Blurred Borders: Trans-Boundary Impacts & Solutions in the San Diego-Tijuana Border Region

Over the years, the border has divided the people of San Diego County and Tijuana over language, culture, national security, public safety and a host of other cross-border issues ranging from human migration to the environment. For some, the 'us' versus 'them' mentality has become more pervasive following the tragedy of September 11, 2001, with a growing number of San Diegans focusing greater attention on terrorism and homeland security, as well as the need to re-think immigration policy in the United States as a means of fortifying the international border. This is validated by a recent KPBS/Competitive Edge research poll that found 46% of English-speaking San Diegans desiring that the U.S. impose tighter restrictions on the border. Yet the question remains: if San Diegans and Tijuana are so different, why is our shared port of entry the most busily crossed international border in the world with over 56 million crossings a year? The answer is simple. Opposites attract. The contrasts and complementarities between San Diego and Tijuana are so powerful that residents, as well as visiting tourists and business people, endure post-9/11 traffic and pedestrian delays to cross the border for work, school, cultural enrichment, maintaining family ties or sheer economic necessity

Civic Engagement, Volunteerism and Charitable Giving: Americans Retiring in Mexico's Coastal Communities

This study examines whether the American commitment to volunteerism and charitable giving is as evident among U.S. retirees in other countries as it is in the U.S., and in particular, how committed U.S. retirees in their adopted Mexican communities are engaged in civic engagement and charitable giving.As baby boomers - - the generation of 77 million Americans born between 1946 and 1964 - - retire, they represent a tremendous potential resource to their communities for public service and volunteerism. A recent study undertaken by the U.S. Corporation for National Public Service (CNPS) determined that the number of volunteers aged 65 and older will increase 50% over the 13 year period from 2007 to 2020, from approximately 9 million senior volunteers to over 13 million.1 According to CNPS, that number is likely to continue to rise because the youngest baby boomers will not reach age 65 until 2029. Furthermore, research has shown that that older volunteers may derive additional health benefits from volunteering such as greater life satisfaction and lower rates of depression.2While the pool of potential baby boomers engaged in voluntary service is expected to grow in the coming years, not everyone in that population is expected to remain in the United States. In fact, due to the rising costs of retiring in the United States, a growing number of American retirees are opting to retire overseas. And, among overseas retirement destinations, Mexico is considered one of the most preferred retirement locales because of its affordability, lifestyle options, and its close proximity to the United States. To better understand perceptions and lifestyle trends of U.S. retirees in Mexico, the International Community Foundation conducted a comprehensive study of U.S retirees in Mexican coastal communities between July and November 2009. A key focus of this research included an analysis of civic engagement, volunteerism and charitable giving trends among the U.S. expatriate community. The target populations surveyed were those aged 50 years or older who are now either retired full time in Mexico or residing there on a part-time basis.Several key findings emerged from the research. Volunteerism and giving to charity is as robust among U.S. retirees living in coastal Mexico as it is among retirees in the U.S. This is especially noteworthy since relatively few of these donors receive a tax deduction for their gifts. Respondents not only give in Mexico, but continue to give in the U.S. as well. These retirees volunteer because of their strong sense of social responsibility, and desire to make a difference in their communities. They report that their volunteer efforts increase their sense of belonging in Mexico, and contribute to an increased sense of community among local neighbors and friends.Respondents engage in a wide range of volunteer activities, most prominently with education-focused charities, community projects, and the environment. Social issues such as poverty, stray animals, economic challenges, unemployment, and lack of educational opportunities for youth concern them. Many retirees are willing to get involved to solve such problems, and report they would even consider Peace Corps service should the program be expanded to include retirees.Despite their inclination to be civically involved, there is a gap between U.S. retirees and Mexican-led nonprofit organizations in Mexico. Many respondents to this survey indicated that they were more likely to start their own nonprofit or to be involved in nonprofits created by other expats than to engage in work with a Mexican nonprofit. This could be due to doubts retirees have about the accountability and transparency of Mexican nonprofits, which often exist in a nascent state. Factors such as cultural misunderstandings and language barriers may also influence the willingness of retirees to engage with Mexican nonprofits. Yet, despite these findings, many U.S. retirees have a favorable impression of Mexican nonprofits in terms of program strength and effectiveness. Nevertheless, the potential for connection between retirees and Mexican communities is rich. Many retirees are willing to consider not only volunteering and giving, but planned giving and property bequests to Mexican nonprofits. At this time, Mexican nonprofits have a limited capacity to leverage this valuable resource. Thus, there exists a very real potential, for the gap between Mexican nonprofits and the U.S. retiree community to increase. This report makes a number of specific recommendations for both Mexican nonprofits, and U.S. policy makers to make improvements and promote future collaboration in volunteerism, philanthropy, and civic engagement

