Forced displacement and the health workforce crisis: Venezuelan healthcare workers in Peru.

The migration of health workforces tends to be economically based benefiting high-income countries, while draining lower-income countries of workers and skills However, national instability or civil conflict may also have the effect of forcing out health workers. However, few articles focus on the experiences of these types of migrants. Peru has become the second largest Latin American destination for Venezuelan forced displaced migrants, a number of which are health workers. While the exact numbers of these workers is unknown, it is estimated that 4000 and 3000 doctors and about 2500 nurses and health technicians from Venezuela reside in Peru. These workers find entry into the heath system difficult due to bureaucratic and costly registration and qualification validation procedures. However, during Covid-19 these conditions were relaxed, and a large number of these heath workers entered the heath workforce. These workers were primarily doctors and worked in urban medical facilities, though there was some distribution across the country's departments. This avenue to the health workforce allowed the mobilisation of dormant health skills and lifted workforce density numbers. Nonetheless, it is too early to see if there have been sustainable improvements, and it remains uncertain how these policies have contributed to the country's UHC goals. Peru's experiences raise the issue of how to mobilise dormant displaced health worker migrants.

Health workforce governance and professions: a re-analysis of New Zealand's primary care workforce policy actors.

BACKGROUND: This article contributes to the health workforce planning literature by exploring the dynamics of health professions in New Zealand's Primary Care sector and deriving broad lessons for an international audience. Professions tend influence health policy and governance decisions and practices to retain their place, status and influence. Therefore, understanding their power dynamics and the positions that they have on workforce policies and issues assists workforce governance or health system reform plans. METHODS: Using the infrequently reported health workforce policy tool, actor analysis, a reanalysis of previously collected data is undertaken using an actor-based framework for the study of professionalism. Two models were developed, (1) the framework's original four-actor model and (2) a five-actor model for the comparison of the Medical and Nurse professions. Existing workforce actor data were reclassified, formatted, and entered into actor analysis software to reveal the professions' relative power, inter-relationships and strategic workforce issue positions. RESULTS: In the four-actor model, the Organised user actor is found to be most influential, while the others are found to be dependent. In the five-actor model, the Medical and Nurse professions are individually more influential than their combined position in the four-actor model. Practicing professionals and Organised user actors have strong converging inter-relationships over workforce issues in both models, though in the five-actor model, the Nurse profession has weaker coherency than the Medical profession. The Medical and Nurse professions are found to be in opposition over the workforce issues labelled divisive. CONCLUSIONS: These results reflect the professions' potential to influence New Zealand's Primary Care sector, indicating their power and influence over a range of policy and reform measures. As such, the four lessons that are derived from the case indicate to policy makers that they should be aware of situational contexts and actor power, take care when encountering divisive issues and try to achieve broad-based support for proposed policies.

The implications of COVID-19 for health workforce planning and policy: the case of Peru.

Like many countries Peru is confronting uncertainties due to the COVID-19 pandemic and its consequences. This is having impacts not only on health systems but also on the planning and preparation of its workforces. In this case article we summarise the progress Peru has been making to improve its workforce capacity and planning and review how Peru has coped with the stresses put on its health system arising from the pandemic. By recounting the responses that the Ministry of Health made through mobilising existing capabilities, additional workers and collaboration with health science faculties and health professional colleges, the article identifies that a longer-term planning perspective based on skills that services require is something that Peru may consider to compliment the health workforce investments that are already being made. As such, this case provides an example for workforce planners and policy makers to contemplate when considering health workforce planning in post-COVID uncertainty.

Rethinking workforce planning for integrated care: using scenario analysis to facilitate policy development.

BACKGROUND: A goal of health workforce planning is to have the most appropriate workforce available to meet prevailing needs. However, this is a difficult task when considering integrated care, as future workforces may require different numbers, roles and skill mixes than those at present. With this uncertainty and large variations in what constitutes integrated care, current health workforce policy and planning processes are poorly placed to respond. In order to address this issue, we present a scenario-based workforce planning approach. METHODS: We propose a novel mixed methods design, incorporating content analysis, scenario methods and scenario analysis through the use of a policy Delphi. The design prescribes that data be gathered from workforce documents and studies that are used to develop scenarios, which are then assessed by a panel of suitably qualified people. Assessment consists of evaluating scenario desirability, feasibility and validity and includes a process for indicating policy development opportunities. RESULTS: We confirmed our method using data from New Zealand's Older Persons Health sector and its workforce. Three scenarios resulted, one that reflects a normative direction and two alternatives that reflect key sector workforce drivers and trends. One of these, based on alternative assumptions, was found to be more desirable by the policy Delphi panel. The panel also found a number of favourable policy proposals. CONCLUSIONS: The method shows that through applying techniques that have been developed to accommodate uncertainty, health workforce planning can benefit when confronting issues associated with integrated care. The method contributes to overcoming significant weaknesses of present health workforce planning approaches by identifying a wider range of plausible futures and thematic kernels for policy development. The use of scenarios provides a means to contemplate future situations and provides opportunities for policy rehearsal and reflection.

