Assessing the Predictive Value of Combining Risk Scoring Systems and Ultrasonography for Short-Term Adverse Outcomes in Syncope: A Prospective Observational Study.

BACKGROUND: In the emergency department (ED), the role of ultrasonography (USG) in risk stratification and predicting adverse events in syncope patients is a current research area. However, it is still unclear how ultrasound can be combined with existing risk scores. OBJECTIVES: In this study, it was aimed to examine the contribution of the use of bedside USG to current risk scores in the evaluation of patients presenting to the ED with syncope. The predictive values of the combined use of USG and risk scores for adverse outcomes at 7 and 30 days were examined. METHODS: The Canadian Syncope Risk Score (CSRS), San Francisco syncope rules (SFSR), USG findings of carotid and deep venous structures, and echocardiography results were recorded for patients presenting with syncope. Parameters showing significance in the 7-day and 30-day adverse outcome groups were utilized to create new scores termed CSRS-USG and SFSR-USG. Predictive values were evaluated using receiver operating characteristic (ROC) analysis. The difference between the predictive values was evaluated with the DeLong test. RESULTS: The study was carried out with 137 participants. Adverse outcomes were observed in 45 participants (32.8%) within 30 days. 32 (71.7%) of the adverse outcomes were in the first 7 days. For 30-day adverse outcomes, the SFSR-USG (p = 0.001) and CSRS-USG (p = 0.038) scores had better predictive accuracy compared to SFSR and CSRS, respectively. However, there was no significant improvement in sensitivity and specificity values. CONCLUSION: The use of USG in the evaluation of syncope patients did not result in significant improvement in sensitivity and specificity values for predicting adverse events. However, larger sample-sized studies are needed to understand its potential contributions better.

Liver transplantation for hepatocellular carcinoma in India: Are we ready for 2040?

BACKGROUND: Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out comes are controversial. AIM: To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future. METHODS: We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und ergoing LT for HCC was noted. RESULTS: Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%-15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down staging was at least 4-6 wk in all centers. Contrast-enhanced CT was the preferred imaging modality for post-LT surveillance in 52% of the centers. Approximately 65% of the centers preferred to start everolimus between 1 and 3 months post-LT. CONCLUSION: The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.

Antigenic Characterization of Novel Human Norovirus GII.4 Variants San Francisco 2017 and Hong Kong 2019.

Norovirus is a major cause of acute gastroenteritis; GII.4 is the predominant strain in humans. Recently, 2 new GII.4 variants, Hong Kong 2019 and San Francisco 2017, were reported. Characterization using GII.4 monoclonal antibodies and serum demonstrated different antigenic profiles for the new variants compared with historical variants.

Orthopedic Team Surgeons in Major Professional Sports: An Analysis of Affiliation With the Top 10 Sports Medicine Fellowship Programs and Implications for Leadership and Diversity.

This paper examines the correlation between orthopedic team surgeons in major professional sports and their affiliation with the top 10 sports medicine fellowship programs. With a growing trend in post-residency fellowship training, particularly in sports medicine, the study focuses on the implications of fellowship program choice for aspiring major professional sports team physicians. By analyzing data from Major League Baseball (MLB), the National Basketball Association (NBA), the National Football League (NFL), and the National Hockey League (NHL), the research reveals that 61 of 124 (49.19%) team surgeons graduated from the top 10 sports medicine fellowship programs. The results identify a noticeable pipeline effect in professional sports, where teams often hire graduates from a select number of esteemed fellowship programs. The study suggests that choosing a fellowship program from the top 10 list may enhance the prospects of becoming a major league team surgeon. Additionally, our results found a significant gender disparity among team surgeons, with only two (1.6%) of all major professional team physicians being women. This emphasizes the imperative for diversity improvement in orthopedic sports medicine. In conclusion, the research underscores the impact of top-tier fellowship programs on professional team surgeons, with implications for aspiring sports medicine physicians and a call for addressing gender disparities.

Effects of incubation temperature on the upper thermal tolerance of the imperiled longfin smelt (Spirinchus thaleichthys).

