Identifying barriers to healthcare delivery and access in the Circumpolar North: important insights for health professionals.

Lack of access to healthcare services for people living in the Circumpolar North may have important consequences for their health and well-being, both in terms of the actual treatment and other possible health-related consequences intertwined with their life situation. The aim of the present study was to identify the specific challenges to healthcare service delivery and access for populations in the Circumpolar North that are addressed in contemporary literature. A scoping review of literature published between 2005 and 2016 was conducted and 43 articles were selected for inclusion into the review. The review findings address 4 main themes identified in the literature: (1) the influence of physical geography, (2) healthcare provider-related barriers, (3) the importance of culture and language and (4) the impact of systemic factors. The review of the literature enabled us to identify existing gaps in both health service access and issues discussed in the available literature, particularly for informing healthcare services in the Circumpolar North, as well as point towards opportunities for future research. The thematic findings drawn from interdisciplinary and international literature inform understandings of the impact of health system barriers on healthcare services and the opportunities for Northern residents to support their own health.

Characterization of a synthetic bioactive polymer by nonlinear optical microscopy.

Tissue Engineering is a new emerging field that offers many possibilities to produce three-dimensional and functional tissues like ligaments or scaffolds. The biocompatibility of these materials is crucial in tissue engineering, since they should be integrated in situ and should induce a good cell adhesion and proliferation. One of the most promising materials used for tissue engineering are polyesters such as Poly-ε-caprolactone (PCL), which is used in this work. In our case, the bio-integration is reached by grafting a bioactive polymer (pNaSS) on a PCL surface. Using nonlinear microscopy, PCL structure is visualized by SHG and proteins and cells by two-photon excitation autofluorescence generation. A comparative study between grafted and nongrafted polymer films is provided. We demonstrate that the polymer grafting improves the protein adsorption by a factor of 75% and increase the cell spreading onto the polymer surface. Since the spreading is directly related to cell adhesion and proliferation, we demonstrate that the pNaSS grafting promotes PCL biocompatibility.

A comparison of quartz OSL and isothermal TL measurements on Chinese loess.

The reliability of equivalent doses (De) from Chinese loess, measured using isothermal thermoluminescence (ITL) is tested. Dose calculations use the single-aliquot regenerative-dose (SAR) procedure. Despite good reproducibility of laboratory-induced signals and negligible response at zero dose, a significant overestimation of De is observed, compared with OSL measurements. Measurement of a known laboratory dose administered after optical bleaching, but before any heating, demonstrates that the first heating during measurement of the natural signal causes a significant sensitivity change, undetected by SAR. Using the single-aliquot regeneration and added (SARA) dose procedure, which allows for initial sensitivity change, good agreement with OSL is obtained after allowance is made for initial incomplete bleaching. It is concluded that SAR-ITL, in its present form, is not a suitable method for dating Chinese loess; it is very important to undertake a dose recovery test before any TL procedure is used to date sediments.

Effectiveness of a focused educational intervention on resident evaluations from faculty a randomized controlled trial.

OBJECTIVE: To improve the quality and specificity of written evaluations by faculty attendings of internal medicine residents during inpatient rotations. DESIGN: Prospective randomized controlled trial. SETTING: Four hospitals: tertiary care university hospital, Veterans' Administration hospital, and two community hospitals. PARTICIPANTS: Eighty-eight faculty and 157 residents from categorical and primary-care internal medicine residency training programs rotating on inpatient general medicine teams. INTERVENTION: Focused 20-minute educational session on evaluation and feedback, accompanied by 3 by 5 reminder card and diary, given to faculty at the start of their attending month. PRIMARY OUTCOMES: 1) number of written comments from faculty specific to unique, preselected dimensions of competence; 2) number of written comments from faculty describing a specific resident behavior or providing a recommendation; and 3) resident Likert-scale ratings of the quantity and effect of feedback received from faculty. Faculty in the intervention group provided more written comments specific to defined dimensions of competence, a median of three comments per evaluation form versus two in the control group, but when adjusted for clustering by faculty, the difference was not statistically significant (P =.09). Regarding feedback, residents in the intervention group rated the quantity significantly higher (P =.04) and were significantly more likely to make changes in clinical management of patients than residents in the control group (P =.04). CONCLUSIONS: A brief, focused educational intervention delivered to faculty prior to the start of a ward rotation appears to have a modest effect on faculty behavior for written evaluations and promoted higher quality feedback given to house staff.

