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Importance: Depression is common in adults experiencing homelessness. It is unclear whether continued homelessness is associated with more depressive symptoms. Objective: To examine the association between residential status and depressive symptoms in adults aged 50 years or older experiencing homelessness at study entry. Design, Setting, and Participants: This cohort study analyzed results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME) project, which in 2013 began enrolling adults aged 50 years or older experiencing homelessness in Oakland, California, and conducted structured interviews every 6 months for a mean duration of 5.5 years through 2023 (for this cohort study). Eligible participants included those aged 50 years or older, able to speak English, and experiencing homelessness at enrollment. We analyzed data collected from 2013 to 2023. Exposures: The exposure of interest was residential status. At follow-up visits, residential status was categorized as (1) homelessness (meeting the HEARTH [Homeless Emergency Assistance and Rapid Transition to Housing] Act definition) or (2) housed (living in a noninstitutional environment and not meeting the HEARTH Act definition). Main Outcomes and Measures: The primary outcome was moderate to severe depressive symptoms (with Center for Epidemiologic Studies-Depression [CES-D] scale score ≥22). The augmented inverse probability of treatment weighting (AIPTW) approach was used to examine the association between continued homelessness and depressive symptoms. The AIPTW adjusted for the following variables: number of chronic health conditions, age, sex, visiting a health care practitioner, receiving outpatient mental health treatment, receiving mental health medication, exposure to abuse, substance use disorder, and binge drinking. Results: The cohort was composed of 450 participants, of whom 343 (76.2%) were males, and the mean (SD) age was 58.5 (5.2) years. Participants completed a median (IQR) of 8.9 (8-11) follow-up visits. With 1640 person-years of observation time, participants continued homelessness for 880 person-years (57.1%) and experienced being housed for 715 person-years (44.3%). Many participants (304 [78.0%]) were housed during at least 1 follow-up visit. The odds of a CES-D scale score of 22 or higher was significantly higher among participants who continued experiencing homelessness than among housed participants (marginal causal odds ratio, 1.08; 95% CI, 1.04-1.11; P < .001). Conclusions and Relevance: This cohort study found that continued homelessness was associated independently with increased odds of depressive symptoms. Obtaining housing may have a favorable role in depression and overall well-being of older adults experiencing homelessness and may be considered as a mental health intervention.
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Depresión , Personas con Mala Vivienda , Humanos , Personas con Mala Vivienda/estadística & datos numéricos , Personas con Mala Vivienda/psicología , Masculino , Femenino , Persona de Mediana Edad , Depresión/epidemiología , Anciano , Estudios de Cohortes , California/epidemiologíaRESUMEN
Rates of homelessness among adults aged 50 and over are rising. Common strategies for exiting homelessness rely on social and family support. However, intergenerational trauma may disrupt these social support networks and contribute to homelessness. Understanding the impact of intergenerational trauma on living with family or friends may give insight into addressing homelessness among older adults. We purposefully sampled 46 adults who reported living with family or friends from the HOPE HOME study cohort (350 community-recruited adults, ≥ 50 years and experiencing homelessness in Oakland, California) and 19 family/friends who had hosted the participants in their living spaces. We conducted independent, semi-structured interviews and used grounded theory methodologies to analyze data. We identified four major themes from the interviews: (1) Intergenerational trauma was common and made it difficult to stay with family or friends; (2) Participants and hosts sought to protect future generations from intergenerational trauma; (3) Relationships endured despite intergenerational trauma; and (4) social structures exacerbated the impact of intergenerational trauma and played a significant role in perpetuating homelessness. Trauma-informed policies that confront the structures that propagate or exacerbate intergenerational trauma may mitigate their impact and facilitate housing for older adults.
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This cohort study examines housing status and acute care use after a cancer diagnosis among individuals treated at a public hospital in San Francisco, California.