Upper thermal limits in many fish species are limited, in part, by the heart's ability to meet increased oxygen demand during high temperatures. Cardiac plasticity induced by developmental temperatures can therefore influence thermal tolerance. Here, we determined how incubation temperatures during the embryonic stage influence cardiac performance across temperatures during the sensitive larval stage of the imperiled longfin smelt. We transposed a cardiac assay for larger fish to newly hatched larvae that were incubated at 9°C, 12°C or 15°C. We measured heart rate over increases in temperature to identify the Arrhenius breakpoint temperature (TAB), a proxy for thermal optimum and two upper thermal limit metrics: temperature when heart rate is maximized (Tpeak) and when cardiac arrhythmia occurs (TArr). Higher incubation temperatures increased TAB, Tpeak and TArr, but high individual variation in all three metrics resulted in great overlap of individuals at TAB, Tpeak and TArr across temperatures. We found that the temperatures at which 10% of individuals reached Tpeak or TArr and temperatures at which number of individuals at TAB relative to Tpeak (ΔN(TAB,Tpeak)) was maximal, correlated more closely with upper thermal limits and thermal optima inferred from previous studies, compared to the mean values of the three cardiac metrics of the present study. Higher incubation temperatures increased the 10% Tpeak and TArr thresholds but maximum ΔN(TAB,Tpeak) largely remained the same, suggesting that incubation temperatures modulate upper thermal limits but not Topt for a group of larvae. Overall, by measuring cardiac performance across temperatures, we defined upper thermal limits (10% thresholds; Tpeak, 14.4-17.5°C; TArr, 16.9-20.2°C) and optima (ΔN(TAB,Tpeak), 12.4-14.4°C) that can guide conservation strategies for longfin smelt and demonstrated the potential of this cardiac assay for informing conservation plans for the early life stages of fish.

Measurement of the Association of Pain with Clinical Characteristics in Oral Cancer Patients at Diagnosis and Prior to Cancer Treatment.

Aim: Oral cancer patients suffer pain at the site of the cancer, which degrades quality of life (QoL). The University of California San Francisco Oral Cancer Pain Questionnaire (UCSFOCPQ), the only validated instrument specifically designed for measuring oral cancer pain, measures the intensity and nature of pain and the level of functional restriction due to pain. Purpose: The aim of this study was to compare pain reported by untreated oral cancer patients on the UCSFOCPQ with pain they reported on the Brief Pain Inventory (BPI), an instrument widely used to evaluate cancer and non-cancer pain. Patients and Methods: The correlation between pain measured by the two instruments and clinical characteristics were analyzed. Thirty newly diagnosed oral cancer patients completed the UCSFOCPQ and the BPI. Results: Pain severity measurements made by the UCSFOCPQ and BPI were concordant; however, the widely used BPI average pain over 24 hours score appeared less sensitive to detect association of oral cancer pain with clinical characteristics of patients prior to treatment (nodal status, depth of invasion, DOI). A BPI average score that includes responses to questions that measure both pain severity and interference with function performs similarly to the UCSFOCPQ in detection of associations with nodal status, pathologic T stage (pT stage), stage and depth of invasion (DOI). Conclusion: Pain assessment instruments that measure sensory and interference dimensions of oral cancer pain correlate with biologic features and clinical behavior.

Japanese Immigration in America: Fleeing Riots, Escaping Imprisonment, and Assimilating.

When 13-year-old Teruichi Nakayama, my grandfather, came to San Francisco from Osaka in 1906, he was assured of an education in a public school by an 1894 treaty between the United States and Japan that gave the latter most-favored-nation status. In 1906, racist mobs forced a decision by the school board to assign 41 school aged Japanese children, including him, to a segregated school for Asian children in violation of the pact. In 1907, he escaped street violence to work as a migrant laborer on inland farms. Settling in the state's Central Coast, he started a confectionary, the family business he knew from his childhood in Japan. He eked enough money to raise a family with a wife arranged for him in the traditional manner by a go-between in Japan. The school board action opened a diplomatic rift between the 2 countries that never resolved and ended in war in 1941. Just days ahead of the imprisonment of Japanese living in California in 1942, he and his family fled to Colorado, a sanctuary state where he reestablished the confectionery. He faced every misapprehension of the current immigration crisis: racism, unfair labor competition, the impossibility of assimilation, and suspicion of a fifth column. Now 5 generations later, none of the fearful predictions when he first arrived came true. His legacy proves immigration as an essential rejuvenating force in America.

