ABSTRACT
Study Objectives: Asylum applications in the United States have been steadily growing over the past decade, with roughly 90, 000 applications submitted in 2020 alone. Asylum seekers are required to have proof of a well-founded fear of persecution due to a person’s race, religion, nationality, membership in a particular social group, or political opinion, and physicians can play an important role in providing critical forensic medical evaluations documenting physical and psychological trauma for these victims’ cases. Due to lock-downs and isolation, the COVID pandemic has made it increasingly difficult for asylees to obtain this critical evaluation to bolster their case, and thereby ensure their safety. Our objective was to establish the first virtual student-run asylum clinic in Western Massachusetts to address the growing need for medical forensic evaluations during the COVID pandemic where travel and in-person evaluations are limited. Methods: The Worcester Asylum Clinic was founded in Spring 2020 to meet the growing need for forensic evaluations in Western and Central Massachusetts. Through emails, listservs, and other recruitment initiatives, we established a network of physician evaluators, medical students, interpreters, and lawyers with a shared goal of pro-bono assistance for local asylum cases, each integral to the clinic’s success. Lawyers submitted cases through a HIPAA-compliant REDcap form from our website, triggering medical student case coordinators to start organizing and processing their request. National virtual trainings offered by Physicians for Human Rights and other similar organizations were utilized to train volunteer physician evaluators and medical students on the principles of forensic evaluation and case sensitivity. Additionally, we developed a virtual mentorship program to allow clinic volunteers to work alongside trained evaluators/students to provide technical and emotional support. Monthly meetings were also conducted separately with faculty and medical students to discuss clinic operations and to provide a space for peer- support. Results: From July 2020 to April 2021, 29 evaluations were conducted using Zoom. 36 case requests were submitted by 12 law firms, 2 cases were cancelled by the lawyers and 8 cases referred to nearby clinics due to limitations on language, sex, or provider availability. Through the virtual training and peer mentorship program, 10 providers conducted evaluations independently, and another 9 are being onboarded. Additionally, 33 medical students have completed training of which many are actively supporting cases. While asylee and volunteer feedback was overwhelmingly positive, limitations included wireless internet connectivity issues and access to video-enabled devices, though highly infrequent. Conclusion: The development of a fully virtual alternative to in-person asylum case evaluations has greatly increased the capacity of Worcester Asylum Clinic to meet the growing needs of asylum seekers in Central Massachusetts. As in-person encounters resume, virtual clinics can complement in person evaluations to continue to provide asylees and their case teams a more flexible option to acquiring needed evaluations.
ABSTRACT
Study Objective: The contribution of social determinants of health (SDOH) to poor health outcomes is well established, and the emergency department (ED) is the most common site of contact between socially vulnerable patients and the healthcare system. The ED is thus uniquely well positioned to screen patients for social determinants of health and connect those identified as having social needs with appropriate community resources. Before such programs are developed, more information regarding the needs and characteristics of the target patient population is required. Our objective was to characterize the prevalence of common social determinants of health among adult patients presenting to a high volume, urban ED at an academic medical center in New England. Methods: During April 2021, four research assistants (RAs) administered a SDOH survey based on Boston Medical Center’s THRIVE Social Determinants of Health Screening and Referral Program. Patients were screened during 8-hr shifts over 16 days, corresponding to 24-hr coverage over 7 days. Exclusion criteria included patients with age under 18 yr, medical or cognitive inability to participate, or currently in state or federal custody. Patients were verbally consented in their preferred language and survey responses were entered into a dedicated REDCap database;interpreter services were used for all low-English proficiency patients. All patients were offered referrals to local community resources via text or email through the platform at the conclusion of the survey. Patients were considered to have a positive screen for social risk factors if they responded “Sometimes true” or “Often true” to Likert scale questions regarding the frequency of risk, or “Yes” to binary risk questions. Results: A total of 650 patients were approached by RAs, of whom 343 were eligible to participate in the survey;122 eligible patients (35.6%) were identified as screen positive for SDOH risk factors. Patients screening positive were significantly more likely to be of Hispanic ethnicity (23.0% v. 9.1%, p<0.001), nonwhite race (30.3% v. 16.9%, p=0.004), and income < $40, 000/yr (51.0% v. 23.7%, p<0.001). Among patients with positive screens, the most common risks identified were concerns regarding food insecurity (n=59, 48.4%), access to transportation for medical appointments (n=36, 29.5%), cost of medications (n=34, 27.9%), and heat or electricity bills (n=34, 27.9%). A significantly greater proportion of patients with positive SDOH screens reported an increase in their needs during the COVID-19 pandemic (55.9% v. 21.0%, p<0.001). Conclusion: This SDOH screening study indicates that our ED population has significant unmet social risks and needs. More research on ED-based solutions will be necessary address this growing need in our population, and thereby improve health outcomes.
ABSTRACT
Introduction: While most cases of COVID-19 recover completely within 2-6 weeks, some may develop complications including residual lung fibrosis. We describe an interesting case of late-onset post-COVID fibrosis that presented more than 4 months after the initial infection. Case: A 52-year-old male, an operating room technician by profession tested positive for COVID-19 after coming in contact with an infected patient early in May 2020. He was asymptomatic, vitally stable with no comorbidities, and was given a course of oral hydroxychloroquine, oseltamivir, and multivitamins. He remained asymptomatic for a week in the isolation ward with all investigations within normal range and was discharged home. HRCT thorax on the first follow-up at 2 weeks was normal and the patient resumed work as usual for the next 3 months. In mid-September, the patient presented to the outpatient clinic with a sudden onset of dyspnea on exertion that was progressive for 5 days with an oxygen saturation of 93% on room air. He was unable to perform a 6-minute walk test (6MWT). Spirometry was suggestive of moderate restriction and reduced DLCO. HRCT thorax at this point revealed bilateral extensive reticular opacities with few ground-glass opacities (GGO's) in all lobes bilaterally with a basal predominance. These findings were suggestive of late-onset of residual fibrosis more than 4 months after the initial infection. RT-PCR for COVID-19 was negative and ruled out re-infection. The patient was unwilling for admission and was started on oral pirfenidone, a tapering dose of oral prednisolone, and was advised home oxygen therapy. He did not take home oxygen but was compliant with oral steroids and antifibrotic. In the 7th-month of post-COVID follow-up, HRCT showed significant improvement as compared to the previous scan with reduced reticular opacities and minimal GGO's. The patient was symptomatically better with a saturation of 98% on room air and could perform 6MWT satisfactorily. Spirometry showed mild restriction and improvement in FVC. The antifibrotic dose was stepped up and the patient was referred for pulmonary rehabilitation. Discussion Despite an uncertain natural history of post-COVID sequelae, it has been observed that post-COVID fibrosis can develop as early as 3 weeks after the initial infection. This case was unique in its late presentation during the second post-COVID follow up at 4 months with normal imaging and clinical parameters during the first follow up. Hence a meticulous long-term follow-up should be done for all patients.