Responding to health inequities: Indigenous health system innovations.

Over the past decades, Indigenous communities around the world have become more vocal and mobilized to address the health inequities they experience. Many Indigenous communities we work with in Canada, Australia, Latin America, the USA, New Zealand and to a lesser extent Scandinavia have developed their own culturally-informed services, focusing on the needs of their own community members. This paper discusses Indigenous healthcare innovations from an international perspective, and showcases Indigenous health system innovations that emerged in Canada (the First Nation Health Authority) and Colombia (Anas Wayúu). These case studies serve as examples of Indigenous-led innovations that might serve as models to other communities. The analysis we present suggests that when opportunities arise, Indigenous communities can and will mobilize to develop Indigenous-led primary healthcare services that are well managed and effective at addressing health inequities. Sustainable funding and supportive policy frameworks that are harmonized across international, national and local levels are required for these organizations to achieve their full potential. In conclusion, this paper demonstrates the value of supporting Indigenous health system innovations.

The Effects of Chronic Nitrate Supplementation and the Use of Strong and Weak Antibacterial Agents on Plasma Nitrite Concentration and Exercise Blood Pressure.

Chlorhexidine-containing mouthwash (STRONG), which disturbs oral microflora, has been shown to diminish the rise in plasma nitrite concentration ([NO2-]) and attenuate the reduction in resting blood pressure (BP) typically seen after acute nitrate (NO3-) ingestion. We aimed to determine whether STRONG and weaker antiseptic agents attenuate the physiological effects of chronic NO3- supplementation using beetroot juice (BR). 12 healthy volunteers mouth-rinsed with STRONG, non-chlorhexidine mouthwash (WEAK) and deionised water (CON) 3 times a day, and ingested 70 mL BR (6.2 mmol NO3-), twice a day, for 6 days. BP (at rest and during 10 min of treadmill walking) and plasma and salivary [NO3-] and [NO2-] were measured prior to and on day 6 of supplementation. The change in salivary [NO3-] 4 h post final ingestion was higher (P<0.05) in STRONG (8.7±3.0 mM) compared to CON (6.3±0.9 mM) and WEAK (6.0±3.0 mM). In addition, the rise in plasma [NO2-] at 2 h was lower in STRONG compared with WEAK (by 89±112 nM) and CON (by 200±174 nM) and in WEAK compared with CON (all P<0.05). Changes in resting BP were not different between conditions (P>0.05). However, during treadmill walking, the increase in systolic and mean arterial BP was higher 4 h after the final nitrate bolus in STRONG compared with CON (P<0.05) but not WEAK. The results indicate that both strong and weak antibacterial agents suppress the rise in plasma [NO2-] observed following the consumption of a high NO3- diet and the former can influence the BP response during low-intensity exercise.

The enigma of post-natal depression: an update.

This paper aims to provide a critical analysis of key concepts associated with post-natal depression (PND) to facilitate healthcare professionals with improving standards of care. Post-natal depression is often inadequately understood by healthcare professionals. The objective was to clarify and present understandings of PND. Post-natal depression may result in referral to Community Mental Health Teams and although initial contact and management is usually through Primary Care, increasingly there is involvement of liaison mental health nurses. A literature review and synthesis of research papers on PND was conducted. Using the keywords post-natal depression, post-partum, puerperium, perinatal, therapy, trial, review, systematic, 135 articles were yielded and limited to 57, which were critically reviewed and categorized into key concepts and themes. Synthesis of literature in relation to PND has facilitated construction of an evidence-based contemporary picture of clinical manifestation, aetiology, methods of screening, preventing, treating and managing PND. The veracity of the evidence surrounding the aetiology and treatment of PND is variable. Interventions are often ineffective and a vacuum in the evidence base exists leaving a dynamic environment for researchers to identify more successful ways of predicting, detecting, treating and managing PND.

Newborn frontal horn cysts: cause for concern?