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Vivienda , Neoplasias , Humanos , Femenino , Masculino , Neoplasias/diagnóstico , Persona de Mediana Edad , Anciano , AdultoRESUMEN
PURPOSE: The aim of this study was to investigate the influence of preoperative anxiety and depression on subjective function, pain and revision rates following total knee arthroplasty (TKA). METHODS: A prospective comparative study was conducted, including 349 patients undergoing TKA surgery between January 2019 and April 2021. Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire preoperatively, and a set of Patient-Reported Outcome Measures (PROMs) preoperatively and at 6, 12 and 24 months postoperatively. Patients were categorized into anxiety and depression groups based on HADS scores. PROMs included the Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS) and NRS-Pain. Differences in PROM scores between the anxiety/depression group and, respectively, nonanxiety/nondepression group were assessed, as well as differences in minimal clinical important difference (MCID) and attainment of Patient Acceptable Symptom State (PASS). Lastly, revision rates were compared. RESULTS: Anxiety and depression groups exhibited inferior subjective function preoperatively and postoperatively compared to nonanxiety and nondepression groups (all p < 0.05), experienced more pain preoperatively (p < 0.001) and also postoperatively for depression patients (all p < 0.05). Significantly fewer patients with anxiety and depression reached the PASS for KOOS-PS, OKS and NRS-Pain (all p < 0.05). There were no differences in the proportion of patients reaching the MCID for all PROMs (all p > 0.060), and revision rates did not differ between groups (both p > 0.96). CONCLUSION: Preoperative anxiety and depression negatively influence subjective function and pain preoperatively and up to 2-year follow-up in patients undergoing TKA. Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain. LEVEL OF EVIDENCE: Level II, prospective comparative study.
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BACKGROUND: The long-term sustainability of arthroscopic bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT) remains a matter of debate. The primary aim of the present study was to assess the 10-year survival free from revision in ankles that had undergone arthroscopic BMS for an OLT. The secondary aim was to evaluate the influence of baseline patient and lesion characteristics on survival. METHODS: Patients who underwent arthroscopic BMS for a symptomatic OLT and had a minimum follow-up of 10 years were included to assess procedure survival. The primary outcome, the 10-year cumulative survival rate, was analyzed by the Kaplan-Meier survival method. Secondary outcomes were the median time to revision and the effects of baseline factors (lesion size, primary or non-primary lesion type, preoperative cysts, and obesity as defined by a body mass index [BMI] of ≥30 kg/m 2 ) on survival, analyzed with a Cox regression model and reported using hazard ratios (HRs). RESULTS: The 262 included patients had a mean follow-up of 15.3 ± 4.8 years. The 10-year cumulative survival rate of the arthroscopic BMS procedures was 82% (95% confidence interval [CI]: 77% to 87%). At 15 years of follow-up, the cumulative survival rate was 82% (95% CI: 76% to 86%). The median time to revision was 2.4 years (interquartile range: 1.3 to 5.1 years). Of the baseline factors, obesity (HR: 3.0 [95% CI: 1.44 to 6.43], p < 0.01) was associated with decreased survival. Lesion size (HR: 0.9 [95% CI: 0.5 to 1.8], p = 0.8), non-primary lesion type (HR: 1.8 [95% CI: 0.9 to 3.4], p = 0.1), and the presence of preoperative cysts (HR: 1.0 [95% CI: 0.6 to 1.9], p = 0.9) were not significantly associated with survival. CONCLUSIONS: At a minimum follow-up of 10 years, the survival rate of arthroscopic BMS for OLT was 82%. At 15 and 20 years of follow-up, survival appeared to remain stable. Obesity (BMI ≥ 30 kg/m 2 ) was associated with a higher likelihood of revision surgery. This risk factor should be incorporated into the treatment algorithm for OLT when counseling patients regarding surgery. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Artroscopía , Astrágalo , Humanos , Astrágalo/cirugía , Astrágalo/patología , Masculino , Femenino , Adulto , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Médula Ósea/patología , Estudios Retrospectivos , Estudios de Seguimiento , Resultado del Tratamiento , Cartílago Articular/cirugía , Cartílago Articular/patologíaRESUMEN