Uniting for Ukraine Tuberculosis Screening Experience, San Francisco, California, USA.

Ukraine surveillance data suggest high tuberculosis (TB) incidence, including multidrug resistance. Of 299 newcomers from Ukraine screened in San Francisco, California, USA, by using an interferon-γ-release-assay (IGRA) and chest radiograph, 7.4% were IGRA positive and 1 had laboratory-confirmed pansusceptible TB. Screening with IGRA and chest radiograph can help characterize TB risk.

San Francisco's Citywide COVID-19 Response: Strategies to Reduce COVID-19 Severity and Health Disparities, March 2020 Through May 2022.

San Francisco implemented one of the most intensive, comprehensive, multipronged COVID-19 pandemic responses in the United States using 4 core strategies: (1) aggressive mitigation measures to protect populations at risk for severe disease, (2) prioritization of resources in neighborhoods highly affected by COVID-19, (3) timely and adaptive data-driven policy making, and (4) leveraging of partnerships and public trust. We collected data to describe programmatic and population-level outcomes. The excess all-cause mortality rate in 2020 in San Francisco was half that seen in 2019 in California as a whole (8% vs 16%). In almost all age and race and ethnicity groups, excess mortality from COVID-19 was lower in San Francisco than in California overall, with markedly diminished excess mortality among people aged >65 years. The COVID-19 response in San Francisco highlights crucial lessons, particularly the importance of community responsiveness, joint planning, and collective action, to inform future pandemic response and advance health equity.

Effects of turbidity, temperature and predation cue on the stress response of juvenile delta smelt.

The San Francisco Estuary (SFE) is one of the most degraded ecosystems in the United States, and organisms that inhabit it are exposed to a suite of environmental stressors. The delta smelt (Hypomesus transpacificus), a small semi-anadromous fish endemic to the SFE and considered an indicator species, is close to extinction in the wild. The goal of this study was to investigate how environmental alterations to the SFE, such as reductions in turbidities, higher temperatures and increased prevalence of invasive predators affect the physiology and stress response of juvenile delta smelt. Juvenile delta smelt were exposed to two temperatures (17 and 21°C) and two turbidities (1-2 and 10-11 NTU) for 2 weeks. After the first week of exposure, delta smelt were exposed to a largemouth bass (Micropterus salmoides) predator cue at the same time every day for 7 days. Fish were measured and sampled on the first (acute) and final (chronic) day of exposures to predator cues and later analyzed for whole-body cortisol, glucose, lactate, and protein. Length and mass measurements were used to calculate condition factor of fish in each treatment. Turbidity had the greatest effect on juvenile delta smelt and resulted in reduced cortisol, increased glucose and lactate, and greater condition factor. Elevated temperatures reduced available energy in delta smelt, indicated by lower glucose and total protein, whereas predator cue exposure had negligible effects on their stress response. This is the first study to show reduced cortisol in juvenile delta smelt held in turbid conditions and adds to the growing data that suggest this species performs best in moderate temperatures and turbidities. Multistressor experiments are necessary to understand the capacity of delta smelt to respond to the multivariate and dynamic changes in their natural environment, and results from this study should be considered for management-based conservation efforts.

Exploring the merits of research performance measures that comply with the San Francisco Declaration on Research Assessment and strategies to overcome barriers of adoption: qualitative interviews with administrators and researchers.

