The number of migrants and asylum seekers at the Mexico-US border has increased to historic levels. Our objective was to determine the medical diagnoses and treatments of migrating people seeking ...care in humanitarian clinics in Matamoros, Mexico.
We conducted a cross-sectional study of patient encounters by migrating people through a humanitarian clinic in Matamoros, Mexico, from November 22, 2019, to March 18, 2021. The clinics were operated by Global Response Medicine in concert with local non-governmental organizations. Clinical encounters were each coded to the appropriate ICD-10/CPT code and categorized according to organ system. We categorized medications using the WHO List of Essential Medicines and used multivariable logistic regression to determine associations between demographic variables and condition frequency.
We found a total of 8,156 clinical encounters, which included 9,744 diagnoses encompassing 132 conditions (median age 26.8 years, female sex 58.2%). People originated from 24 countries, with the majority from Central America (n = 5598, 68.6%). The most common conditions were respiratory (n = 1466, 15.0%), musculoskeletal (n = 1081, 11.1%), and skin diseases (n = 473, 4.8%). Children were at higher risk for respiratory disease (aOR = 1.84, 95% CI: 1.61-2.10), while older adults had greater risk for joint disorders (aOR = 3.35, 95% CI: 1.73-6.02). Women had decreased risk for injury (aOR = 0.50, 95% CI: 0.40-0.63) and higher risk for genitourinary diseases (aOR = 4.99, 95% CI: 3.72-6.85) compared with men. Among 10,405 medications administered, analgesics were the most common (n = 3190, 30.7%) followed by anti-infectives (n = 2175, 21.1%).
In this large study of a migrating population at the Mexico-US border, we found a variety of clinical conditions, with respiratory, musculoskeletal, and skin illnesses the most common in this study period which encompassed a period of restrictive immigration policy and the first year of the COVID-19 pandemic.
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There is an old Romanian folk tale about a young boy and a magical ox named Tellerchen. The boy, abandoned by his cruel stepmother, is starving when he is found by a kind, rich man. The young boy ...works on the man’s farm for seven years, and when he is finally old enough to leave, the rich man gifts the boy with Tellerchen, the magical ox, as a thank you for the years of hard work. Tellerchen has the ability to produce just enough bread and wine from his horns to feed the boy. The boy returns home, hoping to regain the favor of his stepmother, but she is jealous of the boy’s good fortune and demands that the boy slaughter the ox. The boy is distraught, and that night, tries to set Tellerchen free. However, Tellerchen tells the boy to trust that it is okay have him slaughtered. The ox tells him to save only his horn after he is killed and to open the horn once he is far away. The boy reluctantly slaughters Tellerchen the next day, saving only the horn before his stepmother banishes him from his home. The boy is starving without Tellerchen and desperately wishes that he had not slaughtered his magical ox. However, the boy remembers to open Tellerchen’s horn, and a herd of magical oxen appears, with powers even greater than Tellerchen’s. The boy is saved from starvation, and he lives the rest of his days wealthy and prosperous. The moral of the story? A seemingly unthinkable action, which may appear to lead to negative consequences, can, with trust and faith, instead favor those brave enough to take the leap. And in no time and place is this more applicable than in Romania’s current healthcare situation. Romania’s health system is currently perched on a dangerous precipice- it faces a major dual dilemma of a “brain drain” of Romanian physicians to other European countries, as well as negative health outcomes from the widespread practice of bribery in physicians and other healthcare practitioners. Compared to their western counterparts, Romanian physicians lack prestige, power, and profits, a dangerous lack of incentives for an already weak health system. Romania’s current healthcare problems has roots in the mid-20th century, during which both the west and the east experienced their own revolutions. In the west, a scientific revolution. In the east, especially across eastern Europe, a communist one. Though Romania was only officially within communism’s chokehold for about forty years, the bruises from this indelible part of Romania’s history are apparent even now, almost thirty years later. While mid-twentieth century physicians in western Europe and the United States were blessed with a golden age, in which medicine was glamorized in popular media and shined with “miracle” breakthroughs, Romanian physicians were suppressed under a communist rule that favored the common farmer and factory worker over the intellectual. And now, that historic disregard for physicians has translated into a weak foundation for healthcare in Romania. As a result, its healthcare remains severely underfunded, and physicians are emigrating in search of better status and higher wages. Romanian-born and educated doctors are fleeing the nation as if escaping from a plague, and the impact of such is nearly as deadly. In 2011, there were 21,400 doctors in Romania. As of November of 2013, there were 14,400.1 Romania has lost nearly a third of its skilled physicians to the UK and other countries in the European Union, and the number of Romanian doctors emigrating to work abroad has rocketed since. This mass exodus of thousands of highly-skilled physicians is taking its toll on the country, in almost ridiculous statistics. For a population of 19 million, Romania has only 48 radiotherapy physicians, despite high rates of cancer