Housing and Real Estate Trends among Americans Retiring in Mexico's Coastal Communities

For years, U.S. and Canadian retirees have flocked to Mexico as an alternative overseas retirement destination that was affordable, offered desirable weather and was close to their communities of origin in North America. These attributes have made Mexico the top overseas retirement destination for older Americans, resulting in a building boom that reached its peak in 2005/06 and stretched from Playas de Tijuana-Rosarito and Los Cabos along the Baja California peninsula, and from Puerto Penasco, Sonora to Mazatlan, Sinaloa. In southern Mexico, the real estate focus has been on expanding the Cancun corridor to the Riviera Maya

Tuberculosis in the San Diego-Tijuana Border Region: Time for Bi-National Community-Based Solutions

The close geographical proximity of San Diego and Tijuana, the stark contrast between their distinct economies and levels of socio-economic development, and the ease and magnitude of cross-border exchange between these two metropolitan areas, demand our undivided attention. According to the San Diego Association of Governments (SANDAG), over 60 million persons cross into San Diego from Tijuana at the San Ysidro border crossing each year. In fact, many have come to agree that the San Diego-Tijuana border region does not identify with one particular country, but rather has a broader identity of its own. The blending of economic, social and cultural activities in this region charges us to find bi-national solutions to the unique bi-national issues facing the region. One such regional issue we must confront is that of tuberculosis (TB). Both California and Baja California have TB incidence rates that are much higher than the national rates of their respective countries. Furthermore, Tijuana reports approximately 4 times as many new TB cases per year than does San Diego. There is an urgent need to confront this disparity, and address the issue of bi-national TB control in the San Diego-Tijuana border region to find sustainable, community-based solutions that will benefit both Mexico and the United States. Importantly, as an air-borne infection, successful models of TB control will have applicability to other emerging diseases threats that require cross-border solutions, such as H1N1.TB is a subtle and complex chronic infectious disease that can remain dormant for years after the initial infection. Once active or reactivated, TB often takes weeks or months to be diagnosed correctly, allowing for ongoing exposure and transmission to others. The World Health Organization (WHO) estimates that 2 billion people, or one-third of the global population, are currently infected with the M. tuberculosis bacilli. Of those infected, it is estimated that 1 in 10 will develop the active, contagious form of disease at some time in their lives, and those with active TB will infect an average of 10 to 15 people per year if they are not treated. Likely an underestimate, over 600 cases of pulmonary TB were confirmed and reported annually in Tijuana in 2006 and 2007 with an overall rate of 46 per 100,000 inhabitants, which is substantially higher than rates in neighboring Mexican states. In the last decade, there has been an average of over 300 new TB cases per year in San Diego County, of which nearly 40% were born in Mexico. This estimate is likely to understate the influence of Mexico on the TB case load in San Diego, since USborn, Hispanic TB cases are not identified in TB surveillance data as being of Mexican origin. Nevertheless, these cases have significant interaction with Mexico when they, or their contacts, cross the border for social, cultural and economic reasons. Prior to the discovery in 1946 that streptomycin cured TB, the disease claimed the lives of half its victims. Hopes of eradicating TB grew when a 6-month course of daily drug treatment was found to be highly effective for curing TB and rates of disease began to drop worldwide. However, interrupted or inconsistent treatment, combined with the AIDS epidemic, led to the emergence of drug resistant strains of TB bacteria that could no longer be cured with first-line antibiotics, and rates of TB began to increase in the 1980s. To date, the WHO and other agencies have documented cases of TB that are resistant to standard first-line antibiotics and second-line antibiotics in all regions of the world, including the US-Mexico border region. This reverses years of progress in TB control as successful management of drug resistance requires more sophisticated laboratory capacity, educated personnel and access to significantly more expensive drugs. Importantly, drug resistance is completely preventable with appropriate diagnosis that includes drug sensitivity testing and programs like directly observed therapy (DOT) that ensure patients are on proper treatment regimens and do not interrupt therapy or miss doses. Until a vaccine or single-dose treatment is discovered, our best hope for preventing TB from returning to an untreatable disease depends on accurately diagnosing and completely treating patients with TB.Like the disease itself, the costs of TB are complex and difficult to quantify. The direct costs can be described in terms of infrastructure - diagnostic laboratories and equipment, clinic and hospital units appropriately designed for infection control, and surveillance systems; personnel - trained laboratory technicians, informed healthcare providers, DOT workers, contact investigators, and surveillance system managers; and consumables - laboratory reagents, anti-TB medications, infection control supplies, and educational materials. Indirect costs include lost wages for those infected, decreased productivity by employers, and disruption to the community affected by contact tracing activities. We estimate that TB costs in San Diego amount to be at least $21.3 million annually, which includes approximately$12.7 million in lost earnings for patients due to their disease. Beyond the loss of earned wages is the loss by San Diego employers in productivity. Workforce productivity is impacted in several ways by TB. Most significant is that TB symptoms are slow to develop and many infected individuals continue day-to-day activities for weeks or months before their disease is detected, potentially exposing large numbers of contacts at work, home and in the community to TB. This results in additional infections in the workplace and disruptions due to the extensive contact tracing activities that need to take place after a workplace infection. The costs presented here include the major measurable factors and costs to San Diego, but, while high, are certainly an underestimate of total costs. They do not include the substantial hidden costs of lost productivity to employers or other more subtle losses like loss of income to school districts due to scheduled absences for children with TB; nor do they account for other social costs related to stigmatization or infected individuals and their contacts. Importantly, there is consensus for what constitutes a comprehensive TB control program: the WHO DOTS program. This strategy includes early detection of cases, contact tracing, accurate diagnosis through bacterial culture and drug sensitivity testing, uninterrupted access to effective drugs, and DOT. Although incidence rates are declining globally and domestically, the number of cases worldwide is increasing due to population growth and the emergence of resistance threatens to reverse the advances to date. Thus, there is an urgent call by multiple political and professional organizations for a coordinated global response. While the San Diego-Tijuana region is impacted by the growing challenges of TB, this is a preventable and treatable disease and there is tremendous potential to contribute and participate in an international mobilization of public health, clinical personnel, business leaders and communities to effectively combat the disease.Economic analyses clearly indicate that US investment in TB control in Mexico can be a cost-effective means of controlling TB in the United States. Given the epidemiology of TB in the San Diego- Tijuana border such economic benefits are likely to be true for this bi-national region. While this is so, the active involvement of both private businesses and governmental agencies will be required to make this a reality. Successful working models in which businesses located in high TB-incidence areas have taken a lead role in TB control programs already exist through the work of member companies of the Global Business Coalition for HIV, Tuberculosis and Malaria (GBC). This novel approach to address emerging high impact threats through private-public partnerships provides a promising model that can be adopted in the US-Mexico border region