Metabolic complications of urinary diversions: an overview.

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

Medical Grand Rounds: refractory hypertension and renal insufficiency in a patient with renal artery stenosis.

Renal artery stenosis has become increasingly common as a cause of refractory hypertension and renal insufficiency. There is a high prevalence of bilateral disease and the lesions tend to progress over time. Newer, less invasive, imaging modalities such as doppler ultrasound, magnetic resonance angiography, and spiral CT scanning are evolving technologies in the diagnosis of renal artery stenosis. Advances in surgical technique, particularly the development of extra-anatomical procedures such as spleno-renal and hepato-renal by pass, have significantly lowered surgical morbidity and mortality and provides revascularization options for patients with complex vascular disease that would previously not have been considered because of their high surgical risk. Improvements in angioplasty technique and the use of stents are broadening the types of lesions that can be successfully approached with these techniques and may be particularly helpful for patients with more severe cardiac or cerebrovascular disease. The benefits of revascularization may be even greater for preservation of renal function than for control of blood pressure in properly selected patients. It is difficult to predict which patients will benefit from surgical revascularization versus medical management of RAS. Knowledge of the progressive nature of RAS, the high prevalence of bilateral disease, and the clinical characteristics that correlate with progression (e.g., decreasing renal size) are helpful in guiding clinical decisions regarding intervention. Additional studies to determine the predictive value of non-invasive tests such as CRS, doppler ultrasound before and after administration of angiotensin converting enzyme inhibitors, and other tests, are needed to assist the clinician in identifying who will benefit most from revascularization both in terms of renal function and blood pressure control.

Acyloin production from aldehydes in the perfused rat heart: the potential role of pyruvate dehydrogenase.

Aldehydes represent an important class of cytotoxic products derived from free radical-induced lipid peroxidation which may contribute to reperfusion injury following myocardial infarct. Metabolism of aldehydes in the heart has not been well characterized aside from conjugation of unsaturated aldehydes with glutathione. However, aliphatic aldehydes like hexanal do not form stable glutathione conjugates. We have recently demonstrated in vitro that pig heart pyruvate dehydrogenase catalyses a reaction between pyruvate and saturated aldehydes to produce acyloins (3-hydroxyalkan-2-ones). In the present study, rat hearts were perfused with various aldehydes and pyruvate. Acyloins were generated from saturated aldehydes (butanal, hexanal or nonanal), but not from 2-hexanal (an unsaturated aldehyde) or malondialdehyde. Hearts perfused with 2 mM pyruvate and 10-100 microM hexanal rapidly took up hexanal in a dose-related manner (140-850 nmol/min), and released 3-hydroxyoctan-2-one (0.7-30 nmol/min), 2,3-octanediol (0-12 nmol/min) and hexanol (10-200 nmol/min). Small quantities of hexanoic acid (about 10 nmol/min) were also released. The rate of release of acyloin metabolites rose with increased concentration of hexanal, whereas hexanol release attained a plateau when hexanal infusion concentrations rose above 50 microM. Up to 50% of hexanal uptake could be accounted for by metabolite release. Less than 0.5% of hexanal uptake was found to be bound to acid-precipitable macromolecules. When hearts perfused with 50 microM hexanal and 2 mM pyruvate were subjected to a 15 min ischaemic period, the rates of release of 2,3-octanediol, 3-hydroxyoctan-2-one, hexanol and hexanoate during the reperfusion period were not significantly different from those in the pre-ischaemic period. Our results indicate that saturated aldehydes can be metabolically converted by the heart into stable diffusible compounds.

The use of temperature as a discharge criterion for ambulatory surgery patients.

