HIV Viral Suppression Among Psychiatric Inpatients with Schizophrenia in San Francisco: A Retrospective Cohort Study.

People with schizophrenia are at increased risk for contracting HIV and face higher mortality rates compared with the general population. Viral suppression is key to HIV care, yet little is known about this metric among people with HIV and schizophrenia. A chart review was conducted among people with HIV/AIDS and schizophrenia living in San Francisco who had received inpatient mental health services between 2010 and 2016. Demographic, laboratory, medication, encounter, and discharge data were collected, and were compared with all people living with HIV in San Francisco (PLWH-SF). Among 153 people living with HIV and comorbid schizophrenia, 77% were virally suppressed, compared to 67% for all PLWH-SF. Viral suppression for people with comorbid HIV and schizophrenia living in San Francisco appears higher than PLWH-SF. Further research is needed to confirm the association and mechanisms behind better treatment outcomes for people living with HIV and comorbid schizophrenia.

A Co-Created Tool to Help Counter Health Misinformation for Spanish-Speaking Communities in the San Francisco Bay Area.

BACKGROUND: Health misinformation, which was particularly prevalent during the COVID-19 pandemic, hampers public health initiatives. Spanish-speaking communities in the San Francisco Bay Area may be especially affected due to low digital health literacy and skepticism towards science and healthcare experts. Our study aims to develop a checklist to counter misinformation, grounded in community insights. METHODS: We adopted a multistage approach to understanding barriers to COVID-19 vaccine uptake in Spanish-speaking populations in Alameda and San Francisco counties. Initial work included key informant and community interviews. Partnering with a community-based organization (CBO), we organized co-design workshops in July 2022 to develop a practical tool for identifying misinformation. Template analysis identified key themes for actionable steps, such as source evaluation and content assessment. From this, we developed a Spanish-language checklist. FINDINGS: During formative interviews, misinformation was identified as a major obstacle to vaccine uptake. Three co-design workshops with 15 Spanish-speaking women resulted in a 10-step checklist for tackling health misinformation. Participants highlighted the need for scrutinizing sources and assessing messenger credibility, and cues in visual content that could instill fear. The checklist offers a pragmatic approach to source verification and information assessment, supplemented by resources from local CBOs. CONCLUSION: We have co-created a targeted checklist for Spanish-speaking communities to identify and counter health misinformation. Such specialized tools are essential for populations that are more susceptible to misinformation, enabling them to differentiate between credible and non-credible information.

The University of California San Francisco Brain Metastases Stereotactic Radiosurgery (UCSF-BMSR) MRI Dataset.

Supplemental material is available for this article.

Predictive Modeling of Drug-Related Adverse Events with Real-World Data: A Case Study of Linezolid Hematologic Outcomes.

Electronic health records (EHRs) provide meaningful knowledge of drug-related adverse events (AEs) that are not captured in standard drug development and postmarketing surveillance. Using variables obtained from EHR data in the University of California San Francisco de-identified Clinical Data Warehouse, we aimed to evaluate the potential of machine learning to predict two hematological AEs, thrombocytopenia and anemia, in a cohort of patients treated with linezolid for 3 or more days. Features for model input were extracted at linezolid initiation (index), and outcomes were characterized from index to 14 days post-treatment. Random forest classification (RFC) was used for AE prediction, and reduced feature models were evaluated using cumulative importance (cImp) for feature selection. Grade 3+ thrombocytopenia and anemia occurred in 31% of 2,171 and 56% of 2,170 evaluable patients, respectively. Of the total 53 features, as few as 7 contributed at least 50% cImp, resulting in prediction accuracies of 70% or higher and area under the receiver operating characteristic curves of 0.886 for grade 3+ thrombocytopenia and 0.759 for grade 3+ anemia. Sensitivity analyses in strictly defined patient subgroups revealed similarly high predictive performance in full and reduced feature models. A logistic regression model with the same 50% cImp features showed similar predictive performance as RFC and good concordance with RFC probability predictions after isotonic calibration, adding interpretability. Collectively, this work demonstrates potential for machine learning prediction of AE risk in real-world patients using few variables regularly available in EHRs, which may aid in clinical decision making and/or monitoring.