Hippocampal neuroinflammation, functional connectivity, and depressive symptoms in multiple sclerosis

Depression, a condition commonly comorbid with multiple sclerosis (MS), is associated more generally with elevated inflammatory markers and hippocampal pathology. We hypothesized that neuroinflammation in the hippocampus is responsible for depression associated with MS. We characterized the relationship between depressive symptoms and hippocampal microglial activation in patients with MS using the 18-kDa translocator protein radioligand [18F]PBR111. To evaluate pathophysiologic mechanisms, we explored the relationships between hippocampal neuroinflammation, depressive symptoms, and hippocampal functional connectivities defined by resting-state functional magnetic resonance imaging. Methods The Beck Depression Inventory (BDI) was administered to 11 patients with MS and 22 healthy control subjects before scanning with positron emission tomography and functional magnetic resonance imaging. We tested for higher [18F]PBR111 uptake in the hippocampus of patients with MS relative to healthy control subjects and examined the correlations between [18F]PBR111 uptake, BDI scores, and hippocampal functional connectivities in the patients with MS. Results Patients with MS had an increased hippocampal [18F]PBR111 distribution volume ratio relative to healthy control subjects (p = .024), and the hippocampal distribution volume ratio was strongly correlated with the BDI score in patients with MS (r = .86, p = .006). Hippocampal functional connectivities to the subgenual cingulate and prefrontal and parietal regions correlated with BDI scores and [18F]PBR111 distribution volume ratio. Conclusions Our results provide evidence that hippocampal microglial activation in MS impairs the brain functional connectivities in regions contributing to maintenance of a normal affective state. Our results suggest a rationale for the responsiveness of depression in some patients with MS to effective control of brain neuroinflammation. Our findings also lend support to further investigation of the role of inflammatory processes in the pathogenesis of depression more generally

Implementation of corticosteroids in treating COVID-19 in the ISARIC WHO Clinical Characterisation Protocol UK:prospective observational cohort study