Evaluating each patient's return to an acceptable state after surgical and anesthetic intervention is the responsibility of the postanesthesia nurse. Postanesthesia nurses use criteria to determine ambulatory surgical patient readiness to be discharged from phase I recovery to phase II recovery and from phase II recovery to home. Temperature is one indicator of postanesthesia recovery. Temperature discharge criteria from phase I postanesthesia recovery have been reported. However, temperature discharge criteria for phase II postanesthesia recovery have been adapted from phase I standards and nursing traditions. This study sought to describe the postoperative temperatures of ambulatory surgical patients from admission to phase II postanesthesia recovery to discharge home. A convenience sample of 101 adult patients undergoing surgery at a hospital-based ambulatory surgical unit (ASU) participated. Tympanic temperature was measured preoperatively on admission to the ASU, postoperatively, at the beginning of phase II postanesthesia recovery, and at the end of phase II postanesthesia recovery immediately before discharge home. All subjects were normothermic during phase II postanesthesia recovery, with temperatures ranging from 36.0 degrees C (96.8 degrees F) to 38.3 degrees C (101 degrees F). Paired Student's t Test showed significant differences (P < .0001) between temperature means. There was a 0.38 degrees C (0.7 degree F) decrease between preoperative admission temperature and temperature on admission to phase II postanesthesia recovery. During phase II postanesthesia recovery the mean temperature increased 0.16 degree C (0.3 degree F) before discharge home. However, the clinical and practical implications of these findings is questionable.(ABSTRACT TRUNCATED AT 250 WORDS)

Na(+)-H+ exchanger and its role in essential hypertension and diabetes mellitus.

The Na(+)-H+ exchanger is a ubiquitous transport system that is involved in the regulation of intracellular pH, cell growth and proliferation, cell volume regulation, and transepithelial absorption of Na+, Cl-, and HCO3-. Altered activity of the Na(+)-H+ exchanger has been implicated as a mechanism contributing to the development of high blood pressure in subgroups of patients with essential hypertension and in various animal models of hypertension. Many of these studies measured Na(+)-Li+ exchange rather than Na(+)-H+ exchange, hypothesizing that Na(+)-Li+ exchange represents a functional mode of the Na(+)-H+ exchanger. However, this is a controversial assumption. Several studies have also shown an association between erythrocyte Na(+)-Li(+)-exchange rate and predisposition to nephropathy in patients with insulin-dependent diabetes mellitus. The recent cDNA cloning of at least one isoform of the Na(+)-H+ exchanger will help clarify the cellular mechanisms of regulation of the exchanger and its possible role in pathophysiological states such as hypertension.

Humoral Na+-K+ pump inhibitory activity in essential hypertension and in normotensive subjects after acute volume expansion.

Plasma from black male patients with essential hypertension was bioassayed for vascular Na+-K+ pump inhibitory activity. Halves of the same rat tail artery were incubated for two hours in boiled plasma supernates from a hypertensive patient and a paired age-, sex-, and race-matched normotensive subject and then ouabain-sensitive 86Rb uptake was measured. Ouabain-sensitive 86Rb uptake by their leukocytes was also measured. Eighteen pairs of subjects were studied. The uptakes were not significantly different in the hypertensive patients and control subjects. However, when we selected from the eighteen hypertensive patients, nine with low plasma renin activity on the day of the study, uptakes were reduced in the hypertensive patients relative to the paired control subjects. We also assayed plasma supernates from normotensive black and white male subjects before and after acute volume expansion (2.5 L saline IV + 1.5 L distilled water orally over a three-hour period) and from paired normotensive subjects before and after sham volume expansion and obtained a positive bioassay in the expanded subjects both on intraindividual and interindividual comparisons. These studies demonstrate increased vascular Na+-K+ pump inhibitory activity in the plasma of black male patients with low renin essential hypertension and in the plasma of normotensive subjects after acute volume expansion. The findings suggest that the inhibitory activity in the hypertensive subjects' plasma is related to volume expansion, relative or absolute.

Identification and purification of a renal amiloride-binding protein with properties of the Na+-H+ exchanger.

The aim of this study was to identify and purify the Na+-H+ exchanger from rabbit renal brush border membranes by use of affinity chromatography. Triton-solubilized membranes were equilibrated with an affinity matrix consisting of the amiloride analogue A35 (5-N-(3-aminophenyl)amiloride) covalently coupled to Sepharose CL-4B beads through a triglycine spacer arm. The matrix was then washed extensively with buffer and sequentially eluted with buffer, buffer containing 5 mM amiloride, and 1% sodium dodecyl sulfate (SDS). Eluates were concentrated and subjected to SDS-polyacrylamide gel electrophoresis. The silver-stained gel revealed a 25-kDa protein that was not visible in the initial solubilized brush border membrane extract, was not eluted from the affinity matrix by buffer alone, but was eluted with 5 mM amiloride. A subsequent elution with 1% SDS did not release any more of the 25-kDa protein, indicating that it had been completely eluted from the affinity matrix by amiloride. The presence of 5 mM amiloride during equilibration of the solubilized brush border extract with the affinity matrix completely blocked adsorption of the 25-kDa protein. The relative abundance of this protein correlated closely with Na+-H+ exchange activity when preparations of cortical brush border membrane vesicles, outer medullary brush border membrane vesicles, and cortical basolateral membrane vesicles were compared. Moreover, binding of the protein to the affinity matrix was inhibited by amiloride and amiloride analogues with a rank order identical to that for inhibition of Na+-H+ exchange activity. These findings strongly suggest that the 25-kDa protein is a structural component of the Na+-H+ exchanger.