PURPOSE: This study aimed to investigate how psychological factors, including pain catastrophizing (PC), anxiety and depression affect preoperative and postoperative subjective outcomes in patients undergoing unicompartmental knee arthroplasty (UKA). METHODS: A prospective comparative study was performed among 150 patients undergoing medial or lateral UKA for isolated unicompartmental osteoarthritis. Patients were categorized based on their preoperative PC and Hospital Anxiety and Depression Scale, stratifying them into groups with PC, anxiety or depression, and those without these psychological factors. Patient-reported outcomes, including the Knee Injury and Osteoarthritis Outcome Score-Physical function Short form (KOOS-PS), 5-level EQ5D Visual Analogue Scale (EQ5D-VAS), Forgotten Joint Score (FJS) and Numeric Rating Scale for pain (NRS-pain) were compared between groups preoperatively and at 6-, 12-, and 24-month follow-up. RESULTS: At 24 months, PC patients had inferior outcomes in KOOS-PS (66.9 ± 16.5 vs. 77.6 ± 14.7, p = .008), EQ5D-VAS (63.5 ± 19.9 vs. 78.9 ± 20.1, p = .003) and FJS (73.7 ± 14.3 vs. 84.6 ± 13.8, p = .003). Anxiety was associated with inferior KOOS-PS (65.4 ± 15.2 vs. 78.2 ± 14.5, p = <.001), EQ5D-VAS (64.2 ± 23.2 vs. 79.3 ± 19.4, p = .002), FJS (75.7 ± 16.8 vs. 84.6 ± 13.4, p = .008) and NRS-pain (27.4 ± 24.6 vs. 13.7 ± 19.3, p = .023) at 24 months. Depression consistently resulted in inferior outcomes in KOOS-PS, EQ5D-VAS, FJS and NRS-pain across all follow-up assessments (p = <.05). Additionally, patients with anxiety and depression experienced longer length of hospital stay compared to those without these psychological factors (anxiety: 2.3 ± 2.3 vs. 0.8 ± 0.8 days, p = .006; depression: 2.3 ± 2.4 vs. 0.8 ± 0.8 days, p = .017). CONCLUSIONS: Preoperative PC, anxiety and depression are associated with inferior subjective outcomes both prior to and following UKA. Among these factors, depression seemed to exert the most substantial adverse impact on outcomes following UKA. Patients with anxiety and depression had an extended duration of hospitalization lasting over twice as long as patients without these psychological factors. It seems that inferior outcomes primarily stem from the suboptimal preoperative condition rather than an inherent inability to benefit from UKA. LEVEL OF EVIDENCE: Level II, prospective study.
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For diversity to exist in the medical graduate workforce, students from all backgrounds should have equitable opportunities of employment. Specialties have utilized a minimal threshold for USMLE Step 1 score when screening applicants for residency interviews. The OHSU SOM class of 2021 completed a 14-question voluntary survey on their Step 1 score and the following non-modifiable risk factors: Adverse Childhood Experience score (ACEs), sex, gender, Underrepresented in Medicine status (URiM), family income during adolescence, highest degree held by a guardian, discrimination experience during medical school, federal/state assistance use, and rural versus urban primary home. Descriptive statistics and unadjusted risk ratios were applied to study the relation between Step 1 score and non-modifiable risk factors as well as certain non-modifiable risk factors and ACEs ≥ 3. The mean Step 1 score was 230 (213, 247). Of the students, 28.2% identified ACEs ≥ 3, 13.6% were considered URiM, and 65.4% were female. URiM were 2.34 (1.30, 4.23),females were 2.77 (1.06-7.29), and those who experienced discrimination in medical school were 4.25 (1.85, 9.77) times more likely to have ACEs ≥ 3. Students who had ACEs ≥ 3 were 3.58 (1.75, 7.29) times less likely to meet a minimal threshold for residency interviews of 220. These are the first results to demonstrate a relationship between Step 1 score and ACEs. Those who identified as URiM, females, and those who experienced discrimination in medical school were at a higher risk of ACEs of ≥ 3. Step 1 transitioned to pass/fail in January 2022. However, the first application cycle that residencies will see pass/fail scoring is 2023-2024, and fellowships will continue to see scored Step 1 until, at the earliest, the 2026-2027 application cycle. These data contribute to a foundation of research that could apply to Step 2CK testing scores, and help to inform decisions about the diversity and equity of the residency interview process.
