Reimagining Rural: Shifting Paradigms About Health and Well-Being in the Rural United States.

Rural health disparities have attracted increased national attention, compelling an expanded focus on rural health research. In this article, we deconstruct the definitions and narratives of "rural" communities and suggest that a paradigm shift is needed that centers the complexity and strength of rural places. We discuss the relevance of health equity frameworks, implementation science, and community-engaged approaches to promote rural well-being. Focusing on rural in its own right will lead to intervention innovations and reinvention with implications beyond rural areas. We conclude with suggestions for research and practice to inspire renewed interest in partnering with rural communities to promote health equity.

The role of distance learning in specialist medical training.

The Quality Assurance Agency for Higher Education (QAA) defines distance learning (DL) as "a way of providing higher education that involves the transfer to the student's location of the materials that form the main basis of study, rather than the student moving to the location of the resource provider".

Is postnatal depression a risk factor for sudden infant death?

BACKGROUND: In New Zealand, an association has been shown between postnatal depression and sudden infant death syndrome (SIDS). AIM: To replicate the New Zealand study. DESIGN OF STUDY: Case-control study. SETTING: The city of Sheffield, UK. METHOD: The database of the Sheffield Child Development Study was used Demographic and obstetric data were collected and at one month postpartum the Edinburgh Postnatal Depression Scale (EPDS) was administered. Detailed information on the cause of all infant deaths was available. RESULTS: There were 32,984 live births during the study period (from the year 1988 to 1993) and 42 babies died with the cause registered as SIDS. Multivariate analysis showed that smoking was the most important risk factorfor SIDS (odds ratio [OR] = 7.24, 95% confidence interval [95% CI] = 2.76 to 19.01), followed by a high EPDS (OR = 3.20, 95% CI = 1.46 to 6.99) and residence in an area of poverty (OR = 2.33, 95% CI = 1.06 to 5.11). CONCLUSIONS: The Sheffield data confirm the New Zealand findings. A high EPDS score and, by implication, postnatal depression, may be risk factors for SIDS, however, there are many possible explanations for the association.

GalNAc glycoprotein expression by breast cell lines, primary breast cancer and normal breast epithelial membrane.

Over-expression of N-acetylgalactosamine glycoproteins as detected by binding of the lectin from Helix pomatia (HPA), is associated with metastatic competence and poor patient prognosis in a range of human adenocarcinomas. These glycoproteins remain poorly characterised, and their functional role has yet to be elucidated. This study describes characterisation of a range of human breast/breast cancer cell lines for the expression of the N-acetylgalactosaminylated glycoproteins of interest, and their comparison with normal breast epithelium and a range of clinical breast carcinoma samples. Confocal and light microscopy studies revealed cytochemical HPA-binding patterns consistent with a fundamental disruption in normal glycobiosynthetic pathways attending increasing metastatic potential. We report the most complete comparative analysis of HPA-binding ligands from cultured breast cells, clinical breast carcinoma samples and normal breast epithelium to date. Lectin blotting identified 11 major HPA-binding glycoprotein bands common to both clinical tumour samples and breast cell lines and 6 of these bands were also expressed by samples of normal breast epithelium, albeit at much lower levels. Moreover, very marked quantitative but not qualitative differences in levels of expression consistent with metastatic capability were noted.

Aging lowers steady-state antioxidant enzyme and stress protein expression in primary hepatocytes.

It has been reported that the isolation and culture of primary hepatocytes can compromise cellular ability to constituitively express antioxidant enzyme (AE) genes, making it difficult to study their regulation ex vivo. In the present study, the steady-state expression of manganese-containing superoxide dismutase, copper- and zinc-containing superoxide dismutase, catalase, and glutathione peroxidase was assessed in primary hepatocytes isolated from young and senescent rats and cultured in MATRIGEL: There was no change in steady-state superoxide dismutase protein or activity levels in cells collected from young animals and cultured for 7 days. Catalase expression was initially increased, and then it declined 30%. In contrast, superoxide dismutase expression declined 60% and catalase expression declined 50% in cells from senescent animals. Constitutive and inducible 70-kDa heat shock protein expression increased coincident with declining AE levels in the young cells but not senescent cells. For both age groups, electron micrographs showed rounded hepatocytes with abundant rough endoplasmic reticulum, mitochondria, and peroxisomes. Hepatocytes were organized into clusters of 6-12 cells surrounding a large central lumen devoid of microvilli. Each cluster also contained smaller microvilli-lined lumens between adjacent hepatocytes that resembled canniculi. The plasma membranes of these lumens were sealed from the extracellular space by junctional complexes. Gap junctions in the plasma membrane suggest that hepatocytes were capable of intercellular communication. We conclude that the Matrigel system can be used to study AE regulation in primary hepatocytes from young and senescent animals, provided that experiments can be conducted within a time frame of 5-7 days in culture. These data also support the hypothesis that aging compromises hepatocellular ability to maintain AE status and upregulate stress protein expression.

Mechanisms of circulatory and intestinal barrier dysfunction during whole body hyperthermia.