Preclinical development of a high affinity α-synuclein antibody, MEDI1341, that can enter the brain, sequester extracellular α-synuclein and attenuate α-synuclein spreading in vivo.

There are no approved drug therapies that can prevent or slow the progression of Parkinson's disease (PD). Accumulation and aggregation of α-synuclein protein is observed throughout the nervous system in PD. α-Synuclein is a core component of Lewy bodies and neurites that neuropathologically define PD, suggesting that α-synuclein may be a key causative agent in PD. Recent experimental data suggest that PD progression may arise due to spreading of pathological forms of extracellular α-synuclein throughout the brain via a cellular release, uptake and seeding mechanism. We have developed a high affinity α-synuclein antibody, MEDI1341, that can enter the brain, sequester extracellular α-synuclein and attenuate α-synuclein spreading in vivo. MEDI1341 binds both monomeric and aggregated forms of α-synuclein. In vitro, MEDI1341 blocks cell-to-cell transmission of pathologically relevant α-synuclein preformed fibrils (pffs). After intravenous injection into rats and cynomolgus monkeys, MEDI1341 rapidly enters the central nervous system and lowers free extracellular α-synuclein levels in the interstitial fluid (ISF) and cerebrospinal fluid (CSF) compartments. Using a novel lentiviral-based in vivo mouse model of α-synuclein spreading in the brain, we show that treatment with MEDI1341 significantly reduces α-synuclein accumulation and propagation along axons. In this same model, we demonstrate that an effector-null version of the antibody was equally as effective as one with effector function. MEDI1341 is now in Phase 1 human clinical trial testing as a novel treatment for α-synucleinopathies including PD with the aim to slow or halt disease progression.

The evolution of New Zealand's health workforce policy and planning system: a study of workforce governance and health reform.

INTRODUCTION: While considerable attention has been given to improving health workforce planning practice, few articles focus on the relationship between health workforce governance and health reform. By outlining a sequence of health reforms, we reveal how New Zealand's health workforce governance and practices came under pressure, leading to a rethink and the introduction of innovative approaches and initiatives. CASE DESCRIPTION: New Zealand's health system was quite stable up to the late 1980s, after which 30 years of structural and system reform was undertaken. This had the effect of replacing the centralised medically led health workforce policy and planning system with a market-driven and short-run employer-led planning approach. The increasing pressures and inconsistencies this approach produced ultimately led to the re-centralisation of some governance functions and brought with it a new vision of how to better prepare for future health needs. While significant gain has been made implementing this new vision, issues remain for achieving more effective innovation diffusion and improved integrated care orientations. DISCUSSION AND EVALUATION: The case reveals that there was a failure to consider the health workforce in almost all of the reforms. Health and workforce policy became increasingly disconnected at the central and regional levels, leading to fragmentation, duplication and widening gaps. New Zealand's more recent workforce policy and planning approach has adopted new tools and techniques to overcome these weaknesses that have implications for the workforce and service delivery, workforce governance and planning methodologies. However, further strengthening of workforce governance is required to embed the changes in policy and planning and to improve organisational capabilities to diffuse innovation and respond to evolving roles and team-based models of care. CONCLUSION: The case reveals that disconnecting the workforce from reform policy leads to a range of debilitating effects. By addressing how it approaches workforce planning and policy, New Zealand is now better placed to plan for a future of integrated and team-based health care. The case provides cues for other countries considering reform agendas, the most important being to include and consider the health workforce in health reform processes.

Russian dilemma for global arctic science.

Polar regions are critically implicated in our understanding of global climate change. This is particularly the case for the Arctic, where positive feedback loops and climate tipping points enhance complexity and urgency. Half of the Arctic and much of the world's permafrost zone lie within Russian territory. Heightened geopolitical tensions, however, have severely damaged scientific collaboration between Russia and previously well established academic partners in western countries. Isolation is now causing increasingly large data gaps in arctic research that affect our ability to make accurate predictions of the impact of climate change on natural and societal systems at all scales from local to global. Here, we argue that options to resume both practical knowledge of collaborative working and flows of research data from Russia for global arctic science must continue to be asserted, despite an increasing tendency for the Arctic to become disconnected. Time is short, as preparations for the fifth International Polar Year begin to gather momentum. While sanctions remain in place, efforts to foster peer to peer connections and re-activate effective institutional cooperation are vital to address the grand challenges of global climate change.