Racial/Ethnic Disparities in Club Drug Use, Situational Club Drug Use during Sex, and Sexual Risk Behaviors among Alcohol-Using Men Who Have Sex with Men (MSM) in San Francisco.

BACKGROUND: Club drug use-including 3,4-Methylenedioxymethamphetamine, ketamine, crack/cocaine, hallucinogens, gamma hydroxybutyrate, volatile nitrites, and methamphetamine-has been linked to sexual risk behaviors among MSM. Few studies examine how the use of club drugs and the association between club drug use during sex and sexual risk may differ by race/ethnicity. METHODS: Using data from a cross-sectional study among alcohol-using MSM in San Francisco (n = 252), we examined the associations between the interaction of race/ethnicity and club drug use during sex, and the following behavioral outcomes: any condomless anal intercourse (CAI), insertive CAI, receptive CAI, and any serodiscordant sex in the past six months. All models controlled for income, HIV status, relationship status, age, and current use of a biomedical HIV prevention tool (i.e., Pre-Exposure Prophylaxis [PrEP] or antiretroviral therapy). RESULTS: There were significant racial differences in club drug use (p < 0.001) and club drug use during sex (p = 0.01). Asian/Pacific Islander (API) and Latino participants reported using club drugs the most at 78.8% and 79%, respectively. Among users of club drugs, club drug use during sex was most common among Black (100%), and Latino MSM (93%). Significant interactions between race/ethnicity and club drug use during sex were observed for CAI (p = 0.02), insertive CAI (p = 0.01), and receptive CAI (p = 0.01). API participants who used club drug during sex had higher odds of reporting CAI (aOR = 15.27, CI = 1.50-155.34), insertive CAI (aOR = 21.11, CI = 2.04-218.10), and receptive CAI (aOR = 21.11, CI = 2.04-218.10). CONCLUSIONS: Given the differing rates of club drug use during sex by race/ethnicity and the role race/ethnicity plays in modifying the relationships between club drug use during sex and sexual risk behaviors, culturally-tailored interventions may be needed to address the needs of ethnically-diverse, club drug-using MSM.

Leveraging electronic health records and knowledge networks for Alzheimer's disease prediction and sex-specific biological insights.

Identification of Alzheimer's disease (AD) onset risk can facilitate interventions before irreversible disease progression. We demonstrate that electronic health records from the University of California, San Francisco, followed by knowledge networks (for example, SPOKE) allow for (1) prediction of AD onset and (2) prioritization of biological hypotheses, and (3) contextualization of sex dimorphism. We trained random forest models and predicted AD onset on a cohort of 749 individuals with AD and 250,545 controls with a mean area under the receiver operating characteristic of 0.72 (7 years prior) to 0.81 (1 day prior). We further harnessed matched cohort models to identify conditions with predictive power before AD onset. Knowledge networks highlight shared genes between multiple top predictors and AD (for example, APOE, ACTB, IL6 and INS). Genetic colocalization analysis supports AD association with hyperlipidemia at the APOE locus, as well as a stronger female AD association with osteoporosis at a locus near MS4A6A. We therefore show how clinical data can be utilized for early AD prediction and identification of personalized biological hypotheses.

Pragmatic phase II clinical trial to improve depression care in a real-world diverse MS cohort from an academic MS centre in Northern California: MS CATCH study protocol.