BACKGROUND: In prior research, we identified and prioritized ten measures to assess research performance that comply with the San Francisco Declaration on Research Assessment, a principle adopted worldwide that discourages metrics-based assessment. Given the shift away from assessment based on Journal Impact Factor, we explored potential barriers to implementing and adopting the prioritized measures. METHODS: We identified administrators and researchers across six research institutes, conducted telephone interviews with consenting participants, and used qualitative description and inductive content analysis to derive themes. RESULTS: We interviewed 18 participants: 6 administrators (research institute business managers and directors) and 12 researchers (7 on appointment committees) who varied by career stage (2 early, 5 mid, 5 late). Participants appreciated that the measures were similar to those currently in use, comprehensive, relevant across disciplines, and generated using a rigorous process. They also said the reporting template was easy to understand and use. In contrast, a few administrators thought the measures were not relevant across disciplines. A few participants said it would be time-consuming and difficult to prepare narratives when reporting the measures, and several thought that it would be difficult to objectively evaluate researchers from a different discipline without considerable effort to read their work. Strategies viewed as necessary to overcome barriers and support implementation of the measures included high-level endorsement of the measures, an official launch accompanied by a multi-pronged communication strategy, training for both researchers and evaluators, administrative support or automated reporting for researchers, guidance for evaluators, and sharing of approaches across research institutes. CONCLUSIONS: While participants identified many strengths of the measures, they also identified a few limitations and offered corresponding strategies to address the barriers that we will apply at our organization. Ongoing work is needed to develop a framework to help evaluators translate the measures into an overall assessment. Given little prior research that identified research assessment measures and strategies to support adoption of those measures, this research may be of interest to other organizations that assess the quality and impact of research.

Witnessing history: comparison of a century of sedimentary and written records in a California protected area.

We use a combination of proxy records from a high-resolution analysis of sediments from Searsville Lake and adjacent Upper Lake Marsh and historical records to document over one and a half centuries of vegetation and socio-ecological change-relating to logging, agricultural land use change, dam construction, chemical applications, recreation, and other drivers-on the San Francisco Peninsula. A relatively open vegetation with minimal oak (Quercus) and coast redwood (Sequoia sempervirens) in the late 1850s reflects widespread logging and grazing during the nineteenth century. Forest and woodland expansion occurred in the early twentieth century, with forests composed of coast redwood and oak, among other taxa, as both logging and grazing declined. Invasive species include those associated with pasturage (Rume x, Plantago), landscape disturbance (Urtica, Amaranthaceae), planting for wood production and wind barriers (Eucalyptus), and agriculture. Agricultural species, including wheat, rye, and corn, were more common in the early twentieth century than subsequently. Wetland and aquatic pollen and fungal spores document a complex hydrological history, often associated with fluctuating water levels, application of algaecides, raising of Searsville Dam, and construction of a levee. By pairing the paleoecological and historical records of both lakes, we have been able to reconstruct the previously undocumented impacts of socio-ecological influences on this drainage, all of which overprinted known climate changes. Recognizing the ecological manifestations of these impacts puts into perspective the extent to which people have interacted with and transformed the environment in the transition into the Anthropocene. Supplementary Information: The online version contains supplementary material available at 10.1007/s10113-023-02056-9.

Implementation of a novel program to support colorectal cancer screening in a community health center consortium before and after the onset of COVID-19: a qualitative study of stakeholders' perspectives.

BACKGROUND: In 2017, the San Francisco Cancer Initiative (SF CAN) established the Colorectal Cancer (CRC) Screening Program to provide technical assistance and financial support to improve CRC screening processes, and outcomes in a consortium of community health centers (CHCs) serving low-income communities in San Francisco. The purpose of this study was twofold: to evaluate the perceived influence of the support provided by the CRC Screening Program's Task Force on CRC screening processes and outcomes in these settings and to identify facilitators and barriers to SF CAN-supported CRC screening activities before and after the onset of the COVID-19 pandemic. METHODS: Semi-structured key informant interviews were conducted with consortium leaders, medical directors, quality improvement team members, and clinic screening champions. Interviews were audio-recorded, professionally transcribed, and analyzed for themes. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview questions and organize the analysis. RESULTS: Twenty-two participants were interviewed. The most commonly cited facilitators of improved screening processes included the expertise, funding, screening resources, regular follow-up, and sustained engagement with clinic leaders provided by the task force. The most salient barriers identified were patient characteristics, such as housing instability; staffing challenges, such as being understaffed and experiencing high staff turnover; and clinic-level challenges, such as lack of ability to implement and sustain formalized patient navigation strategies, and changes in clinic priorities due to the COVID-19 pandemic and other competing health care priorities. CONCLUSIONS: Implementing CRC screening programs in a consortium of CHCs is inherently challenging. Technical assistance from the Task Force was viewed positively and helped to mitigate challenges both before and during the pandemic. Future research should explore opportunities to increase the robustness of technical assistance offered by groups such as SF CAN to support cancer screening activities in CHCs serving low-income communities.

