Trans* people’s access to gender-affirming health care: A European comparison

Background

Trans* people's life satisfaction is correlated with established legal frameworks for gender recognition and access to trans*-specific health care (Transgender Europe [TGEU], 2021). TGEU's guidelines to human rights-based principles of trans*-specific health care highlight bodily integrity/autonomy, free self-determination of gender, quality, specialized and decentralized care, and the right to determine reproductive paths as important pillars of gender affirming health care. We conducted a policy comparison across Europe regarding access to gender-affirming health care to assess how adherence to human rights-based principles could be strengthened.

Methods

We compared access to health care across four main domains: legal framework (e.g., legally recognised genders), insurance coverage (e.g., out of pocket costs), access barriers (e.g., legal requirements to access gender-affirming surgery), and health care offers (e.g., hormone replacement therapy). Criteria were developed in guided brainstorming sessions. Three researchers rated 28 countries across 28 items based on available policy documents.

Results

The majority of European countries prescribes a medicalised gender-affirming process rather than a self-decided process. Psychiatric diagnosis is also required in most countries to access gender-affirming health care. Gender-affirming health care is partly financed by statutory health insurance in most of the countries. Not all countries authorise full gender-affirming health care. Especially where statutory health insurance-covered gender-affirming health care relied centralised on single outpatient clinics or hospitals, waiting times between 6-24 months are found.

Conclusions

Many European countries fail to fully comply with TGEU's guidelines to human rights-based principles of trans* health care. Given the negative impact of access barriers on life satisfaction, European countries should target these shortfalls in ensuring gender-affirming health care.

Key messages

• Non- or only partly covered trans* health care contributes to health inequality.

• Regarding trans* people, European countries need to strengthen human-rights based access to gender-affirming health care.

CellTrackVis: analyzing the performance of cell tracking algorithms

Live-cell imaging is a common data acquisition technique used by biologists to analyze cell behavior. Since manually tracking cells in a video sequence is extremely time-consuming, many automatic algorithms have been developed in the last twenty years to accomplish the task. However, none of these algorithms can yet claim robust tracking performance at the varying of acquisition conditions (e.g., cell type, acquisition device, cell treatments). While many visualization tools exist to help with cell behavior analysis, there are no tools to help with the algorithm's validation. This paper proposes CellTrackVis, a new visualization tool for evaluating cell tracking algorithms. CellTrackVis allows comparing automatically generated cell tracks with ground truth data to help biologists select the best-suited algorithm for their experimented pipeline. Moreover, CellTackVis can be used as a debugging tool while developing a new cell tracking algorithm to investigate where, when, and why each tracking error occurred.

Inoculation route-dependent Lassa virus dissemination and shedding dynamics in the natural reservoir - Mastomys natalensis

Lassa virus (LASV), a Risk Group-4 zoonotic haemorrhagic fever virus, affects sub-Saharan African countries. Lassa fever, caused by LASV, results in thousands of annual deaths. Although decades have elapsed since the identification of the Natal multimammate mouse (Mastomys natalensis) as a natural reservoir of LASV, little effort has been made to characterize LASV infection in its reservoir. The natural route of infection and transmission of LASV within M. natalensis remains unknown, and the clinical impact of LASV in M. natalensis is mostly undescribed. Herein, using an outbred colony of M. natalensis, we investigate the replication and dissemination dynamics of LASV in this reservoir following various inoculation routes. Inoculation with LASV, regardless of route, resulted in a systemic infection and accumulation of abundant LASV-RNA in many tissues. LASV infection in the Natal multimammate mice was subclinical, however, clinical chemistry values were transiently altered and immune infiltrates were observed histologically in lungs, spleens and livers, indicating a minor disease with coordinated immune responses are elicited, controlling infection. Intranasal infection resulted in unique virus tissue dissemination dynamics and heightened LASV shedding, compared to subcutaneous inoculation. Our study provides important insights into LASV infection in its natural reservoir using a contemporary infection system, demonstrating that specific inoculation routes result in disparate dissemination outcomes, suggesting intranasal inoculation is important in the maintenance of LASV in the natural reservoir, and emphasizes that selection of the appropriate inoculation route is necessary to examine aspects of viral replication, transmission and responses to zoonotic viruses in their natural reservoirs.

Similarities and intersections – A comprehensive view in three studies

Background

Various groups face difficulties in access to, and usage of health care. Research on marginalization in health care, and programs aiming to reduce inequalities usually focus on one single group at a time. Regarding the heterogeneity of groups defined by a few social characteristics, our aim was to question the specificity of barriers, and similarities between different groups.