OBJECTIVE: To document the incidence, natural history and compare neurodevelopmental outcome of newborns with and without frontal horn cysts (FHC). STUDY DESIGN: This was a case-control study. Newborns with and without FHC were identified and matched for demographics and worst cranial ultrasound scan (CUS) findings. Neurodevelopmental outcome was assessed at 18 to 24 months. RESULT: A total of 30 FHC cases were identified from medical imaging database. Twenty-five cases occurred in preterm 32 weeks gestation with an incidence of 1% (25 of 2340). The diagnosis was made on the initial CUS in 28 cases. The cyst size and number varied from 1 to 18 mm and 1 to 6 respectively with no change noted on repeat CUS during hospital stay. Neurodevelopmental outcomes were not statistically significantly different between the groups. CONCLUSION: FHC are not uncommon in the newborn period. They appear to be benign with no impact on neurodevelopmental outcome. This information is vital for counseling parents of infants with FHC.

Cytomegalovirus transmission to extremely low-birthweight infants through breast milk.

AIM: To determine the incidence, timing and clinical significance of acquired postnatal cytomegalovirus (CMV) in extremely low-birthweight (ELBW) infants. METHODS: Prospective, longitudinal surveillance study. ELBW infants were recruited in the first week of life. Maternal blood was tested for CMV-specific IgG antibodies. Weekly urine samples were obtained from infants for CMV culture and rapid antigen testing. Data were collected regarding clinical course and breast milk intake. RESULTS: Of 181 eligible infants, 119 infants, born to 101 mothers, were enrolled. Eighty of the 101 mothers had their serum checked for CMV status. Seventy percent of those tested were seropositive for CMV. Of the 65 infants born to seropositive mothers, 94% received breast milk during their hospital stay. Complete urine collection was obtained in 92 infants. CMV was cultured from the urine of only four infants, all of whom were born to seropositive mothers. Only one of these four infants was symptomatic. The range at which CMV was first detected was between 48 and 72 postnatal days of age. CONCLUSIONS: Despite a very high CMV seropositivity rate in mothers of ELBW infants, and the previously reported high rate of CMV excretion into breast milk, the incidence of postnatal CMV transmission was extremely low in our study.

Excess risk of cancer in patients with primary venous thromboembolism: a national, population-based cohort study.

We conducted a nationwide, retrospective cohort study assessing the risk of cancer in VTE patients diagnosed in Scotland in 1982-2000. Significantly elevated risks of cancer were sustained for 2 years after VTE diagnosis, most notably for ovarian tumours and lymphomas. Younger patients were at an increased relative risk from this association.

Effects of dietary protein concentration and specific amino acids on body weight, body composition and feather growth in young turkeys.

1. Two randomised block factorial experiments were conducted to investigate the relationships between the effects of dietary crude protein and specific amino acid concentrations on the relative growth of the body and feathers of young turkeys. 2. Decreasing dietary crude protein concentration from 300 to 180 g/kg in experiment 1 reduced the body and breast muscle weights of a large male line of turkeys proportionally by 0.44 and 0.52 compared with 0.19 and 0.24 in a small traditional line. 3. Decreasing dietary crude protein concentration was associated with a maximum reduction in feather weight of 0.18 and 0.24 respectively in male line and traditional turkeys. The length of the feathers in the cranial region of the breast decreased from 26 to 19mm in the traditional line compared with an increase from 14 to 25 mm in male line turkeys. 4. Decreasing dietary crude protein concentration was associated with an increase in the fat content of the feather-free carcase. Male line turkeys had a higher carcase fat and lower feather dry matter content than the traditional turkeys. 5. It was concluded that dietary crude protein was preferentially partitioned to feather rather than muscle growth in the male line in contrast to a traditional line of turkeys in which the growth of feathers and muscle were affected equally. 6. In experiment 2, the amino acids arginine, valine, methionine and tyrosine were added separately to a common basal ration (180g CP/kg) to raise their concentration to that of the control ration (260 g CP/kg). Each ration was fed ad libitum to male line turkeys from 2 to 6 weeks of age. 7. Amino acid supplementation increased body and breast muscle weights. 8. Compared with the basal ration, tyrosine was associated with a reduction in feather weight whereas valine had no effect. Supplementation with arginine and methionine resulted in increased feather weights that were similar to that of the controls. 9. It was concluded that arginine and methionine were used preferentially and are essential for feather growth. Excess amino acids that are not required for feather growth such as tyrosine and valine were used for increased body growth and resulted in relatively poor feather cover. 10. The results suggest that feather growth was maintained as much as possible at the expense of body growth when the amino acid concentration of the ration was less than that required to maximise body and muscle weight gain in large male line turkeys.