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Internado y Residencia , Medicina , Estudiantes de Medicina , Humanos , Femenino , Estados Unidos , Masculino , Evaluación Educacional/métodosRESUMEN
Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.
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Neoplasias de la Mama , Personas con Mala Vivienda , Veteranos , Adulto , Humanos , Estados Unidos , Anciano , Femenino , ViviendaRESUMEN
Living with family and friends is a common strategy used to prevent or exit homelessness, but little is known about structural barriers that impede family and friends' ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported having stayed with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived staying with family or friends as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.
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We encountered a case of an 18-year-old woman with persisting ankle pain after a healed Weber-B fracture. Additional imaging through a computed tomography (CT) scan revealed a fully united fragmentous osteochondral lesion of the talus (OLT) (17 âmm â× â9 âmm â× â8 âmm) of the right ankle-as opposed to a non-united OLT when the fracture was diagnosed 19 months prior to the presentation. Our proven hypothesis is that the fragmented OLT was non-symptomatic for many years, based on an osteochondritis dissecans. The ipsilateral ankle trauma induced a fresh fracture in the interface between the talus and the fragmented OLT, and consequently the destabilized fragmented OLT became symptomatic. The ankle trauma initiated fracture healing that resulted in a complete union of the OLT without clinical symptoms. The existing symptoms were established to be based on anterior osseous ankle impingement, due to the presence of osseous fragments in the medial gutter of the ankle joint. Therefore, a nettoyage of the medial gutter including a resection of the corpora libera from the medial gutter with the shaver was performed. Intraoperative macroscopic assessment of the medial osteochondritis dissecans was performed and showed union with completely intact hyaline cartilage at the level of the surrounding articular cartilage requiring no interventions. An increased range of motion was achieved. The patient recovered well with and experienced no more recognizable pain. In this article, the unstable fragmentous lesion of the patient reached spontaneous union within 19 months after destabilization. Although this is not common for an unstable fragmentous OLT, this could be a stepping stone toward an increased role of conservative treatment for fragmentary OLTs.
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Traumatismos del Tobillo , Osteocondritis Disecante , Astrágalo , Osteocondritis Disecante/diagnóstico por imagen , Osteocondritis Disecante/etiología , Astrágalo/diagnóstico por imagen , Astrágalo/lesiones , Humanos , Femenino , Adolescente , Tomografía Computarizada por Rayos X , Traumatismos del Tobillo/complicaciones , Traumatismos del Tobillo/diagnóstico por imagen , Curación de FracturaRESUMEN
Cell-cell communication and physical interactions play a vital role in cancer initiation, homeostasis, progression, and immune response. Here, we report a system that combines live capture of different cell types, co-incubation, time-lapse imaging, and gene expression profiling of doublets using a microfluidic integrated fluidic circuit that enables measurement of physical distances between cells and the associated transcriptional profiles due to cell-cell interactions. We track the temporal variations in natural killer-triple-negative breast cancer cell distances and compare them with terminal cellular transcriptome profiles. The results show the time-bound activities of regulatory modules and allude to the existence of transcriptional memory. Our experimental and bioinformatic approaches serve as a proof of concept for interrogating live-cell interactions at doublet resolution. Together, our findings highlight the use of our approach across different cancers and cell types.
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Transcriptoma , Neoplasias de la Mama Triple Negativas , Humanos , Microfluídica , Perfilación de la Expresión Génica/métodos , Regulación de la Expresión GénicaRESUMEN
Patients experiencing homelessness face significant barriers to screening and treatment for colorectal cancer, leading to worse outcomes. In this perspective, we use an exemplar patient case to highlight potential policy solutions for reducing this health care disparity by increasing access to early detection and treatment in this population.