Methods

The results of a mixed methods study focusing on elderly people with Turkish migration background were compared to the interim results of a qualitative study focusing on transgender persons, and the interim results of a qualitative study focusing persons with trauma related psychiatric diagnoses.

Results

1) While relevant barriers in access to, and usage of health care seem to be group-specific at the first view, their underlying mechanisms of emergence are analogous. 2) Beside more obvious similarities, 3) further barriers arise by the combination of more than the mainly addressed characteristics of the different groups.

Conclusions

Barriers analogous or similar among different groups lead to underlying structural or professionality-related issues. If different dimensions of marginalization intersect, they may be disguised by a concentration on single characteristics. To target health inequalities on the long term, a closer look on similarities between groups facing health inequalities could improve the development of programs for a broader range of persons.

Key messages

The comparison of different marginalized groups is useful to identify and target systematic inequalities in health care. Researchers and stakeholders should consider mechanisms of multiple marginalization.

Determination of Bronopol, Bronidox, and Methyldibromo Glutaronitrile in Cosmetics by Liquid Chromatography with Electrochemical Detection

A method for the simultaneous determination of methyldibromo glutaronitrile, bronopol, and broni-dox in cosmetics, based on liquid chromatography with electrochemical detection, is described. The method is suitable for both aqueous products and emulsions. The detection limit is better than 0.002% for all analytes. Recoveries from an emulsion, spiked to concentrations of 0.03% of the analytes, were 100.4% for bronopol [relative standard deviation (RSD), 0.43%], 97.1% for bronidox (RSD, 0.83%), and 98.4% for methyldibromo glutaronitrile (RSD, 1.7%). Repeatabilities were calculated from 10 replicate analyses of commercial samples. The repeatability for bronopol from an emulsion containing 0.047% bronopol was 0.0027% (RSD, 1.99%); for bronidox from a lotion containing 0.027% bronidox, 0.0014% (RSD, 1.86%); and for methyldibromo glutaronitrile from an emulsion containing 0.031% methyldibromo glutaronitrile, 0.0019% (RSD, 2.16%). A ruggedness test showed that sample amount influenced the results for all 3 analytes. The results obtained for bronidox also depended on detection parameters and composition of extraction solvent. The method was applied to 138 cosmetic products and performed trouble free during these analyses. Bronopol was found in 14 samples, and bronidox was found in 4 samples, including a baby hair lotion, in which it is prohibited. Methyldibromo glutaronitrile was present in 27 samples, including creams, lotions, and sun protection cosmetics.

Quantitative Determination of Paralytic Shellfish Poisoning Toxins in Shellfish Using Prechromatographic Oxidation and Liquid Chromatography with Fluorescence Detection: Collaborative Study

A collaborative study was conducted for the determination of paralytic shellfish poisoning (PSP) toxins in shellfish. The method used liquid chromatography with fluorescence detection after prechromatographic oxidation of the toxins with hydrogen peroxide and periodate. The PSP toxins studied were saxitoxin (STX), neosaxitoxin (NEO), gonyautoxins 2 and 3 (GTX2,3; together), gonyautoxins 1 and 4 (GTX1,4; together), decarbamoyl saxitoxin (dcSTX), B-1 (GTX5), C-1 and C-2 (C1,2; together), and C-3 and C-4 (C3,4; together). B-2 (GTX6) toxin was also included, but for qualitative identification only. Mussels, both blank and naturally contaminated, were mixed and homogenized to provide a variety of PSP toxin mixtures and concentration levels. The same procedure was followed with clams, oysters, and scallops. Twenty-one test samples in total were sent to 21 collaborators who agreed to participate in the study. Results were obtained from 18 laboratories representing 14 different countries. It is recommended that the method be adopted First Action by AOAC INTERNATIONAL.

Transnational medication management by elderly migrants – a mixed-methods approach

Background

Many elderly people of Turkish origin choose a transnational lifestyle and commute between Germany and Turkey every few months. These circular migrants often suffer from chronic diseases. The transnational lifestyle can lead to discontinuities in long-term medication and irregular check-ups. If continuity of care is not ensured transnationally, health risks arise.

Methods

In a mixed-methods study 8 expert-interviews with general practitioners and 25 guideline interviews were conducted with circular migrants to analyze their medication adherence. Additional quantitative analyses were conducted based on data from a German statutory health insurance popular with migrants to investigate discontinuities of prescribed medication.

