"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life.

BACKGROUND: Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL. METHODS: Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently. RESULTS: Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers. CONCLUSIONS: Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

The potential of cinnamon to reduce blood glucose levels in patients with type 2 diabetes and insulin resistance.

AIM: Cinnamon has a long history as an antidiabetic spice, but trials involving cinnamon supplementation have produced contrasting results. The aim of this review was to examine the results of randomized controlled clinical trials of cinnamon and evaluate the therapeutic potential amongst patients with diabetes and insulin-resistant patients, particularly the ability to reduce blood glucose levels and inhibit protein glycation. METHODS: A systematic electronic literature search using the medical subject headings 'cinnamon' and 'blood glucose' was carried out to include randomized, placebo-controlled in vivo clinical trials using Cinnamomum verum or Cinnamomum cassia conducted between January 2003 and July 2008. RESULTS: Five type 2 diabetic and three non-diabetic studies (total N = 311) were eligible. Two of the diabetic studies illustrated significant fasting blood glucose (FBG) reductions of 18-29% and 10.3% (p < 0.05), supported by one non-diabetic trial reporting an 8.4% FBG reduction (p < 0.01) vs. placebo, and another illustrating significant reductions in glucose response using oral glucose tolerance tests (p < 0.05). Three diabetic studies reported no significant results. CONCLUSIONS: Whilst definitive conclusions cannot be drawn regarding the use of cinnamon as an antidiabetic therapy, it does possess antihyperglycaemic properties and potential to reduce postprandial blood glucose levels. Further research is required to confirm a possible correlation between baseline FBG and blood glucose reduction and to assess the potential to reduce pathogenic diabetic complications with cinnamon supplementation.

Review article: Glucosamine.

It has been claimed that glucosamine is able to alleviate pain, slow down losses of, and even restore articular cartilage in patients with damaged or osteoarthritic joints. It is classified as a food additive or nutraceutical; therefore manufacturers do not need to comply with the same regulations that apply for quality assurance within the pharmaceutical industry. Osteoarthritis can be managed by pharmacological and non-pharmacological methods. It is controversial whether glucosamine sulphate is the first structure-modifying drug commercially available. Little evidence suggests that glucosamine is superior to a placebo treatment in restoring articular cartilage.

Autologous stem cell transplantation in diffuse scleroderma: impact on hand structure and function.

BACKGROUND: The aim of the study was to assess the structural and functional effects of autologous stem cell transplantation (ASCT) on scleroderma finger clawing. METHODS: Using photocopies of hands of five scleroderma patients who underwent ASCT using photocopies of hands. Functional assessments used a standardized questionnaire. RESULTS: Pre-ASCT, synovitis and tenosynovitis were present in five and four patients, respectively. Modified Rodnan hand skin scores ranged from 6-12/12. Following pulsed chemotherapy, synovitis resolved. Tenosynovitis often did not. Post-ASCT, skin scores fell in four patients (range 0-6/12). Hand tenosynovitis resolved. With disease remission hand function globally improved. Functional improvement, noted early (+3 months) and continuously (+12 months) in disease remitters, occurred in all areas of function. Greatest hand-functional improvement related to paid employment, followed by self-care and hygiene, home-care activities and least by hobbies/sports. The second to fifth metacarpophalangeal width was reproducible and independent of ASCT therapy. In contrast, hand length and measures of abducted finger span (first to fifth fingertip and second to fifth fingertip distance) improved. Finger abduction (abducted first to fifth fingertips/second to fifth metacarpophalangeal width) was a more sensitive discriminator of finger clawing than hand length or hand length/second to fifth metacarpophalangeal width. CONCLUSION: ASCT improved hand scleroderma over 12 months and resolved previously refractory tenosynovitis. ASCT was unnecessary to treat scleroderma synovitis. ASCT secondarily improved hand function (paid employment, followed by self-care, home care, then by sport/hobbies). Loss of finger abduction was a more sensitive measure of finger clawing than apparent loss of hand length.

Continuing the dialogue: postcolonial feminist scholarship and Bourdieu - discourses of culture and points of connection.