Hypertrophic cardiomyopathy with shared morphology in identical twins: a case report.

We report the case of identical twin sisters, both with hypertrophic cardiomyopathy, and both found to have similar echocardiographic appearances in the form of asymmetric septal hypertrophy. This is unusual, in that published reports commonly describe the heterogeneous expression of this condition in twins.

Effects of ambient temperature and restricted feeding on the growth of feathers in growing turkeys.

1. Male turkeys were reared to 6 weeks of age at 15 degrees C and 26 degrees C and fed ad libitum or restricted to 0.5 of the body weight of birds fed ad libitum. Basal metabolic rate was determined by indirect calorimetry at an ambient temperature of 20 degrees C. 2. Turkeys at 15 degrees C were lighter than those kept at 26 degrees C. Feather lengths and weight were similar in both groups. Fasting heat production corrected for both metabolic body size and activity was greater in turkeys reared at 15 degrees C than those at 26 degrees C. 3. Cranial breast feathers were significantly longer in restricted birds than in those fed ad libitum in contrast to a proportional decrease in the lengths of other feathers of 0.1 to 0.3. Feather weight as a proportion of body weight was 0.072 in restricted turkeys compared with 0.046 in birds fed ad libitum. There was no difference in basal metabolic rate between ad libitum and restricted turkeys. 4. It was concluded that feather growth was maintained in preference to body and muscle growth and that rearing birds at 15 degrees C did not improve breast feather cover. It is suggested that the growth of breast feathers in turkeys fed ad libitum is impaired.

Investigation of mechanisms for the reductive dechlorination of chlorinated ethylenes using electroanalytical techniques.

Chlorinated ethenes in the environment can dechlorinate by accepting electrons from electron donors fortuitously found in nature under a wide range of conditions in the sub-surface by both abiotic and biotic pathways. A source of electron donors is a range of dehalorespiratory bacteria, in which Co(I) in vitamin B12, in the presence of strong reductants such as Ti(III) citrate, aids dehalogenation. In this work we investigated a range of reducing conditions using electron donors of varying strengths and proposed mechanisms for dechlorination. Initially, the reducing abilities of one of the strongest electron donors known, tetrakis(dimethylamino)ethylene (TDAE), was studied. Subsequently, the reducing ability of a cobalt salt under reducing conditions was examined. Molasses was used as a source of hydrogen. The reactions were followed using electrochemistry, UV-Vis spectroscopy and ion chromatography. TDAE was found to form adducts with tetrachloroethylene and trans-dichloroethylene and to reduce trichloroethylene and cis-dichloroethylene very rapidly. On application of a negative potential, cobalt, in the presence of molasses, was also found to dechlorinate trichloroethylene rapidly. Dechlorination of PCE was considerably slower.

Feeding-induced tonic pain suppression in the chicken: reversal by naloxone.

Endogenous analgesia induced by changes in motivation has been identified in the chicken in previous studies but either the motivational changes were difficult to interpret or the motivation was unpredictable. Experimental sodium urate (SU) arthritis of the ankle joint resulted in pain-coping behaviour (one-legged standing or sitting) for a 2-h period in non-food-deprived birds without access to food. Complete analgesia or marked hypoalgesia was observed in birds which had been food deprived overnight and given access to food immediately after SU injection. This analgesia seen during feeding behaviour in the food-deprived bird could be completely reversed by intravenous injection of naloxone. These results demonstrate that feeding motivation can totally suppress, in some animals, the severe tonic pain of SU arthritis and that this analgesia may be opioid mediated.

