough time to work on projects between sessions and losing momentum during their clinical rotations were their biggest challenges. NEXT STEPS: Residents found DT useful for completing needs assessments, piloting interventions, and outlining essential design principles to improve well-being in residency. DT's focus on human values may be particularly suited to developing well-being interventions to enhance institutional community and culture. One outcome-that DT promoted creativity and trust for participants-may have applications in other spheres of medical education.


Asunto(s)
Educación de Postgrado en Medicina/métodos , Medicina Interna/educación , Solución de Problemas/fisiología , Pensamiento/fisiología , Educación Médica/métodos , Emociones/fisiología , Humanos , Internado y Residencia , Evaluación de Programas y Proyectos de Salud , San Francisco/epidemiología , Universidades
18.
Cardiology ; 145(2): 63-70, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31910405

RESUMEN

BACKGROUND: Serial increases in high-sensitivity cardiac troponin (hs-cTnT) have been associated with death in community-dwelling adults, but the association remains uninvestigated in those with coronary artery disease (CAD). METHODS: We measured hs-cTnT at baseline and after 5 years in 635 ambulatory Heart and Soul Study patients with CAD. We also performed echocardiography at rest and after treadmill exercise at baseline and after 5 years. Participants were subsequently followed for the outcome of death. We used a multivariable-adjusted Cox proportional hazards model to evaluate the association between 5-year change in hs-cTnT and subsequent all-cause mortality. RESULTS: Of the 635 subjects, there were 386 participants (61%) who had an increase in hs-cTnT levels between baseline and year 5 measurements (median increase 5.6 pg/mL, IQR 3.2-9.9 pg/mL). There were 182 deaths after a mean 4.2-year follow-up after the year 5 visit. After adjusting for clinical variables, a >50% increase in hs-cTnT between baseline and year 5 was associated with a nearly 2-fold increased risk of death from any cause (hazard ratio 1.7, 95% confidence interval 1.1-2.7). When addition of year 5 hs-cTnT was compared to a model including clinical variables and baseline hs-cTnT, there was a modest but statistically significant increase in C-statistic from 0.82 to 0.83 (p = 0.04). CONCLUSION: In ambulatory patients with CAD, serial increases in hs-cTnT over time are associated with an increased risk of death.


Asunto(s)
Enfermedad de la Arteria Coronaria/mortalidad , Troponina T/sangre , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Causas de Muerte , Enfermedad de la Arteria Coronaria/metabolismo , Ecocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Factores de Riesgo , San Francisco/epidemiología
19.
Occup Environ Med ; 77(2): 84-93, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31896615

RESUMEN

OBJECTIVES: To update the mortality experience of a previously studied cohort of 29 992 US urban career firefighters compared with the US general population and examine exposure-response relationships within the cohort. METHODS: Vital status was updated through 2016 adding 7 years of follow-up. Cohort mortality compared with the US population was evaluated via life table analyses. Full risk-sets, matched on attained age, race, birthdate and fire department were created and analysed using the Cox proportional hazards regression to examine exposure-response associations between select mortality outcomes and exposure surrogates (exposed-days, fire-runs and fire-hours). Models were adjusted for a potential bias from healthy worker survivor effects by including a categorical variable for employment duration. RESULTS: Compared with the US population, mortality from all cancers, mesothelioma, non-Hodgkin's lymphoma (NHL) and cancers of the oesophagus, intestine, rectum, lung and kidney were modestly elevated. Positive exposure-response relationships were observed for deaths from lung cancer, leukaemia and chronic obstructive pulmonary disease (COPD). CONCLUSIONS: This update confirms previous findings of excess mortality from all cancers and several site-specific cancers as well as positive exposure-response relations for lung cancer and leukaemia. New findings include excess NHL mortality compared with the general population and a positive exposure-response relationship for COPD. However, there was no evidence of an association between any quantitative exposure measure and NHL.


Asunto(s)
Bomberos , Neoplasias/mortalidad , Enfermedades Profesionales/mortalidad , Exposición Profesional/efectos adversos , Ocupaciones , Adolescente , Adulto , Anciano , Causas de Muerte , Chicago/epidemiología , Estudios de Cohortes , Femenino , Humanos , Leucemia/mortalidad , Neoplasias Pulmonares/mortalidad , Linfoma no Hodgkin/mortalidad , Masculino , Mesotelioma/mortalidad , Persona de Mediana Edad , Philadelphia/epidemiología , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , San Francisco/epidemiología , Adulto Joven
20.
J Urban Health ; 97(1): 78-87, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31907705

RESUMEN

Women who experience housing instability are at high risk for violence and have disproportionately high rates of emergency department (ED) use. However, little has been done to characterize the violence they experience, or to understand how it may be related to ED use. We recruited homeless and unstably housed women from San Francisco shelters, free meal programs, and single room occupancy (SRO) hotels. We used generalized estimating equations to examine associations between violence and any ED use (i.e., an ED visit for any stated reason) every 6 months for 3 years. Among 300 participants, 44% were African-American, and the mean age was 48 years. The prevalence of violence experienced in the prior 6 months included psychological violence (87%), physical violence without a weapon (48%), physical violence with a weapon (18%), and sexual violence (18%). While most participants (85%) who experienced physical violence with a weapon or sexual violence in the prior 6 months had not visited an ED, these were the only two violence types significantly associated with ED use when all violence types were included in the same model (ORphysical/weapon = 1.83, 95% CI 1.02-3.28; ORsexual = 2.15, 95% CI 1.30-3.53). Only violence perpetrated by someone who was not a primary intimate partner was significantly associated with ED use when violence was categorized by perpetrator. The need to reduce violence in this population is urgent. In the context of health care delivery, policies to facilitate trauma-informed ED care and strategies that increase access to non-ED care, such as street-based medicine, could have substantial impact on the health of women who experience homelessness and housing instability.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Personas sin Hogar/estadística & datos numéricos , Violencia/estadística & datos numéricos , Adulto , Femenino , Personas sin Hogar/psicología , Vivienda , Humanos , Drogas Ilícitas , Persona de Mediana Edad , Prevalencia , San Francisco/epidemiología , Delitos Sexuales/estadística & datos numéricos
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