Offering care for victims of torture among a migrant population in a transit country: a descriptive study in a dedicated clinic from January 2017 to June 2019

Background

Medecins Sans Frontieres set up a clinic to provide multidisciplinary care to a vulnerable migrant population experiencing torture. We describe the population accessing care, the characteristics of care provided and patient outcomes.

Methods

A descriptive retrospective cohort study of patients enrolled in care during January 2017–June 2019 was conducted.

Results

Of 2512 victims of torture cases accessing the clinic, the male: female ratio was 1:1. About 67% of patients received medical care, mostly for chronic pain treatment. About 73% of patients received mental healthcare, 37% received physiotherapy and 33% received social support care; 49% came to the clinic upon the recommendation of a friend or family member. The discharge with improvement rate ranged from 23% in the mental health service to 9% in the sociolegal service. Patients retained in care had a median IQR of 3 (2–4) follow-up visits for medical care, 4 (2–7) for mental health, 6 (3–10) for physiotherapy and 2 (1–4) for sociolegal.

Conclusion

Care for victims of torture cases among vulnerable migrants is complex. For those who did receive care that led to an improvement in their condition, their care models have been described, to allow its implementation in other non-specialised settings.

Screening of asymptomatic rheumatic heart disease among refugee/migrant children and youths in Italy

BACKGROUND

Rheumatic heart disease (RHD) is a chronic condition responsible of congestive heart failure, stroke and arrhythmia. Almost eradicated in high-income countries (HIC), it persists in low- and middle-income countries. The purpose of the study was to assess the feasibility and meaningfulness of ultrasound-based RHD screening among the population of unaccompanied foreign minors in Italy and determine the burden of asymptomatic RHD among this discrete population.

METHODS

From February 2016 to January 2018, Médecins Sans Frontières conducted a weekly mobile screening by echocardiography in reception centers and family houses for unaccompanied foreign minors in Rome, followed by fix echocardiographic retesting for those resulting positive at screening. 'Definite' and 'borderline' cases were defined according to the World Hearth Federation criteria.

RESULTS

Six hundred fifty-three individuals (13-26 years old) were screened; 95.6% were below 18 years old (624/653). Six 'definite RHD' were identified at screening, yielding a detection rate of 9.2‰ (95% CI 4.1-20.3‰), while 285 (436.4‰) were defined as 'borderline' (95% CI 398.8-474.9‰). Out of 172 "non-negative borderline" cases available for being retested (113 "non-negative borderline" lost in follow-up), additional 11 were categorized as 'definite RHD', for a total of 17 'definite RHD', yielding a final prevalence of 26.0‰ (95% CI 16.2-41.5‰) (17/653), and 122 (122/653) were confirmed as 'borderline' (final prevalence of 186.8‰, 95% CI 158.7-218.7). In multivariate logistic regression analysis the presence of systolic murmur was a strong predictor for both 'borderline' (OR 4.3 [2.8-6.5]) and 'definite RHD' (OR 5.2 [1.7-15.2]), while no specific country/geographic area of origin was statistically associated with an increased risk of latent, asymptomatic RHD.

CONCLUSIONS

Screening for RHD among the unaccompanied migrant minors in Italy proved to be feasible. The burden of 'definite RHD' was similar to that identified in resource-poor settings, while the prevalence of 'borderline' cases was higher than reported in other studies. In view of these findings, the health system of high-income countries, hosting migrants and asylum seekers, are urged to adopt screening for RHD in particular among the silent and marginalized population of refugee and migrant children.

Reaching out to the forgotten: providing access to medical care for the homeless in Italy

Background

A program for outpatient and intermediate inpatient care for the homeless was pioneered by the humanitarian organization Médecins Sans Frontières (MSF) in Milan, Italy, during the winter of 2012-2013. We aimed to document the characteristics and clinical management of inpatients and outpatients seen during this program.

Methods

A clinic providing outpatient and intermediate inpatient care (24 bed capacity) was set up in an existing homeless hostel. Patients were admitted for post-hospitalization intermediate care or for illnesses not requiring secondary care. This study was a retrospective audit of the routine program data.

Results

Four hundred and fifty four individuals presented for outpatient care and 123 patients were admitted to inpatient intermediary care. On average one outpatient consultation was conducted per patient per month, most for acute respiratory tract infections (39.8%; 522/1311). Eleven percent of all outpatients suffered from an underlying chronic condition and 2.98% (38/1311) needed referral to emergency services or secondary care facilities. Most inpatients were ill patients referred through public reception centers (72.3%; 89/123), while 27.6% (34/123) were post-hospitalization patients requiring intermediate care. Out of all inpatients, 41.4% (51/123) required more than 1 week of care and 6.5% (8/123) needed counter-referral to secondary care.

Conclusions

The observed service usage, morbidity patterns, relatively long lengths of stay, high referral completion and need for counter-referrals, all reflect the important gap-filling role played by an intermediate care facility for this vulnerable population. We recommend that in similar contexts, medical non-governmental organizations (NGOs) focus on the setup of inpatient intermediary care services; while outpatient services are covered by the public health system.

Derangement of acid-base balance in uremia and under hemodialysis

Uremic acidosis is due to impaired excretion of ammonium ions in the presence of unchanged acid production. However, the degree of acidosis is quite variable among uremic patients and pre-dialytic bicarbonate levels are mainly independent of dialytic base supply. These observations strengthen the suggestion that extra-renal mechanisms may play a significant role in controlling acid-base balance in uremic patients. The possible effects of diet, intestine, bone, intermediate metabolism, and the global acid-base balance are discussed. The metabolic and clinical effects of mild uremic acidosis are not well defined. In fact, no long-term clinical study have produced clear evidence for increased protein catabolism in humans. Some data provide evidence for reduced bone mineral content and osteomalacic lesions in uremic patients with severe acidosis. Overall, the impact of the present dialytic techniques on acid-base control is quite small, since no major difference is observed in uremic patients treated with different dialytic schedules. Furthermore, the base supply by dialysis does not seem to represent the main mechanism for acid-base correction by dialysis. In conclusion, at present time, metabolic acidosis of uremic patients is often mild and not accompanied by major symptoms. Probably, more attention needs to be paid to the possible noxious effect of over-correction of acidosis.