INTRODUCTION: Depression occurs in over 50% of individuals living with multiple sclerosis (MS) and can be treated using many modalities. Yet, it remains: under-reported by patients, under-ascertained by clinicians and under-treated. To enhance these three behaviours likely to promote evidence-based depression care, we engaged multiple stakeholders to iteratively design a first-in-kind digital health tool. The tool, MS CATCH (Care technology to Ascertain, Treat, and engage the Community to Heal depression in patients with MS), closes the communication loop between patients and clinicians. Between clinical visits, the tool queries patients monthly about mood symptoms, supports patient self-management and alerts clinicians to worsening mood via their electronic health record in-basket. Clinicians can also access an MS CATCH dashboard displaying patients' mood scores over the course of their disease, and providing comprehensive management tools (contributing factors, antidepressant pathway, resources in patient's neighbourhood). The goal of the current trial is to evaluate the clinical effect and usability of MS CATCH in a real-world clinical setting. METHODS AND ANALYSIS: MS CATCH is a single-site, phase II randomised, delayed start, trial enrolling 125 adults with MS and mild to moderately severe depression. Arm 1 will receive MS CATCH for 12 months, and arm 2 will receive usual care for 6 months, then MS CATCH for 6 months. Clinicians will be randomised to avoid practice effects. The effectiveness analysis is superiority intent-to-treat comparing MS CATCH to usual care over 6 months (primary outcome: evidence of screening and treatment; secondary outcome: Hospital Anxiety Depression Scale-Depression scores). The usability of the intervention will also be evaluated (primary outcome: adoption; secondary outcomes: adherence, engagement, satisfaction). ETHICS AND DISSEMINATION: University of California, San Francisco Institutional Review Board (22-36620). The findings of the study are planned to be shared through conferences and publishments in a peer-reviewed journal. The deidentified dataset will be shared with qualified collaborators on request, provision of CITI and other certifications, and data sharing agreement. We will share the results, once the data are complete and analysed, with the scientific community and patient/clinician participants through abstracts, presentations and manuscripts. TRIAL REGISTRATION NUMBER: NCT05865405.

Participant experiences in a combination HIV cure-related trial with extended analytical treatment interruption in San Francisco, United States.

BACKGROUND: There is limited systematic information available about the perspectives of participants enrolled in intensive combination HIV cure-related trials inclusive of an extended analytical treatment interruption (ATI). OBJECTIVE: To assess and understand experiences of people with HIV involved in a combination HIV cure-related trial with an extended ATI. METHODS: The trial included five interventions and was followed by an ATI lasting up to 52 wk. From 2022 - 2023, we conducted in-depth interviews with study participants following their extended ATIs. Interviews were audio-recorded, transcribed, and analyzed via conventional thematic analysis. RESULTS: We interviewed seven participants. The majority were male, White, and non-Hispanic, with a median age of 37 years. Trust in the research team, scientific altruism and hope of becoming a post-intervention controller were key motivators for joining the trial. Interviewees reported being satisfied with their decision to participate in the trial and the extended ATI. Most recounted feelings of worry related to viral rebound during the ATI. Participants reported both defeat and relief with ART restart. Four faced challenges with protecting partners from HIV during their ATI, such as trying to find out if their partner(s) were using pre-exposure prophylaxis. CONCLUSIONS: Our findings demonstrate potential improvements for future ATI trial participant experiences, such as more robust resources for psychosocial support and partner protections. Dedicating greater effort to understanding participant ATI experiences can inform the design of future participant-centered HIV cure trial protocols.

Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California.

BACKGROUND: Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades. METHODS: Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades. RESULTS: Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049). CONCLUSIONS: We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women. TRIAL REGISTRATION: NCT, NCT 21-34,978. Registered January 19, 2022.

Economic insecurities and patient-reported outcomes in patients with systemic lupus erythematosus in the USA: a cross-sectional analysis of data from the California Lupus Epidemiology Study.

