Band-Aid Advanced Healing occlusive bandage made in Denmark sold by Johnson & Johnson. Similar made by Elastoplast in Spain not as effective

More violent crime in Toronto. Police hampered by left-wing which prosecutes Officer for shooting a man waving a knife in a bus and refused to drop knife.

Private Wellness clinics Downtown Toronto. Investors invited

$25-mill condos in Downtown Toronto. Only 5 private clinics Cleveland clinic Canada; Medcan; Medisys(2) Virtual Wellness. "New" condo city near Lake Ontario. Aim 24/7/365. Long wait at hosptal ER.alternative is 2 hr Limo drive to Lewiston USA  Mt St  Mary Hosp

Toronto ENT A . OSBORN uses UK CELOX pads ( chitosan from shrimp shells) for epistaxis. Patients have to be told to compress the nasal TIP not the base.

COMMENT

One way of dealing with no-fee Socialist medicine is to have Specialists' private phone numbers

Top Toronto Specialists are often members of CALEDON SKI CLUB, GRANITE CLUB( badminton, curling, skating, squash, swimming, tennis),  ROSEDALE GOLF and ROYAL CANADIAN YACHT CLUB.( incl lawn bowling, squash, swimming) ,

COMMENT

ACCIDENT and EMERG. in TORONTO

Ambulances  have to take patient to nearest Hosp. If possible take a limo to Sunnybrook TEACHING Hosp in North Toronto multi-million home BAYVIEW area away from  downtown knifings, shootings.and drug overdoses. Next choice lakefront St.JOSEPH HOSP in West Toronto in Polish/Ukrainian area. Radisson Hotel ( lakefront) is nearest 4 star  hotel.

Triage is first done by a Nurse. Waiting can be several hours. to be seen first by am ER doc.

It can be quicker to take a limo to Lewiston, USA (approx 2 hours) Cost approx $300. NO WAITING.at
Mt St MARY HOSPITAL phone ahead for SPECIALIST CONSULT with CREDIT CARD number.

COMMENT

OTC meds not available in Ontario pharms probably due to cost.. Available online from USA without Rx.

BENZEDREX NASAL INHALER  propylhexidine
DELSYM COUGH SUPPRESSANT dextromethorphan polistrix (resin) 12-hourly

COMMENT

In ONTARIO "WELLNESS CLINICS" @ $3.500/yr per client bypasses Can Health Act by NOT billing OHIP for GP services and providing extra services e.g. diet; physio.etc. Unlike UK, in Canada private GP clients can still get free Specialist, Lab and Xray services.

Examples
CLEVELAND CLINIC CANADA(  300 LOBLAW grocery executives are members),
MEDCAN
MEDISYS

Average OHIP GP visit 10 min with usual clinic wait
Average WELLNESS GP visit 30 min. Appt usually on time.

COMMENT:

Socialist engineered Liberal Govt controlled-fee OHIP means 7 month wait for a top Toronto Endocrinologist.. Fee-paying forbidden if Canadian permanent resident... A money-maker for the three Mayo Clinics. More Canucks insuring up to $2-million for CRITICAL ILLNESS INSURANCE. that pays with a single cheque on diagnosis.

COMMENT

Medico-Legal risk of treating refugees. CPSO will accept complaints from ANYONE ANYWHERE in the WORLD at no expense  to the complainant. At present Ontario MDs are at RISK of  complaints from a`refugee in Ontario or a member of the family OUTSIDE CANADA.

COMMENT: $25-million condos for sale in Toronto Yorkville area. MD could receive CPSO complaint if $1 charged above OHIP fee now only 50% of OMA suggested rate.

COMMENT: Toronto Hospitals need SECURITY.  Hospitals often have shops and food courts which encourage high visitor flow. No metal detectors. No USA-style control of people wanting to visit Patient floors. Stethoscope and a bugus name tag allows easy access..