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Importance: The population of homeless older adults is growing and experiences premature mortality. Little is known about factors associated with mortality among homeless older adults. Objective: To identify the prevalence and factors associated with mortality in a cohort of homeless adults 50 years and older. Design, Setting, and Participants: In this prospective cohort study (Health Outcomes in People Experiencing Homelessness in Older Middle Age [HOPE HOME]), 450 adults 50 years and older who were homeless at baseline were recruited via venue-based sampling in Oakland, California. Enrollment occurred in 2 phases, from July 2013 to June 2014 and from August 2017 to July 2018, and participants were interviewed at 6-month intervals. Exposures: Baseline and time-varying characteristics, including sociodemographic factors, social support, housing status, incarceration history, chronic medical conditions, substance use, and mental health problems. Main Outcomes and Measures: Mortality through December 31, 2021, based on state and local vital records information from contacts and death certificates. All-cause mortality rates were compared with those in the general population from 2014 to 2019 using age-specific standardized mortality ratios with 95% CIs. Results: Of the 450 included participants, median (IQR) age at baseline was 58.1 (54.5-61.6) years, 107 (24%) were women, and 360 (80%) were Black. Over a median (IQR) follow-up of 55 (38-93) months, 117 (26%) participants died. Median (IQR) age at death was 64.6 (60.3-67.5) years. In multivariable analyses, characteristics associated with mortality included a first episode of homelessness at 50 years and older (adjusted hazard ratio [aHR], 1.62; 95% CI, 1.13-2.32), homelessness (aHR, 1.82; 95% CI, 1.23-2.68) or institutionalization (aHR, 6.36; 95% CI, 3.42-11.82) at any follow-up compared with being housed, fair or poor self-rated health (aHR, 1.64; 95% CI, 1.13-2.40), and diabetes (aHR, 1.55; 95% CI, 1.06-2.26). Demographic characteristics, substance use problems, and mental health problems were not independently associated. All-cause standardized mortality was 3.5 times higher (95% CI, 2.5-4.4) compared with adults in Oakland. The most common causes of death were heart disease (n = 17 [14.5%]), cancer (n = 17 [14.5%]), and drug overdose (n = 14 [12.0%]). Conclusions and Relevance: The cohort study found that premature mortality was common among homeless older adults and associated factors included late-life homelessness and ongoing homelessness. There is an urgent need for policy approaches to prevent and end homelessness among older adults in the US.
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Personas con Mala Vivienda , Trastornos Relacionados con Sustancias , Anciano , Enfermedad Crónica , Estudios de Cohortes , Femenino , Vivienda , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Importance: Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown. Objective: To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use. Design, Setting, and Participants: This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022. Exposures: SIP hotel placement with on-site supportive services. Main Outcomes and Measures: The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits. Results: Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P < .001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P < .001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P < .001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P < .001). Conclusions and Relevance: These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.
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COVID-19 , Personas con Mala Vivienda , Trastornos Relacionados con Sustancias , COVID-19/epidemiología , Refugio de Emergencia , Femenino , Servicios de Salud , Personas con Mala Vivienda/psicología , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Estudios Retrospectivos , Trastornos Relacionados con Sustancias/epidemiologíaAsunto(s)
Infecciones por VIH , Personas con Mala Vivienda , Trastornos Relacionados con Sustancias , Infecciones por VIH/epidemiología , Infecciones por VIH/psicología , Infecciones por VIH/terapia , Personas con Mala Vivienda/psicología , Humanos , Salud Mental , Problemas Sociales , Trastornos Relacionados con Sustancias/terapiaRESUMEN
BACKGROUND: Despite programs to address housing for Veterans, they continue to be at high risk of unstable housing. Interpersonal violence is also highly prevalent among Veterans and may contribute to unstable housing. Our study aimed to determine whether interpersonal violence was associated with unstable housing among Veterans, and how this association was influenced by common co-occurring conditions such as substance use and mental illness. METHODS: Veterans in the Mind Your Heart Study (N = 741) completed survey data on history of interpersonal violence and access to housing in the prior year. Interpersonal violence was defined as experiencing sexual violence, physical violence, or mugging/physical attack using the Brief Trauma Questionnaire. Multivariable models examined associations between interpersonal violence and unstable housing. Primary models were adjusted for age and sex. Potential explanatory factors were added in subsequent models, including marital status, education, income, substance use disorder, PTSD, and other mental illness. RESULTS: Veterans who had experienced interpersonal violence had almost twice the odds of unstable housing after adjustment for age and sex (AOR 1.9, 95% CI 1.2-3.0). This association was attenuated in the fully adjusted model including substance use, PTSD, and other mental illness, illustrating the interdependence of these factors (AOR 1.5, 95% CI 0.91-2.5). Subtypes of interpersonal violence were individually associated with increased odds of unstable housing after adjustment for age and sex (physical abuse AOR 1.7, 95% CI 1.2-2.5; mugging/physical attack AOR 1.8, 95% CI 1.2-2.7; sexual violence AOR 1.4, 95% CI 0.89-2.2), but were no longer significant in the fully adjusted model. CONCLUSIONS: Previous experiences of interpersonal violence were associated with unstable housing among Veterans. Substance use, PTSD, and other mental illness played an important role in this relationship-highlighting the potential to improve health outcomes through trauma informed approaches that address mental health, substance use, and housing concurrently.