Compartmentation of 14CO2 in the perfused rat liver.

The specific activity of the mitochondrial CO2 + bicarbonate system has been measured in perfused livers using the specific activities of urea and acetoacetate derived from 2-ketoisocaproate catabolism. Label was supplied either as NaH14CO3, 2-keto[1-14C]isocaproate, [1-14C]pyruvate, [1-14C]glutamine, or [14C]formate. With labeled bicarbonate, pyruvate, or 2-ketoisocaproate, the specific activities of effluent bicarbonate, urea, and acetoacetate were equal (acetoacetate was labeled only on C-1). In the presence of [14C]formate, the specific activity of acetoacetate was double that of urea. Acetazolamide (0.2 mM), an inhibitor of carbonic anhydrase, decreased the specific activities of urea and acetoacetate labeled from NaH14CO3 and increased the specific activities of urea and acetoacetate labeled from the other tracers. We conclude that: acetoacetate derived from 2-ketoisocaproate is, like urea, an index of the specific activity of mitochondrial CO2 in liver, carbonic anhydrase activity equalizes the specific activities of the CO2 + bicarbonate system on both sides of the mitochondrial membrane, and a fraction of [14C] formate-derived 14CO2 appears to be generated in a mitochondrial compartment, in the close vicinity of methylcrotonyl-CoA carboxylase.

Decreased myocardial Na+K+ATPase activity in rats with reduced renal mass-saline hypertension.

Inhibition of cardiovascular Na,K-pump activity has been shown to promote an increase in the contractile activity of myocardial and vascular smooth muscle and a consequent rise in blood pressure (BP). It has also been shown that vascular Na,K-pump activity and myocardial Na+K+ATPase activity [the energy source for active sodium (Na) and potassium (K) transport] are decreased in rats with various forms of low renin hypertension including rats with reduced renal mass-saline (RRM-saline) hypertension. In the present study, left ventricular Na+K+ATPase activity from rats with RRM-saline hypertension was found to be decreased in membranes prepared by two independent methods: deoxycholate, sodium iodide (Nal)-treated microsomal fractions (method 1) and membranes prepared by the hypotonic, lithium bromide (LiBr) method (method 2). Relative to RRM normotensive control rats which drank distilled water, myocardial Na+K+ATPase activity from RRM-saline drinking rats was decreased by 18.2% in membranes prepared by method 1 and 33.6% in membranes prepared by method 2. The apparent affinities of Na+K+ATPase for K and for ouabain were unaltered relative to controls in membranes prepared from these hypertensive rats by method 1, and the sialic acid content and 5'-nucleotidase activity (two putative sarcolemmal markers) were unaltered in membranes from the hypertensive rats, prepared by methods 1 and 2 respectively. The Mg2+ATPase activity of membranes prepared by method 1 was increased in the RRM-saline hypertensive rats but because it was not increased in membranes prepared by method 2 the former observation does not appear to be of any pathophysiological importance. In other experiments, hypertension was reversed in RRM-saline hypertensive rats by restricting their salt intake (substitution of distilled water for drinking).(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial (Na+,K+)-ATPase activity in Dahl salt-sensitive and resistant rats.