Postcolonial feminist theories provide the analytic tools to address issues of structural inequities in groups that historically have been socially and economically disadvantaged. In this paper we question what value might be added to postcolonial feminist theories on culture by drawing on Bourdieu. Are there points of connection? Like postcolonial feminists, he puts forward a position that aims to unmask oppressive structures. We argue that, while there are points of connection, there are also epistemologic and methodologic differences between postcolonial feminist perspectives and Bourdieu's work. Nonetheless, engagement with different theoretical perspectives carries the promise of new insights - new ways of 'seeing' and 'understanding' that might enhance a praxis-oriented theoretical perspective in healthcare delivery.

Re-thinking the complexities of 'culture': what might we learn from Bourdieu?

In this paper we continue an ongoing dialogue that has as its goal the critical appraisal of theoretical perspectives on culture and health, in an effort to move forward scholarship on culture and health. We draw upon a programme of scholarship to explicate theoretical tensions and challenges that are manifest in the discourses on culture and health and to explore the possibilities Bourdieu's theoretical perspective offers for reconciling them. That is, we hope to demonstrate the need to move beyond descriptions 'of' culture to an understanding of cultures as dynamic, and to show ways cultural practices create contexts that have the potential to foster or impede health. In our early research, largely undertaken in Canada's multicultural context, we sought to make visible the ways in which culture shaped conceptions of health and influenced health practices of immigrant groups. In recent years this focus has expanded to include populations that reflect the cultural and social diversity of our region. From the outset we attempted to move towards a conception of culture as negotiated, unifying, transformative and dynamic. While this position continues to hold appeal we are continually reminded that, despite our leanings towards constructivism, there is salience to the notion of culture as having enduring elements. It is this tension between the view of culture as embodied and enduring and culture as constructed and dynamic that we seek to examine. We explore whether Bourdieu's theoretical perspective offers promise for reconciling these apparently competing views. Using exemplars from our research we share insights that Bourdieu's work has offered to our analyses, thereby enabling us to move towards a view of culture that holds in tension these apparently contradictory positions of culture as both essence (albeit unstable, negotiated) and constructed.

Management of fulminating ulcerative colitis in childhood with chimeric anti-CD25 antibody.

Fulminating acute ulcerative colitis (UC) is a potentially life threatening medical emergency. Up to 30% of individuals respond poorly to corticosteroids alone and second line medical or surgical therapies are indicated. We describe the successful use of chimeric anti-CD25 therapy in 4 such children poorly responsive to combined therapy with intravenous steroids and calcineurin inhibitors with a pretreatment predictive risk of colectomy of 85-100%. Clinical disease activity scores normalized within 72 hours of anti-CD25 administration and colonic histology provided evidence of mucosal healing within 10-14 days. None required emergency colectomy. Anti-CD25 is efficacious in fulminating UC and randomized placebo controlled trials appear indicated.

Fingertip skin wrinkling - the effect of varying tonicity.

Fingertip skin wrinkling after prolonged immersion in water is a well-recognized phenomenon, whereas a denervated digit does not exhibit normal skin wrinkling while a finger with a regenerated or repaired nerve shows at least partial reappearance of wrinkling. This is the basis for the bedside immersion-wrinkling test of autonomic digital nerve function. The exact mechanism of fingertip skin wrinkling is still subject to controversy. The purpose of this study was to investigate the relationship between the tonicity of a solution and the time elapsed to skin wrinkling. Fourteen healthy volunteers (28 hands) were recruited for investigation. We submerged all 28 hands in solutions of varying tonicity while maintaining all other parameters constant. We found that increased tonicity significantly slowed the time to wrinkling (TTW). Hypotonic solutions such as water should be used when performing clinical bedside testing for autonomic digital nerve function.

Multiple carpometacarpal dislocations and an ipsilateral scapho-trapezium-trapezoid fracture-dislocation: a rare pattern of injury.

We report a rare case of simultaneous dorsal dislocation of 4 ulnar carpometacarpal joints and dorsoradial dislocation of the trapezium with an associated fracture of the scaphoid tuberosity. The injuries were diagnosed early and treated successfully with closed reduction and transfixation using Kirschner wires. The functional results were excellent at 17-month follow-up.