across the country, and only 54 geriatric physicians, despite the ageing population.2 In comparison to its central and eastern European peers, in Bulgaria, Hungary, and the Czech Republic, Romania has the lowest life expectancy at birth, the highest infant mortality rate, and the highest incidence rates of AIDS, tuberculosis, and syphilis.3 The root of the problem is that Romanian doctors are not being paid enough. Romanian doctors earn a measly 400 euros a month,4 which is hardly enough to support themselves, let alone a family. Wages are an alarming eight to ten times higher abroad than in Romania.5 Thus, it is no surprise that Romanian physicians are emigrating for better working conditions and higher financial benefits. However, an even more significant implication of Romania’s inability to provide sufficient physician wages is the toxic bribery culture that has erupted within its health system. In 2014, Romania was found to be the second most corrupt country in the European Union, and within the health field, some physicians refuse to even treat patients without a bribe.6 Sadly, stories of impoverished Romanians ignored in hospitals because they lack the money for a bribe, or a woman in labor being coerced into a bribe to just have her child birthed are common anecdotal woes. Here as well, Romania’s communist history has played a role in normalizing bribes. During the communist regime, it was common practice to use bribes to acquire scarce products, and as healthcare is now also becoming a scarce product, with the lack of doctors, so must bribery seem socially acceptable. With a measly 3.6% of Romanian GDP allocated to healthcare, compared to 11% in both Germany and France,7 the nation spends the least on healthcare compared to any other country in the European Union.8 However, with the current state of the economy, it does not seem feasible for the government to subsidize physician wages. On the other hand, instead of seeking to extinguish bribes, Romania should legalize bribes and build these “informal payments” into healthcare costs. It is time for Romania to modify its socialized medical insurance by introducing a copayment system that will place some responsibility for payment on its citizens in a legitimatized fashion. Romania’s current mandatory health insurance system has been chronically underfunded, and complete government support for all healthcare is unsustainable. Many Romanians are already paying for these higher healthcare costs through bribes, with about 25% of Romanians reporting that a doctor or nurse had pressured them into paying a bribe for medical service.9 Legalizing these informal payments will give the Romanian government the authority to standardize prices across hospitals and physicians, as well as more closely monitor payment practices to ensure equity amongst all patients. This proposal may seem like a radical step. However, a similar plan was enacted in 1997 in Cambodia, a country that, like Romania, has also had a communist past and a crippling bribery issue. A formal fee schedule was introduced, with the informal payments built into the cost of healthcare.10 And for critics wary of increasing the financial burden on patients, after just one year of reform, patients were actually paying less than they had paid before the reforms. In short, these informal payments were replaced by formal payments, and this change did not add much additional financial burden to Cambodian patients because the government was able to standardize prices of these supplementary payments. When a similar program was introduced in Albania in the early 2000s, some physicians even saw their incomes quadruple.11 Not only will this plan provide better equity of care to all citizens, but physicians will also receive higher wages and will hopefully retain Romanian physicians. In an effort to promote health equity, government funds can be used to give cash vouchers to the poorest in the nation so that they can afford these copayments. This will allow a better, more efficient use of government funds than the current health insurance system allows. Romania needs a bold step like this to halt the deterioration of its health system. Action is needed now to stop the bleeding out of physicians from Romania before the country becomes too weakened. With over 19 million lives on the line, maybe it’s time for this small eastern European nation to take back control over its current trajectory and to remedy the consequences of its past. I’m sure that Tellerchen would agree. References 1 Gillet, Kit, and Matthew Taylor. "Romanian health service in crisis as doctors leave for UK and other states." The Guardian, February 2, 2014. 2 Ibid. 3 World Health Organization. "Highlights on health in Romania." (1999). 4 Lungescu, Oana. "Romanian healthcare on verge of collapse." BBC News Europe, August 12, 2010. 5 Toma, Diana. "Romania’s health service on brink of collapse." World Socialist Web Site. Last modified June 18, 2010. Accessed June 29, 2016. https://www.wsws.org/en/articles/2010/06/roma-j18.html. 6 Transparency International. Corruption Perceptions Index 2014: Results. Corruption Perceptions Index. N.p.: n.p., 2014. 7 "Health Expenditure, Total (% of GDP)." In The World Bank. 2015. Last modified 2015. Accessed June 29, 2016. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS. 8 Lungescu, Oana. "Romanian healthcare on verge of collapse." BBC News Europe, August 12, 2010. 9 European Commission. Corruption. Special Eurobarometer 397. N.p.: n.p., 2014. 10 Vian, Taryn. "Corruption in the Health Sector: Informal Payments." Lecture, Boston University School of Public Health, Boston, MA. 11 Vian, Taryn. "Corruption in the Health Sector: Informal Payments." Lecture, Boston University School of Public Health, Boston, MA.
