ObjectivesTo examine exposure–response relationships between surrogates of firefighting exposure and select outcomes among previously studied US career firefighters.MethodsEight cancer and four ...non-cancer outcomes were examined using conditional logistic regression. Incidence density sampling was used to match each case to 200 controls on attained age. Days accrued in firefighting assignments (exposed-days), run totals (fire-runs) and run times (fire-hours) were used as exposure surrogates. HRs comparing 75th and 25th centiles of lagged cumulative exposures were calculated using loglinear, linear, log-quadratic, power and restricted cubic spline general relative risk models. Piecewise constant models were used to examine risk differences by time since exposure, age at exposure and calendar period.ResultsAmong 19 309 male firefighters eligible for the study, there were 1333 cancer deaths and 2609 cancer incidence cases. Significant positive associations between fire-hours and lung cancer mortality and incidence were evident. A similar relation between leukaemia mortality and fire-runs was also found. The lung cancer associations were nearly linear in cumulative exposure, while the association with leukaemia mortality was attenuated at higher exposure levels and greater for recent exposures. Significant negative associations were evident for the exposure surrogates and colorectal and prostate cancers, suggesting a healthy worker survivor effect possibly enhanced by medical screening.ConclusionsLung cancer and leukaemia mortality risks were modestly increasing with firefighter exposures. These findings add to evidence of a causal association between firefighting and cancer. Nevertheless, small effects merit cautious interpretation. We plan to continue to follow the occurrence of disease and injury in this cohort.
Drivers of phytoplankton and zooplankton dynamics vary spatially and temporally in estuaries due to variation in hydrodynamic exchange and residence time, complicating efforts to understand controls ...on food web productivity. We conducted approximately monthly (2012–2019; n = 74) longitudinal sampling at 10 fixed stations along a freshwater tidal terminal channel in the San Francisco Estuary, California, characterized by seaward to landward gradients in water residence time, turbidity, nutrient concentrations, and plankton community composition. We used multivariate autoregressive state space (MARSS) models to quantify environmental (abiotic) and biotic controls on phytoplankton and mesozooplankton biomass. The importance of specific abiotic drivers (e.g., water temperature, turbidity, nutrients) and trophic interactions differed significantly among hydrodynamic exchange zones with different mean residence times. Abiotic drivers explained more variation in phytoplankton and zooplankton dynamics than a model including only trophic interactions, but individual phytoplankton–zooplankton interactions explained more variation than individual abiotic drivers. Interactions between zooplankton and phytoplankton were strongest in landward reaches with the longest residence times and the highest zooplankton biomass. Interactions between cryptophytes and both copepods and cladocerans were stronger than interactions between bacillariophytes (diatoms) and zooplankton taxa, despite contributing less biovolume in all but the most landward reaches. Our results demonstrate that trophic interactions and their relative strengths vary in a hydrodynamic context, contributing to food web heterogeneity within estuaries at spatial scales smaller than the freshwater to marine transition.
Reliable estimation of river discharge to the ocean from large tidal rivers is vital for water resources management and climate analyses. Due to the difficulties inherent in measuring tidal‐river ...discharge, flow records are often limited in length and/or quality and tidal records often predate discharge records. Tidal theory indicates that tides and river discharge interact through quadratic bed friction, which diminishes and distorts the tidal wave as discharge increases. We use this phenomenon to develop a method of estimating river discharge for time periods with tidal data but no flow record. Employing sequential 32 day harmonic analyses of tidal properties, we calibrate San Francisco (SF), CA tide data to the Sacramento River delta outflow index from 1930 to 1990, and use the resulting relationship to hindcast river flow from 1858 to 1929. The M2 admittance (a ratio of the observed M2 tidal constituent to its astronomical forcing) best reproduces high flows, while low‐flow periods are better represented by amplitude ratios based on higher harmonics (e.g.,
M4/M22). Results show that the annual inflow to SF Bay is now 30% less than before 1900 and confirm that the flood of January 1862 was the largest since 1858.