Interaction between mycobacteria and mucus on a human respiratory tissue organ culture model with an air interface.

Mycobacteria adhere specifically to extracellular matrix (ECM) and mucus with a fibrous, but not globular, appearance, in organ cultures of human respiratory mucosa examined by scanning electron microscopy. Previously, light microscopy sections made of tissue infected for 7 days demonstrated mycobacteria associated with mucus on the organ culture surface, and within submucosal glands in areas of damaged epithelium. The authors have now investigated the interactions between Mycobacterium avium complex (MAC), Mycobacterium tuberculosis (MTB), and Mycobacterium smegmatis (MS) and mucus by preincubating bacteria with purified mucins MUC5AC and MUC5B prior to inoculation onto the organ culture mucosal surface. They have also measured mucin production by the organ culture after mycobacterial infection. Mucus did not cause clumping of mycobacteria. There was a significant (P=.03) increase in the amount of fibrous mucus, but not globular mucus, observed on tissue inoculated with mucins compared to controls. The number of bacteria adhering to ECM was markedly reduced after incubation with mucins, which could indicate a protective effect. Mycobacterial infection did not increase mucin production by the organ culture. Mycobacterial adherence to mucins may play a role in the pathogenicity of mycobacteria in diseases such as cystic fibrosis, bronchiectasis, and chronic obstructive pulmonary disease (COPD), in which there are changes in mucus composition and clearance.

Regulation of MUC5AC mucin secretion and airway surface liquid metabolism by IL-1beta in human bronchial epithelia.

Mucociliary transport in the airways significantly depends on the liquid and mucin components of the airway surface liquid (ASL). The regulation of ASL water and mucin content during pathological conditions is not well understood. We hypothesized that airway epithelial mucin production and liquid transport are regulated in response to inflammatory stimuli and tested this hypothesis by investigating the effects of the pleiotropic, early-response cytokine, IL-1beta, on cultured primary human bronchial epithelial and second-passage, normal human tracheo-bronchial epithelial (NHTBE) cell cultures. Fully differentiated NHTBE cultures secreted two major airway mucins, MUC5AC and MUC5B. IL-1beta, in a dose- and time-dependent manner, increased the secretion of MUC5AC, but not MUC5B. MUC5AC mRNA levels were only transiently increased at 1 and 4 h after the start of IL-1beta treatment and returned to control levels thereafter, even though MUC5AC mucin production remained elevated for at least 72 h. Synchronous with elevated MUC5AC secretion, ASL volume increased, its percentage of solid was reduced, and the pH/[HCO(3)(-)] of the ASL was elevated. ASL volume changes reflected altered ion transport, including an upregulation of Cl(-) secretory currents (via CFTR and Ca(2+)-activated Cl(-) conductance) and an inhibition of epithelial sodium channel (ENaC)-mediated absorptive Na(+) currents. IL-1beta increased CFTR mRNA levels without affecting those for ENaC subunits. The synchronous regulation of ASL mucin and liquid metabolism triggered by IL-1beta may be an important defense mechanism of the airway epithelium to enhance mucociliary clearance during airway inflammation.

Identification of a nonmucin glycoprotein (gp-340) from a purified respiratory mucin preparation: evidence for an association involving the MUC5B mucin.

Rate-zonal centrifugation of a reduced and alkylated respiratory mucin preparation identified a protein-rich fraction. This was subjected to trypsin treatment and one of the many liberated peptides was purified and its N-terminal sequence determined. The peptide was identical to a 14 amino acid sequence from the scavenger receptor cysteine-rich domain containing glycoprotein gp-340. A polyclonal antiserum, raised against the peptide, stained the serous cells in the submucosal glands of human tracheal tissue. The glycoprotein was purified from respiratory mucus by density-gradient centrifugation, gel chromatography, and anion exchange chromatography. The molecule exhibited a heterogeneous distribution of buoyant density (1.28-1.46 g/ml) that overlapped with the gel-forming mucins, was included on Sepharose CL-2B and was quite highly anionic. SDS-PAGE indicated a mass greater than 208 kDa and measurements performed across the molecular size distribution indicated an average M(r) of 5 x 10(5) with a range of M(r) from 2 x 10(5) to 1 x 10(6). Gel chromatography of respiratory mucus extracts ("associative" and "dissociative") indicated that this glycoprotein forms complexes that may involve the large gel-forming mucins MUC5AC and MUC5B. Rate zonal centrifugation suggested such complexes are more likely to involve MUC5B rather than MUC5AC mucins.