Fate of Research Articles Reported by Ophthalmology Residency Applicants: What Happens to "Submitted" and "In Preparation" Articles?

OBJECTIVE: As coronavirus disease 2019 affects clinical training opportunities and with the transition of U.S. Medical Licensing Examination Step 1 to pass-fail, research may become increasingly important for evaluating ophthalmology residency applicants. Though publication misrepresentation has been studied among ophthalmology residency applicants, eventual publication rates of incomplete articles remain unknown. We aimed to determine publication rates for manuscripts listed as "submitted" or "in preparation" on ophthalmology residency applications and identify factors associated with unpublished manuscripts. DESIGN: San Francisco Match applications to the Wilmer Eye Institute for the 2019 ophthalmology residency cycle were retrospectively reviewed. Each applicant's number of "published," "submitted," and "in preparation" manuscripts was recorded, then verified 1.5 years later through PubMed, Google Scholar, or journal websites. Unverifiable manuscripts were deemed "unpublished." SETTING: Single academic institution (Wilmer Eye Institute, Baltimore, MD, USA) PARTICIPANTS: All 458 medical students who applied to the Wilmer Eye Institute for the 2019 ophthalmology residency cycle through the San Francisco Match. RESULTS: A total of 458 applications were reviewed. Of 428 "submitted" publications, 126 (29.4%) remained unpublished after 1.5 years. Of 324 manuscripts "in preparation," 215 (66.4%) remained unpublished. In a multivariate model, AOA was associated with not having an unpublished manuscript compared to applicants without AOA (OR: 0.423, p = 0.0163). Gender, Step 1 score, additional degrees, and a research year had no association. CONCLUSIONS: Nearly two-thirds of manuscripts listed as "in preparation" remained unpublished. Specific guidance from research mentors may help applicants better represent their publications in residency applications.

Neighborhood-level COVID vaccination and booster disparities: A population-level analysis across California.

Objectives: To describe vaccine and booster uptake by neighborhood-level factors in California. Methods: We examined trends in COVID-19 vaccination up to September 21, 2021, and boosters up to March 29, 2022 using data from the California Department of Public Health. Quasi-Poisson regression was used to model the association between neighborhood-level factors and fully vaccinated and boosted among ZIP codes. Sub-analyses on booster rates were compared among the 10 census regions. Results: In a minimally adjusted model, a higher proportion of Black residents was associated with lower vaccination (HR = 0.97; 95%CI: 0.96-0.98). However, in a fully adjusted model, proportion of Black, Hispanic/Latinx, and Asian residents were associated with higher vaccination rates (HR = 1.02; 95%CI: 1.01-1.03 for all). The strongest predictor of low vaccine coverage was disability (HR = 0.89; 95%CI: 0.86-0.91). Similar trends persisted for booster doses. Factors associated with booster coverage varied by region. Conclusions: Examining neighborhood-level factors associated with COVID-19 vaccination and booster rates uncovered significant variation within the large and geographically and demographically diverse state of California. Equity-based approaches to vaccination must ensure a robust consideration of multiple social determinants of health.

A case series evaluation of comprehensive drug testing in the pediatric acute care setting.