Key Points
estimating river discharge for time periods with tidal data but no flow record.
moves the nexus of measurement away from the complexities of the delta
captures important climate cycles and long‐term hydrological trends
To address gaps in U.S. health care outcomes, medical education is evolving to incorporate new competencies, as well as to align with care delivery transformation and prepare systems-ready providers. ...These new health systems science (HSS) competencies—including value-based care, quality improvement, social determinants of health, population health, informatics, and systems thinking—require formal education and role modeling in both classroom and clinical settings. This is challenging because few faculty had formal training in how to practice or teach these concepts. Thus, these new competencies require both expanding current educators’ skills and a new cohort of educators, especially interprofessional clinicians. Additionally, because interprofessional teams are the foundation of many clinical learning environments, medical schools are developing innovative experiential activities that include interprofessional clinicians as teachers. This combination of a relative “expertise vacuum” within the current cohort of medical educators and expanding need for workplace learning opportunities requires a reimagining of medical school teachers. Based on experiences implementing HSS curricula at two U.S. medical schools (Penn State College of Medicine and University of California, San Francisco, School of Medicine, starting in 2013), this Perspective explores the need for new educator competencies and the implications for medical education, including the need to identify and integrate “new” educators into the education mission, develop faculty educators’ knowledge and skills in HSS, and acknowledge and reward new and emerging educators. These efforts have the potential to better align the clinical and education missions of academic health centers and cultivate the next generation of physician leaders.
IntroductionDepression and diabetes are highly disabling diseases with a high prevalence and high rate of comorbidity, particularly in low-income ethnic minority patients. Though comorbidity ...increases the risk of adverse outcomes and mortality, most clinical interventions target these diseases separately. Increasing physical activity might be effective to simultaneously lower depressive symptoms and improve glycaemic control. Self-management apps are a cost-effective, scalable and easy access treatment to increase physical activity. However, cutting-edge technological applications often do not reach vulnerable populations and are not tailored to an individual’s behaviour and characteristics. Tailoring of interventions using machine learning methods likely increases the effectiveness of the intervention.Methods and analysisIn a three-arm randomised controlled trial, we will examine the effect of a text-messaging smartphone application to encourage physical activity in low-income ethnic minority patients with comorbid diabetes and depression. The adaptive intervention group receives messages chosen from different messaging banks by a reinforcement learning algorithm. The uniform random intervention group receives the same messages, but chosen from the messaging banks with equal probabilities. The control group receives a weekly mood message. We aim to recruit 276 adults from primary care clinics aged 18–75 years who have been diagnosed with current diabetes and show elevated depressive symptoms (Patient Health Questionnaire depression scale-8 (PHQ-8) >5). We will compare passively collected daily step counts, self-report PHQ-8 and most recent haemoglobin A1c from medical records at baseline and at intervention completion at 6-month follow-up.Ethics and disseminationThe Institutional Review Board at the University of California San Francisco approved this study (IRB: 17-22608). We plan to submit manuscripts describing our user-designed methods and testing of the adaptive learning algorithm and will submit the results of the trial for publication in peer-reviewed journals and presentations at (inter)-national scientific meetings.Trial registration numberNCT03490253; pre-results.
Black women have the highest estimated allostatic load (AL). AL and self-perceived health are strong health predictors and have been linked to racial discrimination. Research suggests that everyday ...and institution-specific racial discrimination may predict different AL and self-reported health (SRH) outcomes. Furthermore, discrepancies between AL and self-perceived health could widen disparities. We estimated associations between everyday versus institution-specific racial discrimination with AL and SRH.
Data are from a San Francisco Bay Area community sample of 208 black women aged 30–50 years. Participation involved a questionnaire, self-interview, blood draw, and anthropometric measurements. Adjusted generalized linear regression models estimated associations of racial discrimination with AL and SRH.
After adjusting for age, socioeconomic position, and medication use, institution-specific discrimination was negatively associated with AL (i.e., better health), whereas everyday experiences showed no association. Those reporting very-high (vs. moderate) institution-specific discrimination had lower AL (β = −1.31 95% CI: −2.41, −0.20; AL range: 0–15). No racial discrimination—SRH association was found.
For black women, (1) institution-specific racial discrimination may be differentially embodied compared with everyday experiences and (2) institutional racism may contribute to physiologic stress-regulation regardless of self-perceived health status. Potential factors that may contribute to an inverse racial discrimination—AL association, and future research, are discussed.