Background: Longitudinal cohort studies of Ebola virus disease (EVD) survivors from the 2014-2016 West African outbreak have found evidence of Ebola virus (EBOV) and EBOV RNA persistence in the ...bodily fluids of survivors, particularly in semen. This new evidence has raised the possibility of sexual transmission of EBOV by EVD survivors. The current interim guidance issued by the World Health Organization (WHO) recommends safer sex practices for at least 12 months after acute disease onset (ADO). However, based on new evidence, these recommendations may require revision.Objective: The main aim of this article is to present and evaluate evidence on the persistence of EBOV in genital fluids, as determined by RT-PCR or viral isolation. In addition to determining the length of persistence in these genital fluids, the relation of persistence to sexual transmission of EBOV is also examined.Design: We conducted a systematic review of viral persistence in semen, vaginal, and rectal fluids, and assessed evidence of the potential transmissibility of persistent EBOV via sexual transmission from survivors.Results: We identified 42 published original studies presenting results on EBOV persistence or reporting on suspected sexual transmission of EBOV from survivors. EBOV RNA has been detected in the seminal fluids of an EVD survivor for up to 40 months post-EVD onset. From a cohort of nearly 2,000 male survivors, we estimate an average length of EBOV RNA duration of 370 days. EBOV has also been detected by viral isolation for up to 82 days. Finally, we report that age is a potential determinant of EBOV persistence, with older age associated with a higher likelihood of EBOV RNA detection in seminal fluid.Conclusion: On the basis of the evidence reviewed, we conclude that persistence of EBOV RNA is related to an increased risk of sexual transmission of EBOV, though the evidence remains mixed on whether detectable EBOV RNA necessarily signifies the presence of infectious virus. Due to reports of intermittent detection of EBOV RNA, especially among survivors who experience EBOV persistence for over a year, we recommend that at least two negative RT-PCR results be received before declaring the survivor’s seminal fluid to be cleared of EBOV RNA.
The MilA ELISA has been identified as a highly effective diagnostic tool for the detection of Mycoplasma bovis specific antibodies and has been validated for serological use in previous studies. This ...study aimed to estimate the optimal cut-off and corresponding estimates of diagnostic sensitivity (DSe) and diagnostic specificity (DSp) of the MilA ELISA for testing bovine serum. Serum samples from 298 feedlot cattle from 14 feedlots across four Australian states were tested on entry into the feedlot and approximately 42 days later. The paired serum samples were tested with the MilA ELISA, BIO K302 (Bio-X Diagnostics, Belgium) and BIO K260 (Bio-X Diagnostics, Belgium). A cut-off of 135 AU was estimated to be optimal using Bayesian latent class analysis with three tests in multiple populations, accounting for conditional dependence between tests. At this cut-off, the DSe and DSp of the MilA ELISA were estimated to be 92.1 % (95 % highest probability density HPD interval: 87.4, 95.8) and 95.5 % (95 % HPD: 92.4, 97.8), respectively. The DSes of the BIO K260 and BIO K302 ELISAs were estimated to be 60.5 % (95 % HPD: 54.0, 66.9) and 44.6 % (95 % HPD: 38.7, 50.7), respectively. DSps were 95.6 % (95 % HPD: 92.9, 97.7) and 97.8 % (95 % HPD: 95.9, 99.0), respectively. Mycoplasma bovis seroprevalence was remarkably high at follow-up after 42 days on the feedlots. Overall, this study estimated a cut-off, DSe and DSp for the MilA ELISA with less dependence on prior information than previous analyses and demonstrated that the MilA ELISA has higher DSe than the BIO K260 and BIO K302 assays.