Vascular (Na+,K+)-pump activity (ouabain-sensitive 86Rb+ uptake) and myocardial (Na+,K+)-ATPase activity are reduced in animals with various forms of low renin, experimental hypertension. On the other hand, vascular (Na+,K+)-pump activity is increased in Dahl salt-sensitive relative to resistant rats (a genetic model of hypertension), regardless of salt intake or blood pressure and it is also increased in Dahl salt-sensitive rats on high salt (8% NaCl) relative to low salt (0.4% NaCl) diets. It has been suggested that this increase in vascular (Na+,K+)-pump activity may be secondary to an increase in the vascular sarcolemmal permeability to Na+ in these salt-sensitive rats. In the present study, (Na+,K+)-ATPase activity of left ventricular microsomal fractions, was increased in Dahl salt-sensitive relative to resistant rats on low salt diets; however, this difference disappeared when these salt-sensitive and resistant rats were placed on high salt diets. In contrast, myocardial (Na+,K+)-ATPase activity was decreased in Dahl salt-sensitive rats on high relative to low salt diets. Evidence that this decrease in (Na+,K+)-ATPase activity is not secondary to myocardial hypertrophy in the hypertensive salt-sensitive rats, and mechanisms by which decreased cardiovascular (Na+,K+)-pump activity, increased sarcolemmal permeability or both, might contribute to elevated blood pressure, are discussed.

Periventricular forebrain mechanisms for blood pressure regulation.

Periventricular forebrain regions participate in body fluid and cardiovascular regulatory mechanisms that are intimately related to neural participation in experimental hypertension. Ablation of preoptic-hypothalamic periventricular tissue surrounding the anteroventral third ventricle (AV3V) disrupts both angiotensin (AngII) and sodium regulatory mechanisms and prevents experimental hypertension in either renin-dependent or -independent models. When AV3V is spared, and central AngII pressor mechanisms are interrupted by subfornical organ ablation or anterior hypothalamic knife cuts, renin-dependent but not renin-independent models of hypertension are prevented. Volume-expanded models of hypertension may be mediated by a natriuretic hormone that also inhibits the sodium-potassium pump in vascular smooth muscle, resulting in increased vasoconstriction. Volume expansion-induced release of this humoral ATPase inhibitor is attenuated in rats with AV3V lesions. In the renin-independent, reduced renal mass model, development of hypertension is correlated with increased plasma levels of sodium-potassium pump inhibitor. AV3V ablation blocks both the hypertension and the increase in humoral ATPase inhibitor. Thus, Thus, central angiotensin pressor and natriuretic mechanisms overlap in AV3V, and prevention of renin-dependent and volume-dependent models of experimental hypertension by AV3V ablation appears linked to disruption of these functionally separable systems.

Total GABA and homocarnosine in CSF as indices of brain GABA concentrations.

Treatment of rats with gamma-vinyl-GABA, an inhibitor of GABA-transaminase, caused a dose- and time-related increase in brain GABA concentrations concomitant with increases in the concentrations of total GABA and homocarnosine in the CSF. At 18 h after treatment both CSF parameters correlated significantly with brain GABA concentrations. However, only total GABA in CSF accurately reflected brain GABA concentrations as a function of time after treatment and is therefore the preferred index.

Value of monoamine metabolite determinations in CSF as an index of their concentrations in rat brain following various pharmacological manipulations.

Using reversed-phase high performance liquid chromatography with electrochemical detection it is possible to measure concomitantly the concentration of several monoamines, their metabolites and aminoacid precursors in 100 microliters of rat cerebrospinal fluid. To study the quantitative relationship between CSF and brain, alterations in brain monoamines and monoamine metabolites were effected by treatment with L-DOPA or L-5HTP administered with or without concomitant inhibition of extracerebral aromatic amino acid decarboxylase and by treatment with alpha-monofluoromethyldopa, probenecid, haloperidol, or probenecid plus haloperidol. The concentrations of the monoamine metabolites, 5-hydroxyindoleacetic acid, 3,4-dihydroxyphenylacetic acid, and homovanillic acid as well as of the L-DOPA metabolite, 3-methoxy-4-hydroxyphenylalanine in the cerebrospinal fluid were linearly correlated with the concentrations of these metabolites in the brain. However, these correlations need to be interpreted cautiously, since the slopes of the individual regression lines obtained after different pharmacological treatments differed significantly.

Effects of gamma-vinyl GABA on food intake of rats.

Gamma-vinyl GABA, an inhibitor of GABA-transaminase, produced a dose-related reduction of food intake in rats, after both single, (125-1000 mg/kg IP or 500 mg/kg PO) and repeated (250 mg/kg/day IP) administration. No tolerance was observed to the effect of repeated injections. Catecholamine and indoleamine systems in the CNS do not appear to be implicated in this anorexic effect. Combination of gamma-vinyl GABA with amphetamine (2.5 mg/kg) enhanced the anorexic effects of the latter compound whilst attenuating its stimulant effects. The data suggest an important role for GABA in the control of food intake.