A new mathematical model of dynamic cerebral autoregulation based on a flow dependent feedback mechanism.

A new mathematical model representing dynamic cerebral autoregulation as a flow dependent feedback mechanism is presented. Two modelling parameters are introduced, lambda, the rate of restoration, and tau, a time delay. Velocity profiles are found for a general arterial blood pressure, allowing the model to be applied to any experiment that uses changes in arterial blood pressure to assess dynamic cerebral autoregulation. Two such techniques, thigh cuffs and a lower body negative pressure box, which produce step changes and oscillatory variations in arterial blood pressure respectively, are investigated. Results derived using the mathematical model are compared with data from the two experiments. The comparisons yield similar estimates for lambda and tau, suggesting these parameters are independent of the pressure change stimulus and depend only on the main features of the dynamic cerebral autoregulation process. The modelling also indicates that for imposed oscillatory variations in arterial blood pressure a small phase difference between pressure and velocity waveforms does not necessarily imply impaired autoregulation. It is shown that the ratio between the variation in maximum velocity and pressure variation can be used, along with the phase difference, to indicate the nature of the autoregulatory response.

Physical characterization of the MUC5AC mucin: a highly oligomeric glycoprotein whether isolated from cell culture or in vivo from respiratory mucous secretions.

We have isolated the high-M(r) mucins from growth medium of the early stage of an HT-29 cell culture by gel chromatography and isopycnic density gradient centrifugation. The mucins (buoyant density 1.34-1.44 g/ml) were reactive with an anti-peptide antiserum (MAN-5ACI) raised against a sequence from within the MUC5AC mucin. Similar antisera raised against the MUC2 and MUC5B mucins were not reactive. The MUC5AC reduced-mucin subunits exhibited a homogeneous charge distribution on anion-exchange chromatography, but appeared as two bands, one major and one more minor, after agarose gel electrophoresis. The unreduced mucins had an average M(r) in excess of 40 MDa and were visualized in the electron microscope as large, fine filamentous threads (many microns in length) that after reduction were greatly reduced in size (number average length 570 nm). Agarose gel electrophoresis of unreduced MUC5AC mucins identified a major band just entering the gel with evidence of a 'ladder' of faster-migrating minor bands. Partial reduction of the mucins increased the proportion of the faster bands and at least 16 could be discriminated. M(r) measurements showed that these bands differed by single monomer units. The mucins behaved as very stiff extended structures in solution and this characteristic might explain the poor separation of different-sized oligomers in sedimentation-rate experiments. The cell-culture mucin preparation had similar characteristics of charge and buoyant density to MUC5AC mucins from respiratory secretions in vivo. In addition the MUC5AC mucin from respiratory tract secretions exhibited similar behaviour, reduced and unreduced on agarose gel electrophoresis, indicating that the mucin has a similar molecular phenotype in vivo and in vitro.

Unlicensed uses for medication in a palliative care unit.

The aim of this study was to review the extent of drug use for unlicensed purposes in a palliative care unit. We carried out a prospective study of all patients with advanced malignancy admitted to a 10-bed specialist palliative care unit over a 4-month period. Prescriptions were assessed and compared with licensed prescribing indications. Seventy-six patients were included in the study; 689 prescriptions were made using 84 drugs to treat 34 different symptoms. Fifteen per cent of prescribing events were for unlicensed indications. We conclude that drugs are frequently used in the palliative care setting for purposes unsupported by product licences, although usually backed by literature. These drugs are often prescribed for symptoms which are difficult to control.