BACKGROUND: Social determinants of health are consistently associated with systemic lupus erythematosus (SLE) outcomes. However, social determinants of health are typically measured with conventional socioeconomic status factors such as income or education. We assessed the association of economic insecurities (ie, food, housing, health care, and financial insecurity) with patient-reported outcomes in a cohort of patients with SLE. METHODS: In this cross-sectional analysis, data were derived from the California Lupus Epidemiology Study based in the San Francisco Bay Area, CA, USA. Participants were recruited between Feb 25, 2015, and Jan 10, 2018, from rheumatology clinics. Inclusion criteria were Bay Area residency; oral fluency in English, Spanish, Cantonese, or Mandarin; 18 years or older; ability to provide informed consent; and a physician confirmed SLE diagnosis. Food, housing, health care, and financial economic insecurities were assessed by validated screening tools. Patient-reported outcomes were obtained using PROMIS, Quality of Life in Neurological Disorders (known as Neuro-QoL) Cognitive Function short form, Patient Health Questionnaire (PHQ)-8, and General Anxiety Disorder (GAD)-7 instruments. Poverty was defined as household income of 125% or less of the federal poverty limit. Lower education was defined as less than college-graduate education. The association of economic insecurities with patient-reported outcomes was assessed by multivariable linear regression models adjusting for demographics, SLE disease characteristics, and comorbidities. We tested for interactions of insecurities with poverty and education. FINDINGS: The final cohort included 252 participants. Mean age was 49·7 (SD 13·4) years, 228 (90%) of 252 were women and 24 (10%) were men. 80 (32%) individuals self-identified as Asian, 26 (10%) as Black, 101 (40%) as White, eight (3%) as mixed race, and 37 (15%) as other race; 59 (23%) self-identified as Hispanic. 135 (54%) individuals had at least one insecurity. Insecurities were highly prevalent, and more common in those with poverty and lower education. Adjusted multivariate analyses revealed that participants with any insecurity had significantly worse scores across all measured patient-reported outcomes. For physical function, no insecurity had an adjusted mean score of 48·9 (95% CI 47·5-50·3) and any insecurity had 45·7 (44·3-47·0; p=0·0017). For pain interference, no insecurity was 52·0 (50·5-53·5) and any insecurity was 54·4 (53·0-55·8; p=0·031). For fatigue, no insecurity was 50·5 (48·8-52·3) and any insecurity was 54·9 (53·3-56·5; p=0·0005). For sleep disturbance, no insecurity was 49·9 (48·3-51·6) and any insecurity was 52·9 (51·4-54·5; p=0·012). For cognitive function, no insecurity was 49·3 (47·7-50·9) and any insecurity was 45·6 (44·1-47·0; p=0·0011). For PHQ-8, no insecurity was 4·4 (3·6-5·1) and any insecurity was 6·1 (5·4-6·8; p=0·0013). For GAD-7, no insecurity was 3·3 (2·6-4·1) and any insecurity was 5·2 (4·5-5·9; p=0·0008). Individuals with more insecurities had worse patient-reported outcomes. There were no statistically significant interactions between insecurities and poverty or education. INTERPRETATION: Having any economic insecurity was associated with worse outcomes for people with SLE regardless of poverty or education. The findings of this study provide insight into the relationship between economic insecurities and SLE outcomes and underscore the need to assess whether interventions that directly address these insecurities can reduce health disparities in SLE. FUNDING: US Centers for Disease Control, Rheumatology Research Foundation, and National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Surrogate decision-makers from historically marginalized populations have lower levels of preparedness for care planning.

BACKGROUND: Surrogate preparedness for medical decision-making is an important part of care planning. This study examined preparedness and engagement among historically marginalized surrogates. METHODS: Surrogates were included if they were named medical decision-makers by patients ≥55 years at a San Francisco safety-net and Veterans Affairs hospital. We assessed preparedness for medical decision-making by asking if surrogates had been formally asked to be the medical decision-maker, if patients had discussed medical wishes with surrogates, and if the surrogate role and these medical wishes had been documented. We assessed surrogate confidence and readiness using a modified Surrogate ACP Engagement Survey. We used Wilcoxon rank-sum tests to measure the association of engagement scores with surrogate characteristics. RESULTS: Of 422 surrogates, their mean age was 53 years (SD ±14.5), 73% were from minoritized groups, 38% were Spanish-speaking, and 15% had limited health literacy. For preparedness outcomes, 13% of surrogates were not formally asked to play this role, 46% reported the patient had not discussed end-of-life medical wishes, and 51% reported there had been no formal documentation of the surrogate role. Surrogates reported higher confidence 4.43/5 (SD ± 0.64) than readiness 3.70 (1.22) for decision-making (p < 0.001). Confidence and readiness scores were lower among historically marginalized participants. CONCLUSION: More resources are needed to prepare surrogate decision-makers from historically marginalized communities for discussing patient's goals of care and treatment preferences.