Global change research needs international collaboration.

Tackling the grand challenges of global climate change for the sustainability of ecological and societal systems requires data and expertise from Russia, the world's largest country that has the longest Arctic shoreline and the largest forest biome, peatland and permafrost zones. Academic relations and scientific collaborations with Russian scholars and institutions must continue despite the ensuing geopolitical crisis since 2022.

Oxaliplatin-induced acute thrombocytopenia.

We describe a patient who experienced immediate onset severe thrombocytopenia as part of a hypersensitivity reaction to oxaliplatin, following substantial relatively uncomplicated previous exposure to the drug. We review other reports of acute hematological toxicity from oxaliplatin. We draw attention to the important need for vigilance when patients develop unusual acute symptoms during or shortly after oxaliplatin infusion.

Initial stages of enamel erosion: An in situ atomic force microscopy study.

Time-resolved in situ atomic force microscopy has been employed to examine erosion progression in untreated and fluoride-treated enamel specimens during exposure to citric acid. Contact with the acidic reaction solution initiated the emergence and growth of dissolution pits in both the native and the fluoride-treated enamel. In native enamel, pits are first observed after 90 min exposure to the reaction solution, compared to 250 min in the case of the fluoride-treated enamel. These findings indicate that, within the constraints of this study, a single application of fluoride solution (1000 mg/L, 2 min) confers protection to the enamel surface against acid-mediated erosion. This paper also highlights the potential role intrinsic defects may have on the susceptibility of enamel to erosion and, in part, may explain why some people are more susceptible to acid erosion.

Multilocus sequence typing of Clostridium difficile.

A robust high-throughput multilocus sequence typing (MLST) scheme for Clostridium difficile was developed and validated using a diverse collection of 50 reference isolates representing 45 different PCR ribotypes and 102 isolates from recent clinical samples. A total of 49 PCR ribotypes were represented overall. All isolates were typed by MLST and yielded 40 sequence types (STs). A web-accessible database was set up (http://pubmlst.org/cdifficile/) to facilitate the dissemination and comparison of C. difficile MLST genotyping data among laboratories. MLST and PCR ribotyping were similar in discriminatory abilities, having indices of discrimination of 0.90 and 0.92, respectively. Some STs corresponded to a single PCR ribotype (32/40), other STs corresponded to multiple PCR ribotypes (8/40), and, conversely, the PCR ribotype was not always predictive of the ST. The total number of variable nucleotide sites in the concatenated MLST sequences was 103/3,501 (2.9%). Concatenated MLST sequences were used to construct a neighbor-joining tree which identified four phylogenetic groups of STs and one outlier (ST-11; PCR ribotype 078). These groups apparently correlate with clades identified previously by comparative genomics. The MLST scheme was sufficiently robust to allow direct genotyping of C. difficile in total stool DNA extracts without isolate culture. The direct (nonculture) MLST approach may prove useful as a rapid genotyping method, potentially benefiting individual patients and informing hospital infection control.

Anti-PrPC antibody rescues cognition and synapses in transgenic alzheimer mice.

Objective: Amyloid-beta oligomers (Aßo) trigger the development of Alzheimer's disease (AD) pathophysiology. Cellular prion protein (PrPC) initiates synaptic damage as a high affinity receptor for Aßo. Here, we evaluated the preclinical therapeutic efficacy of a fully human monoclonal antibody against PrPC. This AZ59 antibody selectively targets the Aßo binding site in the amino-terminal unstructured domain of PrPC to avoid any potential risk of direct toxicity. Methods: Potency of AZ59 was evaluated by binding to PrPC, blockade of Aßo interaction and interruption of Aßo signaling. AZ59 was administered to mice by weekly intraperitoneal dosing and brain antibody measured. APP/PS1 transgenic mice were treated with AZ59 and assessed by memory tests, by brain biochemistry and by histochemistry for Aß, gliosis and synaptic density. Results: AZ59 binds PrPC with 100 pmol/L affinity and blocks human brain Aßo binding to PrPC, as well as prevents synaptotoxic signaling. Weekly i.p. dosing of 20 mg/kg AZ59 in a murine form achieves trough brain antibody levels greater than 10 nmol/L. Aged symptomatic APP/PS1 transgenic mice treated with AZ59 for 5-7 weeks show a full rescue of behavioral and synaptic loss phenotypes. This recovery occurs without clearance of plaque pathology or elimination of gliosis. AZ59 treatment also normalizes synaptic signaling abnormalities in transgenic brain. These benefits are dose-dependent and persist for at least 1 month after the last dose. Interpretation: Preclinical data demonstrate that systemic AZ59 therapy rescues central synapses and memory function from transgenic Alzheimer's disease pathology, supporting a disease-modifying therapeutic potential.