This work tested the hypotheses that splanchnic oxidant generation is important in determining heat tolerance and that inappropriate.NO production may be involved in circulatory dysfunction with heat stroke. We monitored colonic temperature (T(c)), heart rate, mean arterial pressure, and splanchnic blood flow (SBF) in anesthetized rats exposed to 40 degrees C ambient temperature. Heating rate, heating time, and thermal load determined heat tolerance. Portal blood was regularly collected for determination of radical and endotoxin content. Elevating T(c) from 37 to 41.5 degrees C reduced SBF by 40% and stimulated production of the radicals ceruloplasmin, semiquinone, and penta-coordinate iron(II) nitrosyl-heme (heme-.NO). Portal endotoxin concentration rose from 28 to 59 pg/ml (P < 0.05). Compared with heat stress alone, heat plus treatment with the nitric oxide synthase (NOS) antagonist N(omega)-nitro-L-arginine methyl ester (L-NAME) dose dependently depressed heme-.NO production and increased ceruloplasmin and semiquinone levels. L-NAME also significantly reduced lowered SBF, increased portal endotoxin concentration, and reduced heat tolerance (P < 0.05). The NOS II and diamine oxidase antagonist aminoguanidine, the superoxide anion scavenger superoxide dismutase, and the xanthine oxidase antagonist allopurinol slowed the rates of heme-.NO production, decreased ceruloplasmin and semiquinone levels, and preserved SBF. However, only aminoguanidine and allopurinol improved heat tolerance, and only allpourinol eliminated the rise in portal endotoxin content. We conclude that hyperthermia stimulates xanthine oxidase production of reactive oxygen species that activate metals and limit heat tolerance by promoting circulatory and intestinal barrier dysfunction. In addition, intact NOS activity is required for normal stress tolerance, whereas overproduction of.NO may contribute to the nonprogrammed splanchnic dilation that precedes vascular collapse with heat stroke.

The relationships between neonatal encephalopathy and cerebral palsy: a cohort study.

There is a high risk of cerebral palsy (CP) following neonatal encephalopathy (NE) with fits, often attributed to intrapartum asphyxia. The evidence for the association is inconclusive and antepartum factors offer an alternative explanation. A cohort study was carried out to assess the evidence for and against hypoxic ischaemic injury as the cause of NE-associated CP in term infants. A total of 57 159 consecutive births were enrolled. There were 150 cases with NE, of whom 92 had at least one fit and 58 had no fits. The incidence of all NE was 2.62 per 1000 births and of NE with fits was 1.61 per 1000 births. Infants with NE were followed-up to identify those with cerebral palsy. There were 13 cases of four-limb cerebral palsy and three with hemiplegia among the survivors. In 12 of the 13 cases of four-limb CP, a combination of low Apgar scores, an early onset acute evolving encephalopathy, acidosis, renal dysfunction and the absence of antepartum factors suggested an acute intrapartum event as the immediate cause of the NE. An obstetric event likely to cause acute hypoxic injury was identified in four of the 12 cases. The clinical picture was similar in the four with and the eight without a specific obstetric event. The pathway leading to NE-associated CP remains unexplained, but intrapartum events appear to play a major role in most cases.

Lectin histochemistry to detect altered glycosylation in cells and tissues.

A lectin is "a protein or glycoprotein of non-immune origin, not an enzyme, that binds to carbohydrates and agglutinates cells" (1). Lectins are naturally occurring substances, most commonly derived from plant or sometimes invertebrate sources, that can be exploited in the laboratory to detect and reveal carbohydrate structures in or on the surface of cells in very much the same way that antibodies can be used to reveal specific antigens. Lectins can detect very subtle alterations in cellular glycosylation. This is of interest in metastasis research as there is increasing evidence that marked glycosylation changes can attend both transformation to malignancy and tumor progression. Lectins are named after the source from which they are derived-sometimes the Latin binomial (e.g., Bandeirea simplicifolia lectin or Dolichos biflorus lectin), sometimes the common name (e.g., peanut lectin or wheatgerm lectin), or some-times by a slightly obscure historical term (e.g., Concanavalin A [Con A] for the lectin from Canavalia ensiformis, the jack bean). The term lectin is used fairly interchangeably with the older term "agglutinin," as in peanut agglutinin or Helix pomatia agglutinin. Lectins are often referred to by an abbreviation for their names, for example, PNA (peanut agglutinin) or DBA (Dolichos biflorus agglutinin); obscurely, PHA, which actually stands for phytohaemagglutinin is, for historical reasons, the abbreviation usually employed for the lectin derived from Phaseolus vulgaris. Many sources yield more than one lectin, termed isolectins, which may have quite different carbohydrate binding specificities (e.g., the gorse Ulex europaeus yields two major isolectins, Ulex europaeus agglutinin I [UEA-I], which has a strong binding preference for fucose, and Ulex europaeus agglutinin II [UEA-II], which has a strong binding preference for N-acetylglucosamine).

Hitting the target: the equitable distribution of health visitors across caseloads.