BASEBALL PITCHER PAID USA THIRTY-ONE MILLION A YEAR FOR SEVEN YEARS. No Liberal or NDP furore.

PRO/EDR> Scabies - Switzerland: (SG) asylum seekers

SCABIES - SWITZERLAND: (SANKT GALLEN) ASYLUM SEEKERS
****************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Thu 26 Nov 2015
Source: Obersee News [machine translation, edited]
<http://www.20min.ch/schweiz/ostschweiz/story/-Da-habe-ich-schon-ueble-Sachen-gesehen--20327357>


In a letter, the St. Gallen cantonal doctor Dr. Markus Betschart
[appealed] to all doctors in the canton that when asylum seekers
present with scabies and bacterial infections as skin problems they
should be especially observed.

"GPs increasingly treat asylum seekers, and we want to make them aware
of scabies and the treatment options," explained Betschart in his
letter.

An accumulation of scabies was confirmed by GP Reto Gross, who
regularly deals with refugees from the reception center Altstaetten.
In 2015 dozens of cases have been treated. And he sees only a fraction
of the asylum seekers, who seek out various other doctors in the
region.

Scabies is a parasitic skin disease that is caused by the scabies mite
(_Sarcoptes scabiei_). The female mites burrow into the skin, where
they leave droppings and lay their eggs, resulting in irritation.

Scabies is transmitted by intimate physical contact, such as when you
sleep in the same bed, but also in unhygienic conditions. "For an
infection you have to come very close," says Gross. He knew of no
cases of employees in the processing center having been infected. The
scabies mites also like to embed themselves in clothes and linens.

The skin disease [produces] an itchy rash. Particularly affected are
hands, nipples, armpits and genitals. It is especially unpleasant at
night. The problem arises when the patient scratches a great deal,
when the bubbles can open and become infected. "Because I've seen
severe cases," says Gross.

Treatment for scabies is a cream [that contains a pyrethroid
insecticide]. "You take a shower, apply the cream all over your body
and leave it for 8 hours, preferably overnight," says Gross. In
addition, clothes and bedding must be washed to at least 60 degrees
[centigrade] to kill the mites.

Scabies mites are not the only 'bugs' to be combatted; bed bugs are
also plaguing asylum seekers. The Migration Office of St. Gallen has
developed a containment strategy: "If we accept asylum seekers from
the federal government, we [require them] to leave all their clothes.
These we freeze for 48 hours," says Urs Weber, Head of the St. Gallen
Department of Migration Centres.

Inbox	x
promed@promedmail.org	17:06 (18 hours ago)
to promed-post, promed-edr-post

LOUSE-BORNE RELAPSING FEVER - NETHERLANDS: ASYLUM SEEKERS, ex ERITREA
*********************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Thu 30 Jul 2015
Source: Eurosurveillance edition 2015; 20(30) [edited]
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21196


Louse-borne relapsing fever (_Borrelia recurrentis_) in asylum seekers from Eritrea, the Netherlands, July 2015
----------------------------------------------------------------------
[Authors: Wilting KR, Stienstra Y, Sinha B, Braks M, Cornish D, Grundmann H]

Two patients from Eritrea, recently arrived in the Netherlands, presented with fever and were investigated for malaria. Bloodfilms showed spirochetes but no blood parasites. Louse-borne relapsing fever caused by _Borrelia recurrentis_ was diagnosed. Treatment was complicated by severe Jarisch-Herxheimer reactions [inflammatory reaction observed after antimicrobial treatment of several infectious diseases] in both patients. Physicians should be aware of the possibility of _B. recurrentis_ infection in migrant populations who travel under crowded conditions, especially after passing through endemic areas such as Ethiopia and neighbouring countries.

_Borrelia recurrentis_ has for many centuries caused infections of often epidemic proportions known as relapsing fever. Since the infection is exclusively transmitted by body lice and humans are their only host, large scale outbreaks are only expected under circumstances conducive to louse infestation. We here report the 1st introduction of louse-borne relapsing fever into the Netherlands after World War II.