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BACKGROUND: Acute healthcare utilization attributed to alcohol use disorders (AUD) and other substance use disorders (SUD) is rising. OBJECTIVE: To describe the prevalence and characteristics of emergency department (ED) visits and hospitalizations made by adults with AUD or SUD. DESIGN, SETTING, AND PARTICIPANTS: Observational study with retrospective analysis of the National Hospital Ambulatory Medical Care Survey (2014 to 2018), a nationally representative survey of acute care visits with information on the presence of AUD or SUD abstracted from the medical chart. MAIN MEASURES: Outcome measured as the presence of AUD or SUD. KEY RESULTS: From 2014 to 2018, the annual average prevalence of AUD or SUD was 9.4% of ED visits (9.3 million visits) and 11.9% hospitalizations (1.4 million hospitalizations). Both estimates increased over time (30% and 57% relative increase for ED visits and hospitalizations, respectively, from 2014 to 2018). ED visits and hospitalizations from individuals with AUD or SUD, compared to individuals with neither AUD nor SUD, had higher percentages of Medicaid insurance (ED visits: AUD: 33.1%, SUD: 35.0%, neither: 24.4%; hospitalizations: AUD: 30.7%, SUD: 36.3%, neither: 14.8%); homelessness (ED visits: AUD: 6.2%, SUD 4.4%, neither 0.4%; hospitalizations: AUD: 5.9%, SUD 7.3%, neither: 0.4%); coexisting depression (ED visits: AUD: 26.3%, SUD 24.7%, neither 10.5%; hospitalizations: AUD: 33.5%, SUD 35.3%, neither: 13.9%); and injury/trauma (ED visits: AUD: 51.3%, SUD 36.3%, neither: 26.4%; hospitalizations: AUD: 31.8%, SUD: 23.8%, neither: 15.0%). CONCLUSIONS: In this nationally representative study, 1 in 11 ED visits and 1 in 9 hospitalizations were made by adults with AUD or SUD, and both increased over time. These estimates are higher or similar than previous national estimates using claims data. This highlights the importance of identifying opportunities to address AUD and SUD in acute care settings in tandem with other medical concerns, particularly among visits presenting with injury, trauma, or coexisting depression.