Do the right thing. When it comes to your community, do you know what that is? Roundtable discussion.

What is the health care organization's responsibility to maintaining a healthy community, and how does the board fit into that role? Has the field's understandable fixation on costs and the penetration of managed care into most markets affected that role? Leaders of both for-profit and not-for-profit organizations often believe that they are fulfilling their community obligations as long as they provide uncompensated care to the indigent and the uninsured. But is that really being accountable to the community? And if it's not, then what is community accountability? The American Hospital Association's Division of Trustee Leadership and Trustee magazine posed these questions to 13 health care and community leaders last December. Their different perspectives provide for some surprising answers.

Distribution of insulin-like growth factor peptides in the developing chick embryo.

Growth factors are likely to be of major significance in developmental biology. Here, the distribution of insulin-like growth factor (IGF) peptides is described during development of the chick embryo. IGF was immunolocalised using a polyclonal antibody to human IGF I detected with a modified Vectastain ABC procedure. Under the conditions used, the antibody binds strongly to IGF I and weakly to IGF II; thus the distribution of IGF peptide, rather than the individual factors, is described. Muscle, peripheral nerve and the notochord were labelled whenever present. Muscle label was associated with the myotubes and neural labelling with neurons; Schwann cells were unlabelled. IGF distribution changed during differentiation of connective tissues. Regions of mesenchyme destined to form cartilage labelled weakly or not at all, and cartilage condensations were unlabelled. In the limb, chondrocytes became labelled once cartilage rudiments had formed; however, in later development, label was absent in zones of rounded and flattened chondrocytes and appeared strongly at the onset of hypertrophy. Early osteogenic mesenchyme was also unlabelled, although later bone cells were strongly stained. In the neural tube, label was associated with differentiating neuroblasts and cell bodies and with axons, especially in the developing dorsolateral tracts. These results show a possible correlation between IGF label and cell division in early mesenchyme; cartilage condensations, which have reduced mitotic indices, do not label. In other tissues, notably muscle and nerve but also later connective tissues, label is associated with differentiating, rather than dividing, cells.

The evaluation of a Cardiovascular School Health Curriculum: an assessment of long-term cognitive retention and attitudinal correlates.

This study provided evidence that the Cardiovascular School Health Curriculum was successful in increasing the knowledge levels of high school students and maintaining significant portions of that knowledge during a six month period, indicating that with a strong, well developed curriculum, relatively permanent change in knowledge levels can be achieved. This was particularly gratifying to the researchers who believe that the appropriate knowledge of the cardiovascular system, heart diseases and methods of preventing heart and circulatory problems are essential foundations for having positive impact of youths' future behavioral choices. Additional longitudinal studies are planned to augment the findings of this study.

Doxepin kinetics.

The kinetics of doxepin (DOX) hydrochloride were studied in 7 volunteers after the oral administration of 75 mg. Peak plasma concentrations of DOX ranged from 8.8 to 45.8 ng/ml and were reached within 4 hr. The disappearance of DOX was biphasic and followed first-order kinetics. The mean DOX half life (t1/2) was 16.8 hr and in individuals ranged from 8.2 to 24.5 hr. The mean apparent volume of distribution was 20.2 L/kg and ranged from 9.1 to 33.3 L/kg. The estimated first-pass metabolism of DOX ranged from 55% to 87% of the oral dose assuming complete absorption. Significant quantities of the metabolite desmethyldoxepin (DMD) were produced. Peak levels of DMD ranged from 4.8 to 14.5 ng/ml and were reached between 2 and 10 hr after administration. The mean t1/2 of DMD was 51.3 hr and in individuals ranged from 33.2 to 80.7 hr. There was no correlation between the DOX and DMD t1/2s. The amount of DMD produced correlated with the plasma concentration of DOX and appears to explain the correlation between the steady-state concentrations of DOX and DMD in patients given DOX.