Abstract Objective The goal of this study was to investigate the adverse childhood experiences (ACEs) in youth in a low-income, urban community. Study design Data from a retrospective chart review of ...701 subjects from the Bayview Child Health Center in San Francisco are presented. Medical chart documentation of ACEs as defined in previous studies were coded and each ACE criterion endorsed by a traumatic event received a score of 1 (range = 0–9). This study reports on the prevalence of various ACE categories in this population, as well as the association between ACE score and two pediatric problems: learning/behavior problems and body mass index (BMI) ≥ 85% (i.e., overweight or obese). Results The majority of subjects (67.2%, N = 471) had experienced 1 or more categories of adverse childhood experiences (ACE ≥ 1) and 12.0% ( N = 84) had experienced 4 or more ACEs (ACE ≥ 4). Increased ACE scores correlated with increased risk of learning/behavior problems and obesity. Conclusions There was a significant prevalence of endorsed ACE categories in this urban population. Exposure to 4 or greater ACE categories was associated with increased risk for learning/behavior problems, as well as obesity. Practice implications Results from this study demonstrate the need both for screening of ACEs among youth in urban areas and for developing effective primary prevention and intervention models.
Few urban phenomena command as much attention as displacement. Scholars continue to refine conceptualisations of displacement to more effectively capture its diversity in forms, scales and ...temporalities. Recent research advocates a more inclusive conceptualisation, attuned to the processes of ‘un-homing’ – that is, the more subtle, ‘non-catastrophic’ forms of ‘slow violence’ that rupture residents’ phenomenological attachments to place and home. Advocates of the un-homing approach call on researchers to develop the data and analytical frameworks necessary for capturing the perceptions and lived experiences of displacement from the perspective of longtime residents. This article develops one such analytical framework, which we refer to as displacement frames. Building on the conceptual tools of cultural sociology, displacement frames are the evaluative schema through which residents make sense of, and act towards, the slow violence and micro-events of un-homing. Drawing on 32 interviews with long-time Black residents in San Francisco’s rapidly gentrifying Bayview Hunters Point neighbourhood, we identify three primary displacement frames: (1) displacement-by-design, (2) displacement-as-predation and (3) displacing-the-problem. As a product of residents’ historical experiences, networks and housing tenure, these frames simplify complex (and often ambiguous) experiences into a coherent narrative about the primary causes, conditions and consequences of displacement. In turn, displacement frames influence how and to what extent residents attempt to resist, prevent or perhaps even accept and support local displacement.
San Francisco and the Long 60s tells the fascinating story of the legacy of popular music in San Francisco between the years 1965-69. It is also a chronicle of the impact this brief cultural ...flowering has continued to have in the city a and more widely in American culture a right up to the present day. The aim of San Francisco and the Long 60s is to question the standard historical narrative of the time, situating the local popular music of the 1960s in the city's contemporary artistic and literary cultures: at once visionary and hallucinatory, experimental and traditional, singular and universal. These qualities defined the aesthetic experience of the local culture in the 1960s, and continue to inform the cultural and social life of the Bay Area even fifty years later.The brief period 1965-69 marks the emergence of the psychedelic counterculture in the Haight-Ashbury neighbourhood, the development of a local musical 'sound' into a mainstream international 'style', the mythologizing of the Haight-Ashbury as the destination for 'seekers' in the Summer of Love, and the ultimate dispersal of the original hippie community to outlying counties in the greater Bay Area and beyond. San Francisco and the Long 60s charts this period with the references to received historical accounts of the time, the musical, visual and literary communications from the counterculture, and retrospective glances from members of the 1960s Haight community via extensive first-hand interviews.For more information, read Sarah Hill's blog posts here:http://blogs.cardiff.ac.uk/musicresearch/2014/05/15/san-francisco-and-the-long-60shttp://blogs.cardiff.ac.uk/musicresearch/2014/08/22/city-scale/http://blogs.cardiff.ac.uk/musicresearch/2015/07/21/fare-thee-well/
The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and ...patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts.
This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015.
Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy.
Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.
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