Case descriptions
-----------------
Patient 1
On 4 Jul 2015, a young adult from Eritrea was referred from the National Reception Centre for Asylum Seekers (Asielzoekercentrum, AZC) to a regional hospital in the northern Netherlands with a 5-day history of headache, dizziness, right upper quadrant pain, myalgia, and fever (39.3 deg C [102.7 deg F]). Malaria was suspected. The patient had been in the Netherlands for only 2 days after arriving in Europe 14 days earlier. En route to Europe, they travelled through Ethiopia, Sudan, and Libya. Previously, they had noticed chills while sheltering in an unofficial street camp in Rome where they stayed with a small group of fellow Eritreans before travelling to the Netherlands.

Thick and thin bloodfilms did not show malaria parasites and commercial malaria antigen tests were negative. However, filamentous unidentified structures were reported in the thick film by the laboratory of the peripheral hospital. The patient received empirical treatment with a single dose of ceftriaxone (2000 mg intravenously) for suspected bacterial septicaemia. After administration, their condition deteriorated and the patient was transferred within the next 2 hours to the University Medical Center Groningen (UMCG) where they arrived at the emergency department with headache, peripheral hypothermia (35.3 deg C [95.5 deg F]), hypotension (systolic/diastolic blood pressure 78/52 mmHg, heart rate of 106 beats per minute), abdominal pain but no hepatosplenomegaly, and shortness of breath (respiratory rate 23 breaths/min). Laboratory analysis showed leucocytopenia (leucocytes: 1.6 x 10(9)/L, norm: 4.5-10 x 10(9)/L), anaemia (haemoglobin: 6.5mmol/L, norm: 8.6-11.2 mmol/L) and thrombocytopenia (thrombocytes: 16x10(9)/L, norm: 150-450x10(9)/L). C-reactive protein (CRP) was 254 mg/L (norm: less than 1 mg/L). Kidney function was normal. The patient's liver function tests showed mildly elevated transaminases (alanine transaminase: 58 U/L, norm: 7-56 U/L; aspartate transaminase: 108 U/L, norm: 10-40 U/L; alkaline phosphatase: 124 U/L, norm 20-140 U/L; gamma-glutamyl transferase: 93 U/L, norm 0-51 U/L) and total bilirubin levels of 38 micromole/L (norm: less than 26 micromol/L) and direct bilirubin 35 micromol/L (norm: less than 7 micromol/L). Oxygen saturation was 91 percent (norm: 95-100 percent). Giemsa-stained thick and thin films revealed spirochetes in large numbers (Figure 1 [available at the source URL]) and no malaria parasites.

Given the patient's travel history, louse-borne relapsing fever was suspected. The clinical deterioration was provoked by the ceftriaxone administration leading to a severe Jarisch-Herxheimer reaction [1]. Treatment was switched to doxycyline 200 mg per day intravenously intravenously to reduce the risk of relapse [2]. The patient was transferred to the intensive care unit (ICU) for fluid resuscitation, cardiac support with noradrenalin, and supportive oxygen delivery via high flow nose mask.

_B. recurrentis_ was confirmed by 16S rDNA PCR and sequencing directly from blood 2 days later. The patient stayed at the ICU for 2 days, made a full recovery and was discharged after 6 days. The body louse _Pediculus humanus humanus_ was recovered from [the patient's clothing (Figure 2 [available at the source URL]).

Patient 2
On 9 Jul 2015, a 2nd young adult from Eritrea was directly referred by the responsible physician at the AZC to the UMCG. On arrival, the patient presented with general malaise, headache, fever (38.5 deg C [101.3 deg F]) and cough. Blood tests showed elevated inflammatory parameters (leucocytes: leucocytes: 12.7 x 10(9)/L, CRP: 320 mg/L), normal kidney function and slightly elevated transaminases, but the blood sample was haemolytic. Thick and thin films showed spirochetes and treatment was started with doxycyline 200 mg orally. 2 hours later the patient developed a severe Jarisch-Herxheimer reaction [that] required admission to intensive care where they received fluid resuscitation, inotropic treatment with noradrenalin, and oxygen via a face-mask. _B. recurrentis_ was confirmed by 16S rDNA sequencing.