Medicine plus mindset: A mixed-methods evaluation of a novel mindset-focused training for primary care teams.

OBJECTIVES: Patient mindsets influence health outcomes; yet trainings focused on care teams' understanding, recognizing, and shaping patient mindsets do not exist. This paper aims to describe and evaluate initial reception of the "Medicine Plus Mindset" training program. METHODS: Clinicians and staff at five primary care clinics (N = 186) in the San Francisco Bay Area received the Medicine Plus Mindset Training. The Medicine Plus Mindset training consists of a two-hour training program plus a one-hour follow-up session including: (a) evidence to help care teams understand patients' mindsets' influence on treatment; (b) a framework to support care teams in identifying specific patient mindsets; and (c) strategies to shape patient mindsets. RESULTS: We used a common model (Kirkpatrick) to evaluate the training based on participants' reaction, learnings, and behavior. Reaction: Participants rated the training as highly useful and enjoyable. Learnings: The training increased the perceived importance of mindsets in healthcare and improved self-reported efficacy of using mindsets in practice. Behavior: The training increased reported frequency of shaping patient mindsets. CONCLUSIONS: Development of this training and the study's results introduce a promising and feasible approach for integrating mindset into clinical practice. Practice Implications Mindset training can add a valuable dimension to clinical care and should be integrated into training and clinical practice.

A Community Assessment of Psychological Distress in Pacific Islanders Across San Francisco Bay Area Churches During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has exacerbated health and social disparities among US Pacific Islanders (PI). Historically, PIs have experienced a high burden of mental illness yet have underutilized mental health services. These already large treatment gaps in mental health care among PIs may worsen during the COVID-19 pandemic. In the face of pre-existing challenges, little is known about the impacts of the COVID-19 pandemic on mental health outcomes among PIs. METHODS: A community-based, cross-sectional survey was administered to members of 13 PI churches across the San Francisco Bay Area. We assessed the burden of psychological distress among PIs and its associations with demographic, sociocultural, and health factors. KEY RESULTS: Among 439 PI respondents, nearly half reported moderate or severe psychological distress. Only about one-tenth took prescription medication for mental health and less than half utilized a mental health provider in the past year. Most trusted PI churches to provide health and social services. Respondents reporting moderate or severe psychological distress were less likely to utilize a mental health provider in the past year and more likely to feel marginalized, excluded, isolated, or alienated from society "most of the time" or "always." Psychological distress was also associated with "fair" or "poor" health status, female gender, older adults, low trust in PI churches to provide health and social services, and concern over household finances. CONCLUSION: Partnerships with faith-based and community-based organizations are essential to address unmet mental health needs and promote support-seeking behaviors among PIs during this ongoing pandemic and beyond.

"If you're strung out and female, they will take advantage of you": A qualitative study exploring drug use and substance use service experiences among women in Boston and San Francisco.