BACKGROUND: Dexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care. METHODS: We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260. FINDINGS: Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70–0·89], p=0·0001, for 70–79 years; 0·52 [0·46–0·58], p80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021. INTERPRETATION: Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered. FUNDING: UK National Institute for Health Research and UK Medical Research Council

Procalcitonin Is Not a Reliable Biomarker of Bacterial Coinfection in People With Coronavirus Disease 2019 Undergoing Microbiological Investigation at the Time of Hospital Admission

Abstract Admission procalcitonin measurements and microbiology results were available for 1040 hospitalized adults with coronavirus disease 2019 (from 48 902 included in the International Severe Acute Respiratory and Emerging Infections Consortium World Health Organization Clinical Characterisation Protocol UK study). Although procalcitonin was higher in bacterial coinfection, this was neither clinically significant (median [IQR], 0.33 [0.11–1.70] ng/mL vs 0.24 [0.10–0.90] ng/mL) nor diagnostically useful (area under the receiver operating characteristic curve, 0.56 [95% confidence interval, .51–.60]).</jats:p

Vitamin D insufficiency in COVID-19 and influenza A, and critical illness survivors: a cross-sectional study

Objectives: The steroid hormone vitamin D has roles in immunomodulation and bone health. Insufficiency is associated with susceptibility to respiratory infections. We report 25-hydroxy vitamin D (25(OH)D) measurements in hospitalised people with COVID-19 and influenza A and in survivors of critical illness to test the hypotheses that vitamin D insufficiency scales with illness severity and persists in survivors. Design: Cross-sectional study. Setting and participants: Plasma was obtained from 295 hospitalised people with COVID-19 (International Severe Acute Respiratory and emerging Infections Consortium (ISARIC)/WHO Clinical Characterization Protocol for Severe Emerging Infections UK study), 93 with influenza A (Mechanisms of Severe Acute Influenza Consortium (MOSAIC) study, during the 2009–2010 H1N1 pandemic) and 139 survivors of non-selected critical illness (prior to the COVID-19 pandemic). Total 25(OH)D was measured by liquid chromatography-tandem mass spectrometry. Free 25(OH)D was measured by ELISA in COVID-19 samples. Outcome measures: Receipt of invasive mechanical ventilation (IMV) and in-hospital mortality. Results: Vitamin D insufficiency (total 25(OH)D 25–50 nmol/L) and deficiency (<25 nmol/L) were prevalent in COVID-19 (29.3% and 44.4%, respectively), influenza A (47.3% and 37.6%) and critical illness survivors (30.2% and 56.8%). In COVID-19 and influenza A, total 25(OH)D measured early in illness was lower in patients who received IMV (19.6 vs 31.9 nmol/L (p<0.0001) and 22.9 vs 31.1 nmol/L (p=0.0009), respectively). In COVID-19, biologically active free 25(OH)D correlated with total 25(OH)D and was lower in patients who received IMV, but was not associated with selected circulating inflammatory mediators. Conclusions: Vitamin D deficiency/insufficiency was present in majority of hospitalised patients with COVID-19 or influenza A and correlated with severity and persisted in critical illness survivors at concentrations expected to disrupt bone metabolism. These findings support early supplementation trials to determine if insufficiency is causal in progression to severe disease, and investigation of longer-term bone health outcomes

Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses

To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1–11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely

Viral coinfections in hospitalized coronavirus disease 2019 patients recruited to the international severe acute respiratory and emerging infections consortium WHO clinical characterisation protocol UK study

Background We conducted this study to assess the prevalence of viral coinfection in a well characterized cohort of hospitalized coronavirus disease 2019 (COVID-19) patients and to investigate the impact of coinfection on disease severity. Methods Multiplex real-time polymerase chain reaction testing for endemic respiratory viruses was performed on upper respiratory tract samples from 1002 patients with COVID-19, aged <1 year to 102 years old, recruited to the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK study. Comprehensive demographic, clinical, and outcome data were collected prospectively up to 28 days post discharge. Results A coinfecting virus was detected in 20 (2.0%) participants. Multivariable analysis revealed no significant risk factors for coinfection, although this may be due to rarity of coinfection. Likewise, ordinal logistic regression analysis did not demonstrate a significant association between coinfection and increased disease severity. Conclusions Viral coinfection was rare among hospitalized COVID-19 patients in the United Kingdom during the first 18 months of the pandemic. With unbiased prospective sampling, we found no evidence of an association between viral coinfection and disease severity. Public health interventions disrupted normal seasonal transmission of respiratory viruses; relaxation of these measures mean it will be important to monitor the prevalence and impact of respiratory viral coinfections going forward