Suicides in San Mateo County

The usual surveys of completed suicides, encompassing, as they do, large geographical areas, are of limited value to physicians of a particular community. The unique and differentiating characteristics of the suicides in his locale may be “washed out” in these large surveys.San Mateo County has an annual suicide rate of 17 per 100,000 and a disproportionately high incidence in persons over 65 years old. In this particular county females, widows and Orientals are more prone to suicide than has usually been reported elsewhere. Alcohol was directly or indirectly involved in a significant number of instances. Many of the persons who killed themselves were under a physician''s care at the time of self-destruction.There are probably important ecological and sociological variables as well as personal factors involved in the suicidal process that are of significance to any suicide prevention program. It is urged that there be more extensive and comparative research in this important public health problem.     

Uncompensated and undercompensated care provided by San Francisco Medical Society physicians.

Practicing physician members of the San Francisco Medical Society were surveyed regarding reimbursement rates for medical care provided to underinsured and uninsured patients. Of 394 respondents, about $51,000 per physician practice was written off as uncompensated care or services not billed for in 1985. An average of 7% of each physician''s patients was estimated to be "no-pay" or charity patients, accounting for $19,000 of this total. Almost $32,000 was reported as being uncompensated care, or that which is billed but not paid. In addition to these amounts, an average of $32,000 was reported as being discounted from the usual fee levels by government insurance programs. Extrapolating these results to the physician membership of the local medical society indicates that physicians in San Francisco may be providing as much as $81 million in uncompensated or charity care annually. These results emphasize that private practitioners are providing a significant amount of medical care at reduced or charity rates, an amount that can be expected to increase given present trends. Substantial changes are needed if the burden of providing medical care to poor and uninsured Americans is not to fall disproportionately on private providers.     

OPERATIONS UPON THE AGED

From the point of view of the surgeon, as repeatedly emphasized in the surgical literature, the mortality rate for operations upon old persons is only slightly higher for elective surgical operations than for the same operations on younger persons when proper preoperative and postoperative precautions are taken. However, the mortality rate for emergency operations is much higher in old persons than in younger ones. Many surgeons believe, therefore, that disease for which operation is otherwise indicated should be treated surgically irrespective of the age of the patient per se.The authors'' experience with operations upon old persons at the San Francisco Hospital accords with these conclusions.     

Women and the Acquired Immunodeficiency Syndrome: An Interview

SPECIAL EDITOR''S NOTE: Constance B. Wofsy, MD, is Co-Director of AIDS Activities at San Francisco General Hospital and Medical Center, as well as Associate Clinical Professor of Medicine at the University of California, San Francisco; Assistant Chief, Infectious Diseases, San Francisco General Hospital; and Principal Investigator, Project AWARE (Association for Women''s AIDS Research and Education). Although she was not able to contribute an article for WOMEN AND MEDICINE on this very important subject, she kindly agreed to an interview. Both physicians and nonphysicians were asked what questions they had about the acquired immunodeficiency syndrome (AIDS) and the human immunodeficiency virus (HIV) in women.     

Vulnerability Analysis and Passenger Source Prediction in Urban Rail Transit Networks

Based on large-scale human mobility data collected in San Francisco and Boston, the morning peak urban rail transit (URT) ODs (origin-destination matrix) were estimated and the most vulnerable URT segments, those capable of causing the largest service interruptions, were identified. In both URT networks, a few highly vulnerable segments were observed. For this small group of vital segments, the impact of failure must be carefully evaluated. A bipartite URT usage network was developed and used to determine the inherent connections between urban rail transits and their passengers'' travel demands. Although passengers'' origins and destinations were easy to locate for a large number of URT segments, a few show very complicated spatial distributions. Based on the bipartite URT usage network, a new layer of the understanding of a URT segment''s vulnerability can be achieved by taking the difficulty of addressing the failure of a given segment into account. Two proof-of-concept cases are described here: Possible transfer of passenger flow to the road network is here predicted in the cases of failures of two representative URT segments in San Francisco.     

Genetic Variants of Hemoglobin and Other Blood Proteins in the San Francisco Bay Area

Studies of blood genetics in “normal healthy” persons and patients of different racial groups in the San Francisco Bay Area were carried out from January 1965 to April 1968. They show that diseases due to genetic abnormalities of blood are fairly common in this region. Frequencies for abnormal hemoglobins and erythrocyte enzyme deficiencies and variants were recorded and it was noted that abnormalities in hemoglobin metabolism that may lead to mild or severe clinical and hematological symptoms proved rather common. Accompanying other disease conditions, they may cause difficulties in diagnosis. Several diseases due to or associated with different enzyme abnormalities were encountered.     