BACKGROUND: Health visitors in the United Kingdom work mainly with pre-school children and their mothers. Their distribution across the population is largely historical, highly variable and relates poorly to indicators of population need. METHODS: A range of largely routine data sources were used to describe the nature, variation and statistical determinants of the workload of individual health visitors in Sheffield, England, in 1996-1997. Regression models were tested relating measures of need and deprivation to the total number of client contacts. RESULTS: Caseloads were smaller in the most deprived areas, with wide variation. Most (93 per cent) contacts were with mothers and young children. Health visitors visited the clients designated as highest priority on average 4.7 times more often than routine clients. The main reasons for high priority ratings were child protection concerns, maternal mental health problems, child development and health concerns, and first-time mothers in the postnatal period. Half of all client contacts were with low-priority families for routine child health surveillance or were client initiated. Models based on the number of children under five and any one of a range of measures of social deprivation account for 57-59 per cent of variation in workload and could be used to allocate resources more equitably. CONCLUSIONS: Although most health visitors apparently subscribe to the principle of targeting, the extent varies widely. Constraints on targeting are routine child health surveillance reviews, and client demands. More equitable allocation of health visitors and more explicit targeting policies might increase the effectiveness of the health visiting service.

Aging reduces adaptive capacity and stress protein expression in the liver after heat stress.

A decline in an organism's ability to cope with stress through acute response protein expression may contribute to stress intolerance with aging. We investigated the influence of aging on stress tolerance and the capacity to synthesize the 70-kDa heat shock protein (HSP70) in young and old rats exposed to an environmental heating protocol. Livers were assessed for injury and HSP70 expression after heat stress by use of immunohistochemical and immunoblotting techniques. The inducible HSP70 response in the cytoplasm and nucleus was markedly reduced with age at several time points over a 48-h recovery period, although senescent rats were able to strongly express HSP70 early in recovery. Older animals had extensive zone-specific liver injury, which corresponded to the diminished HSP70 response observed in these regions, and a significant reduction in thermotolerance compared with their young counterparts. These data highlight the regional nature of stress-induced injury and HSP70 expression in the liver and the impact of aging on these responses. Furthermore, the results suggest a functional link between the age-related decrements in the expression of inducible HSP70 and the pathophysiological responses to heat stress.

School nursing: costs and potential benefits.

BACKGROUND: Previous reports that variations in school nursing resources across the UK had no relationship to deprivation; controversy about the changing role of the school nursing service. OBJECTIVES: To measure the resources allocated to school nursing, determine whether the variations can be explained by deprivation, and assess whether the allocation of school nursing time to a range of tasks is in line with current evidence and perceptions of changing needs. STUDY DESIGN: Quantitative economic analysis; qualitative descriptive study. SETTING: Detailed study of four English districts with diverse characteristics; staffing and service questionnaire and telephone survey of 62 districts. MAIN MEASURES: Staff resources and their salaries; measures of population and deprivation; activity statistics. RESULTS: There were wide variations in the cost of the school nursing service, but in contrast to previous reports 24% of the variance was explained by deprivation. There were no clear associations with any other social or educational variables. The greatest allocation of time was in routine screening and surveillance tasks. Relatively little time was allocated to other activities such as health promotion, support of special needs or unwell children, or teenage clinics. The expenditure on school nursing is only loosely related to deprivation and the results of this study offer guidance on what districts should spend to achieve equity of provision. CONCLUSIONS: The current allocation of resources to school nursing in between districts comparisons is not equitable and the use of school nursing time is out of step with current evidence of need and effectiveness.

Levels of satisfaction of 'low-risk' mothers with their current health visiting service.

AIMS AND OBJECTIVES: To assess the expressed levels of satisfaction of 'low-risk' mothers with the current health visiting service. Setting Sheffield, England, Autumn 1997. METHODOLOGY: Self-completion, postal questionnaire (initial postcard reminder followed by a second letter and questionnaire) to a sample of 403 mothers assessed as 'low priority' by their health visitor. Questions largely related to maternal opinion of the adequacy of the health visiting service delivered during the first 9-12 months. The local research ethics committee approved the study. RESULTS: A corrected response rate of 75% with little evidence of significant bias. A high proportion (86%) of women stated that they were either 'fairly' or 'very' satisfied with the service they had received from their health visitor with regard to their baby. A lower proportion (72%) was equally satisfied with the service they had received in respect of their own health. Despite an average number of approximately 10 contacts in relation to infant health with the health visitor during the first year of life, some 6% of women wanted more frequent contacts, particularly in the first few weeks. Study limitations The questionnaire was designed specifically for the study and validation was limited. The study population comprised a selected, 'low-risk' group. CONCLUSIONS: The number of reported contacts with the health visitor seemed to greatly exceed those indicated by a basic child health surveillance programme. The overall level of maternal satisfaction is high, though a minority of women would like more support. Dissatisfaction was expressed with the lack of an appointment system for clinics, poor punctuality in home visits, and inappropriate or inadequate advice.