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Alcoholismo , Trastornos Relacionados con Sustancias , Adulto , Alcoholismo/epidemiología , Alcoholismo/terapia , Servicio de Urgencia en Hospital , Hospitalización , Humanos , Prevalencia , Estudios Retrospectivos , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/terapia , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: A better understanding of pain treatment satisfaction in patients with chronic noncancer pain (CNCP) and substance use is needed, especially as opioid prescribing policies are changing. We sought to identify factors associated with pain treatment satisfaction in individuals with CNCP on recent opioid therapy and prior or active substance use. METHODS: An exploratory cross-sectional analysis using baseline data from a cohort study of 300 adults with CNCP receiving >20 morphine milligram equivalents of opioids for ≥3 of the preceding 12 months and prior or active substance use. Participants completed interviews, clinical assessments, urine drug screening, and medical chart review. RESULTS: Participants were predominantly middle-aged (mean age 57.5 years), Black (44%), and cisgender men (60%). One-third (33%) had high, 28% moderate, and 39% low pain treatment satisfaction. Post-traumatic stress disorder (PTSD), tobacco use, past-year opioid discontinuation, and higher average pain scores were associated with lower satisfaction. HIV and prescription cannabis use were associated with higher satisfaction. CONCLUSIONS: The relationship between PTSD and tobacco use with lower satisfaction should be explored to augment pain outcomes. Higher satisfaction among individuals with HIV and prescription cannabis use presents potential research areas to guide CNCP management and reduce reliance on opioid therapies.
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Dolor Crónico , Trastornos Relacionados con Sustancias , Adulto , Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Dolor Crónico/epidemiología , Estudios de Cohortes , Estudios Transversales , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Satisfacción Personal , Pautas de la Práctica en Medicina , Trastornos Relacionados con Sustancias/epidemiologíaRESUMEN
BackgroundAs COVID-19 vaccines continue to be rolled-out, the "double burden" of health disparities in both exposure to infection and vaccination coverage intersect to determine the current and future patterns of infection, immunity, and mortality. Serology provides a unique opportunity to measure biomarkers of infection and vaccination simultaneously, and to relate these metrics to demographic and geographic factors. MethodsLeveraging algorithmically selected residual serum samples from two hospital networks in San Francisco, we sampled 1014 individuals during February 2021, capturing transmission during the first 11 months of the epidemic and the early roll out of vaccination. These samples were tested using two serologic assays: one detecting antibodies elicited by infection, and not by vaccines, and one detecting antibodies elicited by both infection and vaccination. We used Bayesian statistical models to estimate the proportion of the population that was naturally infected and the proportion protected due to vaccination. FindingsWe estimated that the risk of prior infection of Latinx residents was 5.3 (95% CI: 3.2 - 10.3) times greater than the risk of white residents aged 18-64 and that white San Francisco residents over the age of 65 were twice as likely (2.0, 95% CI: 1.1 - 4.6) to be vaccinated as Black residents. We also found socioeconomically deprived zipcodes in the city had high probabilities of natural infections and lower vaccination coverage than wealthier zipcodes. InterpretationUsing a platform we created for SARS-CoV-2 serologic data collection in San Francisco, we characterized and quantified the stark disparities in infection rates and vaccine coverage by demographic groups over the first year of the pandemic. While the arrival of the SARS-CoV-2 vaccine has created a light at the end of the tunnel for this pandemic, ongoing challenges in achieving and maintaining equity must also be considered. FundingNIH, NIGMS, Schmidt Science Fellows in partnership with the Rhodes Trust and the Chan Zuckerberg Biohub.
RESUMEN
BACKGROUND: Xiphodynia, the painful xiphoid process, is a rare condition with an atypical presentation. Symptoms differ in severity and site, and can consist of chest, throat, and upper abdominal pain. Primarily, other more severe causes of these symptoms need to be excluded. After this exclusion as xiphodynia is diagnosed, treatment can consist of a multitude of options, since there is no consensus regarding the optimal treatment. The aim of this study was to describe the outcomes and efficacy of one of the options, namely surgical resection of the xiphoid in patients with xiphodynia. METHODS: In this retrospective case series, all consecutive patients that underwent xiphoidectomy for xiphodynia between January 2014 and December 2017 were included. Patients' medical files including pre-operative work up, NRS scores, surgical outcomes, and follow up were reviewed. All patients received a questionnaire with follow-up questions. RESULTS: A total of 19 patients were included. None of the patients had surgery-related complications. Response rate of the questionnaire was 84% and showed that 94% of patients had an improvement of complaints after surgery, with 10 patients (63%) being totally pain free, after a mean follow-up from 34 months after surgery. CONCLUSIONS: Xiphoidectomy is feasible and safe for the treatment of patients with xiphodynia with an improvement of complaints in nearly all patients.