Novel quartz crystal microbalance based biosensor for detection of oral epithelial cell-microparticle interaction in real-time.

Recent applications of quartz crystal resonant sensor technology to monitor cell adhesion and specific ligand interaction processes has triggered the development of a new category of quartz crystal microbalance (QCM) based biosensors. In this study human oral epithelial cells (H376) were cultured on quartz sensors and their response to microspheres investigated in situ using the QCM technique. The results demonstrated that this novel biosensor was able to follow cell-microsphere interactions in real-time and under conditions of flow as would occur in the oral cavity. Unique frequency profiles generated in response to the microspheres were postulated to be due to phases of mass addition and altered cellular rigidity. Supporting microscopic evidence demonstrated that the unique frequency responses obtained to these interactions were in part due to binding between the cell surface and the microspheres. Furthermore, a cellular uptake process, in response to microsphere loading was identified and this, by influencing the rigidity of the cellular cytoskeleton, was also detectable through the frequency responses obtained.

Diffusive transport within dentinal tubules: an X-ray microtomographic study.

The hydrodynamic theory of dentine hypersensitivity proposes that external stimuli cause dentinal fluid movement within dentinal tubules thereby triggering mechanosensitive nerves and eliciting a pain response. The aim of this study was to employ X-ray microtomography (XMT) to monitor diffusion of caesium acetate through dentine to investigate the extent to which transport occurs within the primary tubules compared to that through branched microtubules believed to run perpendicular to the direction of the primary dentinal tubules. 2.0-mm thick coronal dentine disks masked to leave half of the upper surface exposed were imaged by XMT, initially in water, which was then replaced with an aqueous solution of 0.50 mol l(-1) caesium acetate. Further XMT images were acquired after 1 and 6 days immersion. The XMT images were used to measure the change in the X-ray linear attenuation coefficient resulting from caesium acetate ingress into dentine. There was clearly considerable ingress of caesium acetate into the dentine lying below the exposed surface, but considerably less beneath the sealed surface, suggesting that diffusive transport occurs predominantly in the direction of the primary dentinal tubules, with no significant lateral transport. Primary tubules are clearly the dominant transmission route for triggering the mechanosensitive nerves present at the dentine-pulp interface, and for delivery of nerve desensitising agents.

Fluoropolymers as low-surface-energy tooth coatings for oral care.

A range of low-surface-energy fluoropolymers has been synthesised and their effectiveness as dental-care coatings for plaque, stain and erosion prevention has been evaluated using a series of oral care models employing pressed discs of calcium hydroxyapatite or sections of human teeth. Since the blocking of dentinal tubules is a key mechanistic strategy in the treatment of dentine hypersensitivity, the capability of these non-permanent fluoropolymer coatings to occlude the pore structure of human dentine and to reduce the outward flow of simulated dentinal fluid has also been investigated. Several of the fluoropolymer coatings have been found to inhibit bacterial adhesion but no correlation has been established between anti-adhesion efficacy and fluorine content or surface energy. All the fluoropolymers have been seen to reduce stain uptake by pellicle-coated HA discs, with homopolymers being considerably more effective than copolymers. Some fluoropolymer coatings have also been shown to inhibit the acid demineralisation of hydroxyapatite discs and to reduce dentine permeability. Coatings of the 2:1 copolymer of 1H,1H,2H,2H-perfluorodecyl acrylate and 2-hydroxyethyl acrylate are most promising, exhibiting significant anti-adhesion and anti-erosion efficacy and reducing dentine permeability to a level that is comparable with that achieved with the standard treatment employed in commercial anti-sensitivity formulations.

Mucoadhesion, hydration and rheological properties of non-aqueous delivery systems (NADS) for the oral cavity.