BACKGROUND: Significant disparities in substance use severity and treatment persist among women who use drugs compared to men. Thus, we explored how identifying as a woman was related to drug use and treatment experiences. METHODS: The study recruited participants for a qualitative interview study in Boston and San Francisco from January-November 2020. Self-identified women, age ≥ 18 years, with nonprescribed opioid use in the past 14 days were eligible for inclusion. The study team developed deductive codes based on intersectionality theory and inductive codes generated from transcript review, and identified themes using grounded content analysis. RESULTS: The study enrolled thirty-six participants. The median age was 46; 58 % were White, 16 % were Black, 14 % were Hispanic, and 39 % were unstably housed. Other drug use was common with 81 % reporting benzodiazepine, 50 % cocaine, and 31 % meth/amphetamine use respectively. We found that gender (i.e., identifying as a woman) intersected with drug use and sex work practices and exacerbated experiences of marginalization. Violence was ubiquitous in drug use environments. Some women reported experiences of gender-based violence in substance use service settings that perpetuated cycles of trauma and reinforced barriers to care. Substance use services that were women-led, safe, and responsive to women's needs were valued and sought after. CONCLUSION: Women reported a cycle of trauma and drug use exacerbated by oppression in substance use services settings. In addition to increasing access to gender-responsive care, our study highlights the need for greater research and examination of practices within substance use service settings that may be contributing to gender-based violence.

Interruptions in HIV and Behavioral Health Care for Criminal-Legal Involved People Living with HIV Following Implementation of Decarceration and Shelter in Place in San Francisco, California.

Decarceration policies, enacted for SARS-CoV-2 mitigation in carceral settings, potentially exacerbated barriers to care for people living with HIV (PWH) with criminal legal involvement (CLI) during Shelter-in-Place (SIP) by limiting opportunities for engagement in provisions of HIV and behavioral health care. We compared health care engagement for PWH with CLI in San Francisco, California before and after decarceration and SIP using interrupted time series analyses. Administrative data identified PWH booked at the San Francisco County Jail with at least one clinic encounter from 01/01/2018-03/31/2020 within the municipal health care network. Monthly proportions of HIV, substance use, psychiatric and acute care encounters before (05/01/2019-02/29/2020) and after (03/01/2020-12/31/2020) SIP and decarceration were compared using Generalized Estimating Equation (GEE) log-binomial and logistic regression models, clustering on the patient-level. Of 436 patients, mean age was 43 years (standard-deviation 11); 88% cisgender-male; 39% white, 66% homeless; 67% had trimorbidity by Elixhauser score (medical comorbidity, psychotic disorder or depression, and substance use disorder). Clinical encounters immediately dropped following SIP for HIV (aOR = 0.77; 95% CI: 0.67, 0.90) and substance use visits (aRR = 0.83; 95% CI: 0.70, 0.99) and declined in subsequent months. Differential reductions in clinical encounters were seen among Black/African Americans (aRR = 0.93; 95% CI: 0.88, 0.99) and people experiencing homelessness (aRR = 0.92; 95% CI: 0.87, 0.98). Significant reductions in care were observed for PWH with CLI during the COVID-19 pandemic, particularly among Black/African Americans and people experiencing homelessness. Strategies to End the HIV Epidemic must improve engagement across diverse care settings to improve outcomes for this key population.

Forecasting marine spill risk along the U.S. Pacific coasts.

This study analyzes historical trends and forecasts of spill risks in coastal counties along the U.S. Pacific, including Alaska and Hawaii. The method calculates spill impact, which rises with size but diminishes with age and distance from the coast. Over the past two decades, spill risks in California and Washington have increased significantly. Coastal counties in Puget Sound and San Francisco Bay have seen the highest increases, surpassing 2000 levels by 79 % and 39 %, respectively. Alaska experienced a moderate rise, while Oregon and Hawaii had smaller but noteworthy increases. Ocean currents may reduce risk by 38 % on average. Most counties are expected to experience increasing spill risks, particularly in Southern California and Southwest Washington, which could see nearly a 50 % increase by 2033 compared to present levels. These findings can help coastal zone monitoring and inform policies for protecting coastal regions, regulating marine transportation and reducing spill vulnerability.

Experiences of discrimination and support among trans men and women partnered with cis men.