The patient reported symptoms of chills and fever 2 weeks before presentation at our hospital. Their journey through North Africa followed the same route as that of Patient 1, but Patient 2 had arrived in Europe a week earlier. Patient 2 had camped out in the streets for 5 days in Rome (as had Patient 1). Patient 2 arrived in the Netherlands 2 weeks before presenting at our hospitals after travelling through Austria and Germany. The patient made a full recovery and was discharged after 5 days. Lice could not be recovered from the clothing.

Discussion
----------
_B. recurrentis_ should be suspected in patients presenting with fever and a recent history of migration from or through endemic countries (Ethiopia, Sudan, Eritrea, and Somalia). The infection is transmitted through body lice (_P. humanus humanus_, formally known as _P. humanus corporis_), which typically lives and breeds in the seams of clothes but can occasionally also be found in bed linens. Immigrants may share their clothing and that can pose an additional risk of transmission. The incubation period for relapsing fever is usually 4 to 8 days with a range of 2 to 15 days [3]. It should be noted that head lice (_P. humanus capitis_), which are not uncommon in Northern Europe, are incompetent vectors and cannot transmit _B. recurrentis_. The spirochetes are easily visible under a microscope in a Giemsa-stained thick or thin blood film as used for the diagnosis of _Plasmodium_ spp [4]. In our patients, the diagnosis was confirmed in both cases by 16S rDNA PCR and sequencing from blood.

Published evidence supports a single dose of tetracycline 500 mg intravenously as the conventional treatment, but considering the limited availability of this drug, doxycycline 200 mg can be used as an effective alternative [2,5]. In young children, pregnant women, or patients with a tetracycline allergy, erythromycin 500 mg can be used instead [6].

Both patients had travelled independently along a similar route before arriving in the Netherlands. Given the incubation period, it cannot be ruled out that the infection was acquired within Europe. Crucial information about risk factors such as exact travel history, recollection of louse infestation or bites and onset of symptoms was, however, impossible to obtain from our patients. Apart from being very sick and the fact that communication required an interpreter versed in Tigre our patients appeared to be traumatised and intimidated and not eager to volunteer information for fear of legal consequences.

Both patients developed a severe Jarisch-Herxheimer reaction after starting antibiotic treatment. _B. recurrentis_ evades host immune defences, resulting in very high bacterial loads (10(6)-10(8)/microl), and effective antibiotic therapy is followed by severe reactions characterised by sudden rigors, fever, and hypotension in virtually all treated patients [3]. Clinical symptoms are associated with increased plasma concentrations of tumour necrosis factor alpha (TNF-alpha), interleukin-6 and interleukin-8 [7]. Treating physicians should be aware of this complication and the chances that ICU admission may be warranted. It is advised that patients receive 2 well-placed intravenous lines for rapid fluid resuscitation. Treatment of Jarisch-Herxheimer reaction consists mainly of supportive care. Corticosteroids seem to have limited beneficial effect but studies suggests that TNF-alpha blockers may be useful [8].

An ad hoc survey at the AZC on [16 Jul 2015] found body lice on 2 newly arrived Eritreans. Since then, all asylum seekers arriving from endemic countries to the AZC have been segregated into a different compound, where they turn over all of their personal clothes in exchange for disposable overalls. Personal clothes are then washed and returned on the next day. Used overalls and bed linen are subsequently destroyed. In addition to delousing, all arrivals receive a single dose of ivermectin as pre-emptive treatment against scabies and Eritreans who arrive with clinically manifest scabies (about 80 percent of all new arrivals) receive a 2nd dose a week later. No new cases of _B. recurrentis_ infection have been identified since mandatory delousing was implemented.