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Victoria experienced the greatest burden of COVID-19 in Australia in 2020. This report describes key epidemiological characteristics and corresponding control measures between 17 January 2020 and 26 ...March 2021.
COVID-19 notifications made to the State Government Department of Health were used in this analysis. Epidemiological features are described over 4 phases, including enhancements to testing, contact tracing and public health interventions. Demographic and clinical features of cases are described.
Victoria recorded 20,483 cases of COVID-19, of which 1073 (5•2%) were acquired overseas and 19,360 (95%) were locally acquired. The initial epidemic (Phase I) was well-contained through public health interventions and was followed by relaxation of restrictions and low-level community transmission (Phase II). However, an outbreak in a hotel used to quarantine returned travellers led to wide-scale community transmission accounting for a majority (91%) of cases (Phase III). Outbreaks occurred in vulnerable settings including aged care and hospitals, contributing to high hospitalisation (12%) and case fatality rates (3•7%). Aggressive restrictions ultimately led to local elimination, and subsequent outbreaks have been swiftly managed with improved processes (Phase IV). The demographic composition of cases evolved across phases from an older, wealthier population to a less advantaged younger population, with many from culturally and linguistically diverse backgrounds.
Over time, adaptations to the public health response have strengthened capacity to respond to new cases and outbreaks in a more effective manner. The Victorian experience underscores the importance of authentic engagement with diverse communities and balancing restrictions with livelihoods.
Funding: None
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Patient support programs (PSPs) offer a unique opportunity to collect real-world data that can contribute to improving patient care and informing healthcare decision making. In this perspective ...article, we explore the collection of data through PSPs in Canada, current advances in data collection methods, and the potential for generating acceptable real-world evidence (RWE). With PSP infrastructure already in place for most specialized drugs in Canada, adding and strengthening data collection capacities has been a focus in recent years. However, limitations in PSP data, including challenges related to quality, bias, and trust, need to be acknowledged and addressed. Forward-thinking PSP developers have been taking steps to strengthen the PSP datasphere, such as engaging third parties for data analysis, publishing peer-reviewed studies that utilize PSPs as a data source and incorporating quality controls into data collection processes. This article illustrates the current state of PSP data collection by examining six PSP RWE studies and outlining their data characteristics and the health outcomes collected from the PSP. A framework for collecting real-world data within a PSP and a checklist to address issues of trust and bias in PSP data collection is also provided. Collaboration between drug manufacturers, PSP vendors, and data specialists will be crucial in elevating PSP data to a level acceptable to healthcare decision makers, including health technology assessors and payers, with the ultimate beneficiary being patients.
Estrogen-receptor alpha (ERα) neurons in the ventrolateral region of the ventromedial hypothalamus (VMHVL) control an array of sex-specific responses to maximize reproductive success. In females, ...these VMHVL neurons are believed to coordinate metabolism and reproduction. However, it remains unknown whether specific neuronal populations control distinct components of this physiological repertoire. Here, we identify a subset of ERα VMHVL neurons that promotes hormone-dependent female locomotion. Activating Nkx2-1-expressing VMHVL neurons via pharmacogenetics elicits a female-specific burst of spontaneous movement, which requires ERα and Tac1 signaling. Disrupting the development of Nkx2-1+ VMHVL neurons results in female-specific obesity, inactivity, and loss of VMHVL neurons coexpressing ERα and Tac1. Unexpectedly, two responses controlled by ERα+ neurons, fertility and brown adipose tissue thermogenesis, are unaffected. We conclude that a dedicated subset of VMHVL neurons marked by ERα, NKX2-1, and Tac1 regulates estrogen-dependent fluctuations in physical activity and constitutes one of several neuroendocrine modules that drive sex-specific responses.
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•Stimulating female Nkx2-1+ VMHVL neurons via DREADDs elicits a burst of movement•ERα hormone signaling and Tac1 are required for DREADD-induced locomotion•Loss of ERα, Tac1, and NKX2-1 neurons in the VMHVL leads to inactive, obese females•A VMHVL module controls female activity, but not reproduction or BAT thermogenesis
Metabolism and reproduction are tightly linked in females and regulated by estrogen-responsive neurons in the ventrolateral region of the ventromedial hypothalamus (VMHVL). Correa et al. identify a neuronal subpopulation in the VMHVL marked by NKX2-1, ERα, and Tac1 that is dedicated to driving estrogen-dependent fluctuations in female physical activity.
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