Trans individuals routinely experience discrimination. In this study, thirty-nine couples consisting of a trans partner and a cis male partner from the San Francisco Bay Area were interviewed about their relationship. The interviews were digitally recorded, transcribed and reviewed for accuracy. Guided by grounded theory, coders began thematic analysis until inter-coder reliability was achieved. Further qualitative coding produced several codes, two of which are focused upon here: namely, discrimination and support. This study highlights discrimination at the institutional level, such as being denied housing and employment, and at the interpersonal level, such as experiencing harassment from strangers and exclusion from queer community spaces. Trans individuals reported becoming desensitised to discrimination, moving to safer geographic locations, and acknowledged cis or straight passing as a privilege and a prevention tactic against discrimination, although this sometime left participants feeling their gender had been invalidated. Although most trans individuals sought support from their cis partners, some cis partners reacted with violence to discrimination, provoking the situation's severity and upsetting their trans partner. Transphobic discrimination is widespread, and it is crucial for frontline health and other service providers to understand the impact it has on both trans individuals and trans/cis couples, and for agencies to offer resources to support these relationships.

A Year of Deaths Due to or With COVID-19 Under Universal Postmortem Testing in San Francisco.

ABSTRACT: The Health Officer of the City and County of San Francisco, California, issued the order that all decedents were required to have a documented COVID-19 test effective from June 2020 to June 2021. The justification for the requirement was that complete data on COVID-19 status at the time of death were needed to help protect first responders and funeral home workers, identify missed cases, and characterize the places of death for otherwise unknown COVID-19 cases. To fill the gap in COVID-19 testing for all decedents, particularly among persons dying outside of hospitals, a specialized Decedent Testing Unit was created along with an increased capacity of the Office of the Chief Medical Examiner. From July 1, 2020, to June 30, 2021, the Decedent Testing Unit and Office of the Chief Medical Examiner provided postmortem testing results for 2776 decedents. Of these, 80 tested positive for COVID-19 for a positivity rate of 2.97%. The largest number of COVID-19-positive specimens were collected from persons who died at home (n = 37, 46.3%), followed by those who died in hospice (n = 20, 25.0%), other places outside of homes or facilities (n = 8, 10.0%), and in skilled nursing or long-term care facilities (n = 7, 8.8%). Follow-up of California death records found that 17 of these 80 cases (21.3%) had COVID-19 listed as one of the causes of death, 22 (27.5%) mentioned COVID-19 under "other conditions," and 41 (51.3%) made no mention of COVID-19. In the context of providing the COVID-19 status of decedents not otherwise known to have infection, our data help gauge the likelihood of missing deaths due to or with COVID-19 and inform future public health decisions on whether to require universal postmortem testing with COVID-19 resurgences or with new deadly epidemics.

Comparative stable isotope analyses of green sturgeon (Acipenser medirostris) and white sturgeon (A. transmontanus) in the San Francisco estuary.

Green sturgeon (Acipenser medirostris) and white sturgeon (A. transmontanus) are closely related, sympatric species that inhabit the San Francisco estuary. Green sturgeon have a more marine life history but both species spawn in the Sacramento River and reside for some duration in San Francisco Bay. These sturgeons are of conservation concern, yet little is known about their dietary competition when they overlap in space and time. To examine evidence of dietary differentiation, we collected whole blood and blood plasma from 26 green sturgeon and 35 white sturgeon in San Francisco Bay. Using carbon and nitrogen stable isotope analyses, we compared their relative trophic levels and foraging locations along the freshwater to marine gradient. Sampling blood plasma and whole blood allowed comparison of dietary integration over shorter and longer time scales, respectively. Plasma and whole blood δ13 C values confirmed green sturgeon had more marine dietary sources than white sturgeon. Plasma δ15 N values revealed white sturgeon fed at lower trophic levels than green sturgeon recently, however, whole blood δ15 N values demonstrated the two species fed at the same trophic level over longer time scales. Larger individuals of both species had higher δ13 C values than smaller individuals, reflecting more marine food sources in adulthood. Length did not affect δ15 N values of either species. Isotope analyses supported the more marine life history of green than white sturgeon and potentially highlight a temporary trophic differentiation of diet between species during and preceding the overlapping life stage in San Francisco Bay.