The Concept of Mainstream Medicine for All Californians—Part III (Conclusion) Fifth Progress Report of the Committee on Role of Medicine in Society

This Fifth Progress Report is being printed in three parts in California Medicine. Following the appearance of Part III the report will be bound in a pamphlet which may be ordered at $1 a copy from 693 Sutter Publications, Inc., 693 Sutter Street, San Francisco, California 94102.     

The Concept of Mainstream Medicine for All Californians—Part II Fifth Progress Report of the Committee on Role of Medicine in Society

This Fifth Progress Report is being printed in three parts in California Medicine. Following the appearance of Part III the report will be bound in a pamphlet which may be ordered at $1 a copy from 693 Sutter Publications, Inc., 693 Sutter Street, San Francisco, California 94102.     

A century of landscape disturbance and urbanization of the San Francisco Bay region affects the present-day genetic diversity of the California Ridgway’s rail (<Emphasis Type="Italic">Rallus obsoletus obsoletus</Emphasis>)

Fragmentation and loss of natural habitat have important consequences for wild populations and can negatively affect long-term viability and resilience to environmental change. Salt marsh obligate species, such as those that occupy the San Francisco Bay Estuary in western North America, occupy already impaired habitats as result of human development and modifications and are highly susceptible to increased habitat loss and fragmentation due to global climate change. We examined the genetic variation of the California Ridgway’s rail (Rallus obsoletus obsoletus), a state and federally endangered species that occurs within the fragmented salt marsh of the San Francisco Bay Estuary. We genotyped 107 rails across 11 microsatellite loci and a single mitochondrial gene to estimate genetic diversity and population structure among seven salt marsh fragments and assessed demographic connectivity by inferring patterns of gene flow and migration rates. We found pronounced genetic structuring among four geographically separate genetic clusters across the San Francisco Bay. Gene flow analyses supported a stepping stone model of gene flow from south-to-north. However, contemporary gene flow among the regional embayments was low. Genetic diversity among occupied salt marshes and genetic clusters were not significantly different. We detected low effective population sizes and significantly high relatedness among individuals within salt marshes. Preserving genetic diversity and connectivity throughout the San Francisco Bay may require attention to salt marsh restoration in the Central Bay where habitat is both most limited and most fragmented. Incorporating periodic genetic sampling into the management regime may help evaluate population trends and guide long-term management priorities.     

Association between Diabetes Mellitus and Tuberculosis in United States-Born and Foreign-Born Populations in San Francisco

Setting

The impact of diabetes on tuberculosis in United States and foreign-born populations in San Francisco has not been studied.

Objective

To determine the characteristics, prevalence and temporal trends of diabetes in US and foreign-born persons attending the San Francisco Tuberculosis Clinic.

Design

We analyzed data from individuals seeking medical attention at the San Francisco Tuberculosis Clinic. We included patients with diagnosis of tuberculosis, latent infection, or not infected with Mycobacterium tuberculosis. We assessed the temporal trend and the characteristics of individuals with and without diabetes.

Result

Between 2005 and 2012, there were 4371 (19.0%) individuals without evidence of tuberculosis infection, 17,856 (77.6%) with latent tuberculosis, and 791 (3.4%) with tuberculosis. 66% were born in the United States, China, Mexico, and the Philippines. The prevalence of diabetes was the highest among individuals with tuberculosis and increased during the study period. Patients with tuberculosis and diabetes were more likely to be male, older than 45 years and born in the Philippines. There was a disproportionate association of TB and DM relative to LTBI and DM among Filipinos in individuals older than 45 years old.

Conclusions

Our data suggest that Filipinos older than 45 years old are more likely to have tuberculosis probably due to a higher prevalence of diabetes. In San Francisco, tuberculosis-screening programs in individuals with diabetes and latent tuberculosis may be beneficial in patients older than 45 years old especially from the Philippines.     

