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
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A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
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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

UK DAILY MAIL

Organs can be taken from the dead without any consent: Landmark law change in Wales gives doctors right to assume all adults have agreed to be donors

• New system means adults have to 'opt out' from the register to not donate
• Health officials argue the change of system will save hundreds of lives 
• Relatives will still have the right to object to a family member's donation
• 1,000 people in the UK die every year while they are waiting for a transplant

By Ben Spencer Medical Correspondent For The Daily Mail

Published: 00:25 GMT, 1 December 2015 | Updated: 00:31 GMT, 1 December 2015

Organs will be transplanted from the dead without consent for the first time in Britain from today.

A landmark law change in Wales gives doctors the right to assume that all adults consent to be organ donors after their death.

The new system means that adults have to ‘opt out’ from the register if they do not want to be donors - a dramatic change from the current ‘opt in’ system.

If they have not opted out, they will be treated as if they had given their approval, a principle known as ‘deemed consent’.

A landmark law change in Wales means that doctors have the right to assume that all adults consent to be organ donors after their deaths, and people will have to opt out of the register (file image)

Officials in England are carefully monitoring whether the new system is successful.

Some religious groups have criticised the move, but health officials argue that it will save hundreds of lives.

The Welsh Government predicts the new law could increase the number of organ donors by as much as a quarter.

Under the new system, relatives will still have the right to object to a family member’s organs being removed - but if they cannot be contacted a transplant will go ahead.

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According to the latest figures, 1,000 people in the UK die every year while waiting for a transplant.

Organ transplants dropped in number last year for the first time in a decade, NHS figures show.

The number of transplants fell from 4,655 in 2013/14 to 4,431 in 2014/15.

The 5 per cent decrease is the first drop in 11 years, meaning that 224 fewer people received an organ transplant.

The British Heart Foundation last night called for England to follow the Welsh lead.

Simon Gillespie, chief executive at the charity, said organ donation rates in the UK are 40 per cent lower than in other countries in Europe, such as Spain and Croatia, that already use the opt-out system.

According to the latest figures, 1,000 people in the UK die every year while waiting for a transplant (file image)

‘Sadly hundreds of people die every year waiting for a transplant because there is a desperate shortage of organ donors,’ he said.

‘Other European countries that already use an opt-out system have much higher donor rates than the UK.

‘We campaigned strongly in Wales to introduce soft opt-out and now it’s time for the rest of the UK to follow their lead.’

Wales’ health minister Mark Drakeford said: ‘The change to a soft opt-out system for organ donation will deliver a revolution in consent.

‘Organ donation saves lives; increasing the rate of organ donation allows us to save more lives. That’s the key motivation for this significant change.’

Under the new system, those over 18 will become potential donors either by registering their decision to opt in - as they do currently - or by doing nothing at all.

It will apply to adults who have lived in the country for more than 12 months.

Organs available will be the same as the ‘opt-in’ method - including kidneys, heart, liver, lungs and pancreas - and would go anywhere in the UK.

Some 8 per cent of eligible adults in Wales have decided to opt out ahead of the new law today.

Ahead of the new law coming into effect leading Welsh Christian, Jewish and Muslim clerics signed an open letter expressing their unease about the plan.

‘We remain opposed to any weakening of the principle the donation of organs should be free and voluntary,’ they said.

The Archbishop of Wales, Dr Barry Morgan, has warned that the scheme could turn ‘volunteers into conscripts’.

But in an open letter published today, Church of Wales bishops called on people to make a positive decision one way or the other.

It said: ‘As Bishops we are wholeheartedly in favour of organ donation.

‘It is love in action and a wonderful example of what it can mean to love our neighbours, especially those in need. Such generosity is a response to God’s generosity towards us.

‘We urge and encourage you to sign the Organ Donor Register, and tell your families, so that there can be no doubt about your wishes in the event of your death.’

A spokesman for the Department of Health said England had no plans to follow the lead set by Wales - but admitted officials would be watching closely.

He said: ‘Our opt-in system is working well. In 2008 independent experts advised against an opt-out system and recommended more specialist nurses, clinical leads and donation committees. This has seen organ donation rates increase by 60 per cent.