Results

Cross-border care involves different health risks with regard to medication adherence. For example, patients in Germany rarely receive the amount of medication they need for their stay in Turkey and there are discontinuities in medication delivery. The multi-perspective insight into the patients’ experiences of medical care and the view of general practitioners shows strong variations of preferred strategies to handle the challenges of transnational medication management. Single strategies, such as leaving the health insurance card in one state for prescription and sending of medication through family members or asking for higher amounts of medication to store before travel, lead to frustration both at GPs’ and patients’ sides. GPs experience high pressure by the health system’s structure in providing good care for the patients, especially in providing enough time for information transfer between GPs and patients.

Conclusions

Transnational solutions for health care, and in particular medication care, such as an interprofessional collaborative care across borders or transnational e-health records need to be developed.

Key messages

A transnational lifestyle can lead to discontinuities in the provision of medication. Transnational, inter-professional cooperation is needed to ensure continuity of health care for circular migrants.

The influence of culturalisation on GP consultations and in research on GP care

Background

General practitioners (GPs) have a gatekeeping function in the healthcare system. Research shows that patients of Turkish origin in Germany manage to access specialist care less often than non-immigrant patients. Underlying could be problems related to interactions with the GP. Focusing on interaction instead of individual patients’ characteristics might help identifying underappreciated barriers in health care.

Methods

We conducted a scoping review to identify research on interaction-related aspects of GP consultations of people of Turkish origin. Goffman’s interactional theory was used for operationalisation. Analysis focused on the process of consultation from the perspectives of patients, GPs, and interpreters. Additionally, noticeable issues in researchers’ perspectives on migrants’ utilization of health care were identified.

Results

Patients of Turkish origin expect similar professional performances from their GPs as patients without a migration background. If informal interpreters take part, misinformation might remain unrecognised. Frequently, GPs experience insecurity, which sometimes results in lower empathy and prejudice-based, unprofessional reactions or misdiagnoses. Researchers’ interpretations refer partly to unfounded explanations such as a homogeneous Turkish culture or somatization tendencies of Turkish patients.

Conclusions

Difficulties in GP care of patients of Turkish origin, and access barriers to specialist care, arise less from culture-bound performances of these patients as from culturalising expectations and performances of GPs. Researchers often show similar expectations and interpretations. Such culturalising interpretations should be avoided in future research.

Key messages

Difficulties in GP care of patients of Turkish origin, and access barriers to specialist care, arise less from culture-bound performances of these patients as from culturalising expectations of GPs. Future research should avoid culturalising interpretations.

Surface-dominated conduction up to 240 K in the Kondo insulator SmB6 under strain

SmB₆ is a strongly correlated mixed-valence Kondo insulator with a newly discovered surface state, proposed to be of non-trivial topological origin. However, the surface state dominates electrical conduction only below T^∗ ≈ 4 K (ref. ), limiting its scientific investigation and device application. Here, we report the enhancement of T^∗ in SmB₆ under the application of tensile strain. With 0.7% tensile strain we report surface-dominated conduction at up to a temperature of 240 K, persisting even after the strain has been removed. This can be explained in the framework of strain-tuned temporal and spatial fluctuations of f-electron configurations, which might be generally applied to other mixed-valence materials. We note that this amount of strain can be induced in epitaxial SmB₆ films via substrate in potential device applications.

Increased urinary CD80 excretion and podocyturia in Fabry disease

BACKGROUND

Certain glomerulopathies are associated with increased levels of CD80 (B7-1). We measured the urinary excretion of CD80, podocyturia and proteinuria in controls and in subjects with Fabry disease either untreated or on enzyme replacement therapy (ERT).

METHODS

Cross-sectional study including 65 individuals: controls (n = 20) and Fabry patients (n = 45, 23 of them not on ERT and 22 on ERT). Variables included age, gender, urinary protein/creatinine ratio (UPCR), estimated glomerular filtration rate (eGFR), urinary uCD80/creatinine ratio (uCD80) and podocyturia. CD80 mRNA expression in response to lyso-Gb3, a bioactive glycolipid accumulated in Fabry disease, was studied in cultured human podocytes.

RESULTS

Controls and Fabry patients did not differ in age, eGFR and gender. However, UPCR, uCD80 and podocyturia were significantly higher in Fabry patients than in controls. As expected, Fabry patients not on ERT were younger and a higher percentage were females. Non-ERT Fabry patients had less advanced kidney disease than ERT Fabry patients: UPCR was lower and eGFR higher, but uCD80 and podocyturia did not differ between non-ERT or ERT Fabry patients. There was a significant correlation between uCD80 and UPCR in the whole population (r 0.44, p 0.0005) and in Fabry patients (r 0.42, p 0.0046). Lyso-Gb3 at concentrations found in the circulation of Fabry patients increased uCD80 expression in cultured podocytes.