Conservation Investment for Rare Plants in Urban Environments

Budgets for species conservation limit actions. Expending resources in areas of high human density is costly and generally considered less likely to succeed. Yet, coastal California contains both a large fraction of narrowly endemic at-risk plant species as well as the state''s three largest metropolitan regions. Hence understanding the capacity to protect species along the highly urbanized coast is a conservation priority. We examine at-risk plant populations along California''s coastline from San Diego to north of San Francisco to better understand whether there is a relationship between human population density and: i) performance of at-risk plant populations; and ii) conservation spending. Answering these questions can help focus appropriate strategic conservation investment. Rare plant performance was measured using the annualized growth rate estimate between census periods using the California Natural Diversity Database. Human density was estimated using Census Bureau statistics from the year 2000. We found strong evidence for a lack of a relationship between human population density and plant population performance in California''s coastal counties. Analyzing US Endangered Species expenditure reports, we found large differences in expenditures among counties, with plants in San Diego County receiving much higher expenditures than other locations. We found a slight positive relationship between expenditures on behalf of endangered species and human density. Together these data support the argument that conservation efforts by protecting habitats within urban environments are not less likely to be successful than in rural areas. Expenditures on behalf of federally listed endangered and threatened plants do not appear to be related to proximity to human populations. Given the evidence of sufficient performance in urban environments, along with a high potential to leverage public support for nature in urban environments, expenditures in these areas appear to be an appropriate use of conservation funds.     

Diet composition in San Francisco Estuary striped bass: does trophic adaptability have its limits?

Trophic adaptability is a term used to describe feeding flexibility in fishes. Though a useful conceptual starting point, fishes often face constraints on their ability to switch prey that could limit feeding success even when prey switching is observed. We compared striped bass diet compositions summarized from previously published studies in California’s Sacramento-San Joaquin Delta during two time periods (1963–1964 and 2001–2003), which allowed us to evaluate trophic adaptability in San Francisco Estuary striped bass at multiple time scales, ranging from intra-annual to multidecadal. The Delta is the landward region of the San Francisco Estuary; over time between the study periods, the Delta underwent substantial changes in potential prey availability for striped bass. We found evidence for trophic adaptability in San Francisco Estuary (SFE) striped bass at all temporal scales examined. Despite this ability to adapt to changes in prey availability, the relative abundance and carrying capacity of young striped bass have declined. This decline has previously been associated with substantial declines in their dominant historical prey—mysid shrimp. Our results, coupled with these previous findings, indicate that trophic adaptability may have limited usefulness as a conceptual model to predict foraging success when other food web constraints are not considered. We speculate that this is particularly true in highly invaded ecosystems like the San Francisco Estuary because invading species often introduce substantial and permanent changes into food webs, decreasing the likelihood that a predator will find prey assemblages that fully replace historical prey assemblages.     

CEREBRAL PALSY—An Approach to the Problem

A program for the cerebral palsied child has been developed in California which has been made possible through the cooperation of the state and local departments of education, the state and local departments of health, the Children''s Hospital and Orthopedic Hospital at Los Angeles and the University of California School of Medicine in San Francisco. An attempt is being made to deal with not only the medical and educational needs of the cerebral palsied but also the social and emotional aspects.     

Relationship between Vehicle Emissions Laws and Incidence of Suicide by Motor Vehicle Exhaust Gas in Australia, 2001–06: An Ecological Analysis

Background

Globally, suicide accounts for 5.2% of deaths among persons aged 15 to 44 years and its incidence is rising. In Australia, suicide rates peaked in 1997 and have been declining since. A substantial part of that decline stems from a plunge in suicides by one particular method: asphyxiation by motor vehicle exhaust gas (MVEG). Although MVEG remains the second most common method of suicide in Australia, its incidence decreased by nearly 70% in the decade to 2006. The extent to which this phenomenon has been driven by national laws in 1986 and 1999 that lowered permissible levels of carbon monoxide (CO) emissions is unknown. The objective of this ecological study was to test the relationship by investigating whether areas of Australia with fewer noxious vehicles per capita experienced lower rates of MVEG suicide.