Conclusion
----------
Because infections with _B. recurrentis_ pose a significant health risk to other migrants, aid workers, healthcare personnel, and arguably to the general population, screening and delousing should be considered for arriving migrants already at ports of entry into the European Union. Our patients may have acquired body lice before arriving in Europe but transmission of infected lice between migrants after arrival in Europe cannot be ruled out and could pose an additional public health challenge.

[Figures and references are available at the source URL above.]

--
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[Relapsing fever is a bacterial infection caused certain species of the spirochete _Borrelia_. These organisms are able to periodically change their surface protein molecules to evade the host's immune response, thus causing a relapsing illness. Following an incubation period of about 7 days, the illness is characterized by recurring episodes of high fever, headache, muscle and joint pain, nausea and vomiting, each episode lasting several days, followed by a several-day asymptomatic interval. There may be up to 3-4 recurrences. Complications may include involvement of the lungs (ARDS; acute respiratory distress syndrome), central nervous system, spinal cord, eyes, heart, and liver. The bacteremia is intense (more than 10 000 organisms per ml of blood) during febrile episodes, which allows detection of organisms on a Wright-Giemsa stained blood smear. Thick blood smears are more sensitive than thin smears.

There are 2 types of relapsing fever: Tick-borne relapsing fever (TBRF) and louse-borne relapsing fever (LBRF). LBRF is more severe than TBRF, with case-fatality rates without antimicrobial treatment of 30 to 70 percent in outbreaks. TBRF occurs in the Western hemisphere, Africa, Asia, the Mediterranean region and the Middle East. In the western United States, TBRF is usually associated with sleeping in rustic, rodent-infested cabins in mountainous areas. In the United States, 3 species, _Borrelia hermsii_, _B. parkerii_, and _B. turicatae_, transmitted by the bite of soft-bodied ticks (genus _Ornithodoros_) cause TBRF. A recently discovered _Borrelia_ species, _B. miyamotoi_, has been found in hard-bodied ticks (_Ixodes_) in regions where Lyme disease is endemic.

LBRF is caused by a single species, _B. recurrentis_, transmitted through abraded skin when the body louse is crushed during scratching. LBRF is endemic in Ethiopia, Sudan, Eritrea, and Somalia. Outbreaks are found in developing regions affected by war and in refugee camps characterized by overcrowding and poor personal hygiene. While mammals and reptiles may serve as a reservoir for tick-borne _Borrelia_ species, humans are the only host of _B. recurrentis_.

Treatment of relapsing fever consists of either a tetracycline (such as, doxycycline), a macrolide (such as, erythromycin), penicillin, or other beta-lactam antibiotics (such as, ceftriaxone). LBRF can be treated effectively with a single dose of the antibiotic (http://jid.oxfordjournals.org/content/137/5/573), whereas treatment of TBRF requires 7-10 days to prevent relapse. When initiating antibiotic therapy, all patients should be observed for a Jarisch-Herxheimer reaction. The reaction, caused by massive release of tumor necrosis factor alpha (TNF-alpha), interleukin-6, interleukin-8, and other cytokines, is manifest by a worsening of symptoms with rigors, tachycardia, sweating, hypotension, and high fever, occurs in over 50 percent of cases. The Jarisch-Herxheimer reaction can be fatal. Pretreatment with anti TNF-alpha antibody has been found to suppress Jarisch-Herxheimer reactions (http://www.nejm.org/doi/full/10.1056/NEJM199608013350503). Corticosteroids and antipyretic agents have little or no effect (http://jid.oxfordjournals.org/content/137/5/573 and http://www.ncbi.nlm.nih.gov/pubmed/6132178), whereas meptazinol, an opioid agonist-antagonist, has been reported to reduce the severity of the reaction (http://www.ncbi.nlm.nih.gov/pubmed/6132178). Treatment with intravenous fluids and vasopressors to maintain adequate blood pressure may be required. - Mod.ML