‘We are watching how the change in Wales impacts on donations and continue to work hard to build on the significant increase in organ donations achieved in recent years.’

Read more: http://www.dailymail.co.uk/news/article-3340374/Organs-taken-dead-without-consent-Landmark-law-change-Wales-gives-doctors-right-assume-adults-agreed-donors.html#ixzz3t2EzpMtw
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TORONTO MEDICO-LEGAL SOCIETY reception ar ROYAL CANADIAN YACHT CLUB.

RCYC members who attended included Insurance broker and Pres.of STRUCTURED SETTLEMENTS GTOUP INC.(1933). Provides to the mentally & physically injured .an annuity:from the settlement  tax-free and creditor-proof.. Douglas J. MITCHELL BA(UWO-1972) www.structures.ca

When client dies annuity can betransferred to spouse or a payment to Estate depending on age.

(Comment: Stats Can. 46% Canadians are FUNCTIONALLY ILLITERATE.)

FROM D.MITCHELL BA

The only revision ... is that the person has to be mentally or physically injured by the WRONGFUL act of someone else;  who has an obligation to compensate the victim.

Examples are Car Accidents, Medical Malpractice, some Sports Injuries,  Sex Abuse,  Wrongful Imprisonment.

The tax-free creditor-proof annuity MUST be arranged during the settlement of the lawsuit, not by the claimant afterward.

The Canada Revenue Agency allowance for this is based upon the victim and the defendant ( by their insurance company )   agree on a series of payments. Their insurance company buys an annuity to fulfill the payment schedule, and IRREVOCABLY directs the Annuity company to make all payments directly to the Victim,  while all tax notices on the accumulating interest go to the original purchaser  ( for example, the car insurance company)

The ONLY Life Insurance Companies issuing these special annuities are a few Canada's largest and most stable:  Canada Life, Manulife etc.

A government monitored industry fund guarantees every payment,  and in 150 years has NEVER been called upon to fulfill a missed payment.

The original Defendant Insurance Company also guarantees every payment even though they paid the full cost of the annuity during the settlement.

CRA Bulletin   #365 R2   is an enabling document for those who wish to read about it.

On late night USA television you may have seen commercials about cashing in Structured Settlements.   That is only possible in the case of USA issued Structured Settlements where the law was poorly written.   Canadian Structured Settlements cannot be sold, cashed, pledged, garnisheed, changed, or lost in any way.

OMA COUNCIL MEETING Nov..21-22 at Toronto HILTON. About 250 delegates attended together with OMA non-voting member observers.

Smoked salmon breakfast on Saturday..Scrambled eggs .bacon and sausage on Sunday.. Meals by Ruth's Chris. restaurant..

Cost of Council meeting is approx. $2,000,000 includes Delegate daily payment + travel and hotel expenses.

NAVIGATOR Ltd. has been retained for MEDIA COMMUNICATION.regarding recent Liberal Prov. Govt 5% fee cuts.to MDs services.

OMA recommended fees are twice the Prov.Liberal Govt OHIP rate for non-Ontarians.A fall of over 50% in past 45 years since beginning of Ontario State medicine.

Council was concerned that 25,000 Mid-East refugees to be admitted to Canada in 2015 would have medical costs billed to the Provinces instead of the FEDERAL Liberal Govt. The Ontario Liberal govt has set a "cap" on MD fees. If expenses are above the cap there would be further reduction in OHIP fees

ELECT ION of DIRECTOR by COUNCIL (not by the District) from the GENERAL & FAMILY PRACTICE ASSEMBLY (includes Emergency  and Palliative Medicine(, Ottawa ER Dr.Atul Kumar KAPUR MD(UWO 1991) FRCPC-ER(1999) MSc(Ottawa 2002) won on second ballot.
On first ballot ( 6 men) North York Surgical assistant was eliminated.
Another 3 eliminated: Windsor Palliative medicine GP;  Richmond Hill GP & CPSO investigator;  Manotick GP.

ELECTION by COUNCIL of DIRECTOR from SURGICAL ASSEMBLY (3 men)
SUDBURY OPHTHALMOLOGIST Stephen Eugene KOSAR MD (U.tor. 1981) FRCSC (1990)
 Other two candidates Ottawa and Peterborough anaesthetists