Methods and Findings

We merged data on MVEG suicides in Australia (2001–06) with data on the number and age of vehicles in the national fleet, as well as socio-demographic data from the national census. Poisson regression was used to analyse the relationship between the incidence of suicide within two levels of geographical area—postcodes and statistical subdivisions (SSDs)—and the population density of pre-1986 and pre-1999 passenger vehicles in those areas. (There was a mean population of 8,302 persons per postcode in the study dataset and 87,413 persons per SSD.) The annual incidence of MVEG suicides nationwide decreased by 57% (from 2.6 per 100,000 in 2001 to 1.1 in 2006) during the study period; the population density of pre-1986 and pre-1999 vehicles decreased by 55% (from 14.2 per 100 persons in 2001 to 6.4 in 2006) and 26% (from 44.5 per 100 persons in 2001 to 32.9 in 2006), respectively. Area-level regression analysis showed that the suicide rates were significantly and positively correlated with the presence of older vehicles. A percentage point decrease in the population density of pre-1986 vehicles was associated with a 6% decrease (rate ratio [RR] = 1.06; 95% confidence interval [CI] 1.05–1.08) in the incidence of MVEG suicide within postcode areas; a percentage point decrease in the population density of pre-1999 vehicles was associated with a 3% decrease (RR = 1.03; 95% CI 1.02–1.04) in the incidence of MVEG suicide.

Conclusions

Areas of Australia with fewer vehicles predating stringent CO emission laws experience lower rates of MVEG suicide. Although those emission laws were introduced primarily for environmental reasons, countries that lack them may miss the benefits of a serendipitous suicide prevention strategy. Please see later in the article for the Editors'' Summary     

Empirical Evidence for Synchrony in the Evolution of TB Cases and HIV+ Contacts among the San Francisco Homeless

The re-emergence of tuberculosis (TB) in the mid-1980s in many parts of the world, including the United States, is often attributed to the emergence and rapid spread of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Although it is well established that TB transmission is particularly amplified in populations with high HIV prevalence, the epidemiology of interaction between TB and HIV is not well understood. This is partly due to the scarcity of HIV-related data, a consequence of the voluntary nature of HIV status reporting and testing, and partly due to current practices of screening high risk populations through separate surveillance programs for HIV and TB. The San Francisco Department of Public Health, TB Control Program, has been conducting active surveillance among the San Francisco high-risk populations since the early 1990s. We present extensive TB surveillance data on HIV and TB infection among the San Francisco homeless to investigate the association between the TB cases and their HIV+ contacts. We applied wavelet coherence and phase analyses to the TB surveillance data from January 1993 through December 2005, to establish and quantify statistical association and synchrony in the highly non-stationary and ostensibly non-periodic waves of TB cases and their HIV+ contacts in San Francisco. When stratified by homelessness, we found that the evolution of TB cases and their HIV+ contacts is highly coherent over time and locked in phase at a specific periodic scale among the San Francisco homeless, but no significant association was observed for the non-homeless. This study confirms the hypothesis that the dynamics of HIV and TB are significantly intertwined and that HIV is likely a key factor in the sustenance of TB transmission among the San Francisco homeless. The findings of this study underscore the importance of contact tracing in detection of HIV+ individuals that may otherwise remain undetected, and thus highlights the ever-increasing need for HIV-related data and an integrative approach to monitoring high-risk populations with respect to HIV and TB transmission.     

Operations upon the aged

From the point of view of the surgeon, as repeatedly emphasized in the surgical literature, the mortality rate for operations upon old persons is only slightly higher for elective surgical operations than for the same operations on younger persons when proper preoperative and postoperative precautions are taken. However, the mortality rate for emergency operations is much higher in old persons than in younger ones. Many surgeons believe, therefore, that disease for which operation is otherwise indicated should be treated surgically irrespective of the age of the patient per se. The authors' experience with operations upon old persons at the San Francisco Hospital accords with these conclusions.     

Trends in suicide in Scotland 1974-84: an increasing problem.

A detailed investigation of trends in suicide rates in Scotland from 1974 to 1984 showed a complex pattern. Overall rates for men increased by 40% with the greatest increases in those aged 45-64. In contrast, rates for women showed a small decline, which was most noticeable in those aged 15-24. The well recognised decline in poisoning by domestic gas was seen over this period, and suicide by this method virtually stopped. Both sexes showed a decline in suicide by poisoning with drugs, although the decrease was larger among women. The fall in suicide rates among young women was almost all due to the decrease in this method. The rise in rates for men was largely due to increases in hanging and poisoning with vehicle exhaust gases, although all methods except drugs and domestic gas showed some increase. These findings indicate that suicide is an increasing problem with causes that are far from understood, so that prevention may be difficult.     