Introduction: Drug testing typically follows a one-size-fits-all approach that is inadequate in some clinical scenarios, such as child maltreatment, neglect, and unintentional drug exposure. Results from immunoassay-based testing, which are non-specific, insensitive, and far from comprehensive, can lead to unintended consequences for children and their families. Objectives: The objective of this retrospective case series study is to evaluate the utility of real-time (0-1 day) comprehensive drug testing as an alternative to immunoassay-based testing in the pediatric acute care setting. Methods: Comprehensive drug testing results obtained by mass spectrometry testing and associated medical data for all pediatric cases (0-12 years) at one institution from 2019 to 2022 were included in the analysis. The final case series (n = 7) included all cases from patients <3 years with comprehensive drug testing results that were inconsistent with medication history and/or toxicology results by immunoassay. Results: Comprehensive drug testing by mass spectrometry was ordered for 174 urine and blood samples representing 97 patients (0-12 years) from 2019 to 2022. Of these, 76 cases were from patients <3 years old; results were consistent with medication history and confirmatory for immunoassay results (n = 34), consistent with medication history (n = 14), confirmatory for immunoassay results (n = 10), negative (n = 9), or medical history was incomplete (n = 2). The remaining 7 cases were included in the final case series. Conclusions: The cases highlight the value of real-time comprehensive drug testing in acute pediatric cases. Testing results can rule out toxic exposure from the diagnostic differential when negative, and lead to appropriate medical and social interventions when positive.

Developing and Validating Models to Predict Progression to Proliferative Diabetic Retinopathy.

Purpose: To develop models for progression of nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR) and determine if incorporating updated information improves model performance. Design: Retrospective cohort study. Participants: Electronic health record (EHR) data from a tertiary academic center, University of California San Francisco (UCSF), and a safety-net hospital, Zuckerberg San Francisco General (ZSFG) Hospital were used to identify patients with a diagnosis of NPDR, age ≥ 18 years, a diagnosis of type 1 or 2 diabetes mellitus, ≥ 6 months of ophthalmology follow-up, and no prior diagnosis of PDR before the index date (date of first NPDR diagnosis in the EHR). Methods: Four survival models were developed: Cox proportional hazards, Cox with backward selection, Cox with LASSO regression and Random Survival Forest. For each model, three variable sets were compared to determine the impact of including updated clinical information: Static0 (data up to the index date), Static6m (data updated 6 months after the index date), and Dynamic (data in Static0 plus data change during the 6-month period). The UCSF data were split into 80% training and 20% testing (internal validation). The ZSFG data were used for external validation. Model performance was evaluated by the Harrell's concordance index (C-Index). Main Outcome Measures: Time to PDR. Results: The UCSF cohort included 1130 patients and 92 (8.1%) patients progressed to PDR. The ZSFG cohort included 687 patients and 30 (4.4%) patients progressed to PDR. All models performed similarly (C-indices ∼ 0.70) in internal validation. The random survival forest with Static6m set performed best in external validation (C-index 0.76). Insurance and age were selected or ranked as highly important by all models. Other key predictors were NPDR severity, diabetic neuropathy, number of strokes, mean Hemoglobin A1c, and number of hospital admissions. Conclusions: Our models for progression of NPDR to PDR achieved acceptable predictive performance and validated well in an external setting. Updating the baseline variables with new clinical information did not consistently improve the predictive performance. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Use of the Improvement Index to Evaluate Equitable COVID-19 Vaccine Allocation in the San Francisco Bay Area.