CONCLUSIONS

Fabry disease is characterized by early occurrence of increased uCD80 excretion that appears to be a consequence of glycolipid accumulation. The potential for uCD80 excretion to reflect early, subclinical renal Fabry involvement should be further studied.

Integration of geriatric mental health screening into a primary care practice: a patient satisfaction survey

OBJECTIVE

Colocation of mental health screening, assessment, and treatment in primary care reduces stigma, improves access, and increases coordination of care between mental health and primary care providers. However, little information exists regarding older adults' attitudes about screening for mental health problems in primary care. The objective of this study was to evaluate older primary care patients' acceptance of and satisfaction with screening for depression and anxiety.

METHODS

The study was conducted at an urban, academically affiliated primary care practice serving older adults. Study patients (N = 107) were screened for depression/anxiety and underwent a post-screening survey/interview to assess their reactions to the screening experience.

RESULTS

Most patients (88.6%) found the length of the screening to be "just right." A majority found the screening questions somewhat or very acceptable (73.4%) and not at all difficult (81.9%). Most participants did not find the questions stressful (84.9%) or intrusive (91.5%); and a majority were not at all embarrassed (93.4%), upset (93.4%), or uncomfortable (88.8%) during the screening process. When asked about frequency of screening, most patients (72.4%) desired screening for depression/anxiety yearly or more. Of the 79 patients who had spoken with their physicians about mental health during the visit, 89.8% reported that it was easy or very easy to talk with their physicians about depression/anxiety. Multivariate results showed that patients with higher anxiety had a lower positive reaction to the screen when controlling for gender, age, and patient-physician communication.

CONCLUSIONS

These results demonstrate strong patient support for depression and anxiety screening in primary care.

Absence of skin rash in Goodpasture's syndrome: the hyaluronan effect

Goodpasture's syndrome is a rare disease that involves rapidly progressive kidney failure as well as hemorrhagic lung disease. It is a form of autoimmune disorder with unusual features; marked male preponderance, in contrast with other autoimmune disease in which females are at far greater risk. The autoantibodies are directed again the carboxy-extension non-collagenous (NC1) portion of one of the basement membrane-specific collagen IV alpha 3 chains. Basal laminas throughout the body share this structure, including those in kidney, lung and skin. But curiously, skin is rarely involved in Goodpasture's syndrome. Hyaluronan is a large extracellular matrix carbohydrate polymer. Half of total body hyaluronan occurs in skin. High molecular weight hyaluronan, a potent immunosuppressive polymer, might be functioning as an immune shield for skin in Goodpasture's syndrome, and be the basis for the anomaly. A summary of this putative effect is described, including possible molecular mechanisms involved, and suggestions for testing this hypothesis.

In vitro cytotoxicity of the chlorinated naphthoquinone dichlone to human endothelial ECV304 cells

The cytotoxicity of the pro-oxidant fungicide dichlone (2,3-dichloro-1,4-naphthoquinone), to the human endothelial cell line, ECV304, was evaluated. The sensitivity of these cells to dichlone was intermediate between that of human hepatoblastoma HepG2 cells (least sensitive) and that of human GMO5757 fibroblasts. The midpoint cytotoxicity values for a 24-hr exposure to dichlone was about 0.02 mm when evaluated with the neutral red, acid phosphatase, and XTT tetrazolium assays. Lactic acid dehydrogenase leakage, after a 4-hr exposure, occurred initially at 0.05 mm dichlone. As with other naphthoquinones, cellular metabolism of dichlone presumably could proceed either by a one- or a two-electron reduction reaction. The enhancement of potency of dichlone towards ECV304 cells pretreated with the glutathione-depleting agents, dl-buthionine-[S,R]-sulfoximine, 1-chloro-2,4-dinitrobenzene, and 1,3-bis(chloroethyl)-1-nitrosourea; the reduction in potency of dichlone to cells pretreated with (-)-2-oxo-4-thiazolidine carboxylic acid; the decrease in intracellular glutathione on exposure to dichlone; the subtle damage to the plasma membrane of dichlone-treated cells (as detected by the leakage of lactate dehydrogenase from these cells); and the lack of potentiation of dichlone toxicity by pretreatment with dicoumarol, are all consistent with the one-electron reduction reaction as the dominant pathway and with the subsequent generation of reactive oxygen molecules. The ECV304 cell line proved to be a useful research tool to study cytotoxic injury to endothelial cells.