OBJECTIVES: Effective delivery of oral care actives from conventional hydrogel formulations is often compromised by poor retention associated with shear forces present in the mouth, salivary washout and over-hydration of the gel which can lead to structural breakdown and adhesive failure. Non-aqueous gels offer the opportunity to formulate rheologically acceptable vehicles with higher concentrations of bioadhesive polymer than is possible using water as the primary solvent. Accordingly, this study describes the formulation and characterisation of the rheology, hydration and bioadhesive properties of a range of non-aqueous delivery systems (NADS). METHODS: The formulations were composed principally of glycerol, with varying amounts of polyethylene glycol (PEG) 400 and Carbopol 974P being incorporated in the ranges 0-31.34% and 0-4% (w/w). Work of adhesion (WOA) and maximum force of detachment (Fmax) were determined using a Dartec tensile tester after application of a normal force. Rheology was assessed using a Bohlin CS CVO rheometer. RESULTS: WOA and Fmax increased with increasing compression time and Carbopol concentration. Addition of 30% (w/w) PEG 400 to the formulation containing 2% Carbopol in glycerol improved bioadhesive function. Formulation rheology was largely controlled by the Carbopol concentration, and to a lesser extent by the concentration of PEG 400 and these, in turn, largely determined the bioadhesion parameters and rates of hydration. CONCLUSION: The results of this in vitro study suggest that bioadhesion, and consequently potential drug bioavailability, would be enhanced by use of a water miscible non-aqueous delivery vehicle such as glycerol containing a bioadhesive polymer such as Carbopol with the addition of controlled amounts of PEG as plasticiser.

Control of brushing variables for the in vitro assessment of toothpaste abrasivity using a novel laboratory model.

OBJECTIVES: Design and construct a tooth-brushing simulator incorporating control of brushing variables including brushing force, speed and temperature, thereby facilitating greater understanding of their importance in toothpaste abrasion testing methodologies. METHODS: A thermostable orbital shaker was selected as a base unit and 16- and 24-specimen brushing rigs were constructed to fit inside, consisting of: a square bath partitioned horizontally to provide brushing channels, specimen holders for 25 mm diameter mounted specimens to fit the brushing channels and individually weighted brushing arms, able to support four toothbrush holders suspended over the brushing channels. Brush head holders consisted of individually weighted blocks of Delrin, or PTFE onto which toothbrush heads were fixed. Investigating effects of key design criteria involved measuring abrasion depths of polished human enamel and dentine. RESULTS: The brushing simulator demonstrated good reproducibility of abrasion on enamel and dentine across consecutive brushing procedures. Varying brushing parameters had a significant impact on wear results: increased brushing force demonstrated a trend towards increased wear, with increased reproducibility for greater abrasion levels, highlighting the importance of achieving sufficient wear to optimise accuracy; increasing brushing temperature demonstrated increased enamel abrasion for silica and calcium carbonate systems, which may be related to slurry viscosities and particle suspension; varying brushing speed showed a small effect on abrasion of enamel at lower brushing speed, which may indicate the importance of maintenance of the abrasive in suspension. CONCLUSIONS: Adjusting key brushing variables significantly affected wear behaviour. The brushing simulator design provides a valuable model system for in vitro assessment of toothpaste abrasivity and the influence of variables in a controlled manner. Control of these variables will allow more reproducible study of in vitro tooth wear processes.

Assessing and managing communication needs in people with serious mental illness.

Effective communication is essential to maintain mental health and resilience. Communication can be challenging for people who experience serious mental illness (SMI), which can be a barrier to social, employment and educational opportunities, as well as increasing their risk of experiencing abuse. Therefore, it is important that nurses who work with individuals experiencing SMI understand the assessment and management of specific communication, speech and language needs. This article focuses on five areas of communication, speech and language - receptive language, expressive language, speech, social communication and swallowing - to increase nurses' confidence in assessing communication needs and making appropriate referrals to speech and language therapy services. The authors also suggest therapeutic interventions that nurses can use to reduce the effects of speech and language difficulties among people with SMI.

New Zealand's health workforce planning should embrace complexity and uncertainty.

Concerns over New Zealand's health workforce sufficiency, distribution and sustainability continue. Proposed solutions tend to focus on supplying medical professionals to meet predicted numbers or to resolve distributional problems. This is despite quantitative forecasts being known to have poor reliability. A recent study on New Zealand's health workforce planning, which focused less on medical workforce numbers and more on the system's organisation and constituent interrelations, highlights the use of complementary methods to define the problems and design a range of policy responses. Core to deciding on suitable interventions is the use of analysis tools, such as judgement-based approaches, which are commensurate with the actual levels of uncertainty being experienced, and which complement quantitative predictive forecasting.