Distribution and abundance of fishes in the San Francisco Bay estuary between 1980 and 1982

In 1980 a long-term study of the fishery resources of the San Francisco Bay estuary was initiated in an effort to delineate the importance of freshwater inflow to fish and invertebrate abundance and distribution in the bay. An analysis of the trawl data collected between January 1980 and December 1982 illustrates the influence of the timing and magnitude of freshwater inflows on fish fistribution and abundance in this estuary from the perspective of monthly, seasonal and annual time scales. Normally found in the delta, Suisun Bay and San Pablo Bay during periods of increased salinity, pelagic species moved downstream after the two peak flows studied, while demersal species usually found in Central San Francisco Bay moved upstream. Such upstream movements may be due in part to transport by strong density-driven currents.Timing and magnitude of monthly catches of some species varied on a seasonal cycle coincident with variations of freshwater inflow. Most species, especially the marine species, showed no consistent cycle of monthly catches. In the wet years of 1980 and 1982 the distributions of freshwater, estuarine and anadromous species were extended downstream into San Pablo, Central and South San Francisco Bays and some marine species, including the flatfish, were more abundant in the upstream areas. In the dry year of 1981 when bay salinities were higher, few marine species extended their distributions upstream into San Pablo and Suisun Bays. Jacksmelt was the only fish of the 15 most abundant species with its peak abundance in 1981. Most marine species were more abundant in the San Francisco Bay estuary in the wet years.     

Quantification of Hydroxylated Polybrominated Diphenyl Ethers (OH-BDEs), Triclosan,and Related Compounds in Freshwater and Coastal Systems

Hydroxylated polybrominated diphenyl ethers (OH-BDEs) are a new class of contaminants of emerging concern, but the relative roles of natural and anthropogenic sources remain uncertain. Polybrominated diphenyl ethers (PBDEs) are used as brominated flame retardants, and they are a potential source of OH-BDEs via oxidative transformations. OH-BDEs are also natural products in marine systems. In this study, OH-BDEs were measured in water and sediment of freshwater and coastal systems along with the anthropogenic wastewater-marker compound triclosan and its photoproduct dioxin, 2,8-dichlorodibenzo-p-dioxin. The 6-OH-BDE 47 congener and its brominated dioxin (1,3,7-tribromodibenzo-p-dioxin) photoproduct were the only OH-BDE and brominated dioxin detected in surface sediments from San Francisco Bay, the anthropogenically impacted coastal site, where levels increased along a north-south gradient. Triclosan, 6-OH-BDE 47, 6-OH-BDE 90, 6-OH-BDE 99, and (only once) 6’-OH-BDE 100 were detected in two sediment cores from San Francisco Bay. The occurrence of 6-OH-BDE 47 and 1,3,7-tribromodibenzo-p-dioxin sediments in Point Reyes National Seashore, a marine system with limited anthropogenic impact, was generally lower than in San Francisco Bay surface sediments. OH-BDEs were not detected in freshwater lakes. The spatial and temporal trends of triclosan, 2,8-dichlorodibenzo-p-dioxin, OH-BDEs, and brominated dioxins observed in this study suggest that the dominant source of OH-BDEs in these systems is likely natural production, but their occurrence may be enhanced in San Francisco Bay by anthropogenic activities.     

Knowledge,Indications and Willingness to Take Pre-Exposure Prophylaxis among Transwomen in San Francisco, 2013

Safe and effective HIV prevention strategies are needed for transwomen. Transwomen in the US have a 34 times greater odds of being infected with HIV than all adults age 15-49, and in San Francisco, California 42.4% of transwomen are estimated to be infected with HIV. Pre-exposure prophylaxis (PrEP) is the first biomedical intervention with promise for reducing HIV acquisition in transwomen. However, little is known about whether transwomen know about PrEP, are taking PrEP and would be good candidates for PrEP based on their risk profile and behaviors. A population-based dataset was analyzed to determine how many transwomen in San Francisco knew about PrEP by the end of 2013 – more than a year after iPrex results demonstrated efficacy of PrEP in preventing HIV. We found that of 233 transwomen, only 13.7% had heard of PrEP. Transwomen who were living with HIV compared to those who were HIV-negative, and those who recently injected drugs compared to non-injection drug users were more likely to have heard of PrEP. Based on CDC guidelines for PrEP among MSM and IDU, 45 (30.2%) transwomen of the 149 HIV-negative transwomen in the sample were candidates for PrEP. This estimate based on CDC criteria is arguably low. Given that almost half of transwomen in San Francisco are living with HIV, this findings points to a need for further consideration of PrEP criteria that are specific and tailored to the risks for HIV faced by transwomen that are different from MSM and injection drug users. Research to scale up access and test the effectiveness of PrEP for transwomen is also urgently needed.