Introduction: A social determinants of health index score or Vaccine Equity Metric was used to prioritize resources and address geographic disparities in California's vaccination coverage. We calculated the improvement index or percentage of the vaccination disparity gap closed to evaluate the impacts of this vaccination strategy in the San Francisco Bay Area during the SARS-CoV-2 Delta variant surge. Methods: We conducted a cross-sectional study on San Francisco Bay Area ZIP codes during the Delta surge (July 6-October 5, 2021). Data came from the California Immunization Registry and the 2019 5-year American Community Survey. We used Spearman correlations to examine the relationships between Vaccine Equity Metric category and vaccine coverage and Kruskal-Wallis tests to compare vaccination improvement index across Vaccine Equity Metric categories. Results: We studied 248 ZIP codes in the San Francisco Bay Area. Those with the lowest resources (Vaccine Equity Metric Level 1) had the highest absolute increase in vaccination coverage (14.3 vs 5.4 percentage points in Vaccine Equity Metric Level 4), although a contribution was higher starting vaccination rates in Level 4 ZIP codes with the greatest resources. The ratio of vaccination coverage between the lowest- and highest-resourced ZIP codes increased from 0.79 to 0.9, suggesting reduced disparity. However, it is difficult to interpret given wide differences in n (Level 1 n=8 vs Level 4 n=151). In contrast, the vaccination improvement index accounts for each Vaccine Equity Metric category's baseline vaccination; all were statistically similar (grand mean=41.5%, p=0.367), implying comparable improvement across all ZIP codes. Conclusions: Using a Vaccine Equity Metric to identify and prioritize resources to vulnerable communities contributed to equitable vaccine allocation in the San Francisco Bay Area. Our study shows an example of the improvement index's advantages over conventional health equity metrics, such as absolute differences and relative effect measures, which can overestimate an intervention's impact.

Toxic Exposures Among Young Children One Year into the COVID-19 Pandemic: A Retrospective Review of Three San Francisco Bay Area Emergency Departments.

BACKGROUND: Daycare and school closures prompted by shelter-in-place orders may have increased opportunities for unintentional ingestions among young children. OBJECTIVES: We examined emergency department (ED) presentations for toxic exposures among young children during the COVID-19 pandemic in the San Francisco Bay Area, which had some of the strictest and most prolonged shelter-in-place policies in the United States. METHODS: We performed a retrospective cross-sectional study of children 0 to 5 years of age who presented with an ED International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of toxic exposure within a tertiary care hospital system between March 16, 2016 and March 15, 2021. We considered the period after March 16, 2020 to represent the pandemic. RESULTS: During the pandemic, the absolute number of poisonings among young children remained stable. Overall, ED encounters within this cohort decreased by 55%, which doubled the relative toxic exposure rate per 1000 ED encounters from 4.99 (95% confidence interval [CI] 3.19-5.90) to 9.79 (95% CI 8.09-11.49). Rates of admission, severe medical complications, operating room case requests, and length of stay were not significantly different. Shelter-in-place was associated with significantly higher odds of cannabis ingestion (odds ratio = 2.70, 95% CI 1.60-4.49). CONCLUSION: Despite dramatic decreases in overall ED patient volumes, the absolute number and severity of toxic exposures were similar during the pandemic compared with previous years. © 2022 Elsevier Inc.

Rapid CRISPR-Cas13a genetic identification enables new opportunities for listed Chinook salmon management.

Accurate taxonomic identification is foundational for effective species monitoring and management. When visual identifications are infeasible or inaccurate, genetic approaches provide a reliable alternative. However, these approaches are sometimes less viable (e.g., need for near real-time results, remote locations, funding concerns, molecular inexperience). In these situations, CRISPR-based genetic tools can fill an unoccupied niche between real-time, inexpensive, but error-prone visual identification and more expensive or time-consuming, but accurate genetic identification for taxonomic units that are difficult or impossible to visually identify. Herein, we use genomic data to develop CRISPR-based SHERLOCK assays capable of rapidly (<1 h), accurately (94%-98% concordance between phenotypic and genotypic assignments), and sensitively (detects 1-10 DNA copies/reaction) distinguishing ESA-listed Chinook salmon runs (winter- and spring-run) from each other and from unlisted runs (fall- and late fall-run) in California's Central Valley. The assays can be field deployable with minimally invasive mucus swabbing negating the need for DNA extraction (decreasing costs and labour), minimal and inexpensive equipment needs, and minimal training to conduct following assay development. This study provides a powerful genetic approach for a species of conservation concern that benefits from near real-time management decision-making but also serves as a precedent for transforming how conservation scientists and managers view genetic identification going forward. Once developed, CRISPR-based tools can provide accurate, sensitive, and rapid results, potentially without the prohibitive need for expensive specialty equipment or extensive molecular training. Further adoption of this technology will have widespread value for the monitoring and protection of our natural resources.