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This paper explores the relationship between distance and the utilization of health care by a group of elderly residents in rural Vermont. By drawing on recent work on the geography of health we frame the decision to visit a primary care physician in the context of the experience of place. The paper devises a test of this broader reading of the role of distance for utilization, and operationalizes this test using a custom designed survey. Using a randomized mail survey of elderly residents of Vermont's North East Kingdom we explore how grocery shopping, travel to work, home location relative to local services, access to private transportation, and living arrangements are associated with the number of doctor visits made to primary health care providers. Although the results confirm the idea that increased distance from provider does reduce utilization, they strongly suggest that distance to provider is a surrogate for location in a richer web of relations between residents and their local communities. We conclude by calling for further research that establishes links between place and the use of health facilities. [ABSTRACT FROM AUTHOR]

The fate of collagen implants in a wound environment is determined by the host response they elicit, their accommodation for cellular infiltration and their susceptibility to proteolytic attack. Glutaraldehyde cross-linking is most effective in delaying resorption and reducing an antibody response. The proteolytic events reflect the sequence of cellular infiltration of inflammatory cells during the proliferative phase of repair. The fibrous collagen implant is initially degraded by matrix metalloproteinase-1 cleaving the triple helix into 3/4 and 1/4 helical fragments and by cathepsin cleavage of the telopeptide region of the collagen molecule containing the intermolecular cross-links. The resulting triple helical fragments denature at physiological temperature and the resulting gelatin is rapidly degraded to amino acids by many proteases, primarily the gelatinases (matrix metalloproteinase-2 and -9) and the cathepsins. A proportion of the fiber fragments are phagocytosed and digested intracellularly by cathepsins within the lysosomes. The collagen implant is ultimately degraded to its constituent amino acids, which like all other protein metabolic products may be re-utilized. The post-translational products, hydroxyproline and hydroxylysine and the various cross-linking amino acids are excreted. [ABSTRACT FROM AUTHOR]

A 25 patient study was conducted into the relationship between markers of collagen metabolism in venous ulcer exudates and healing status, and their prognostic value in predicting healing performance. Wounds were sampled on at least 5 occasions over 12 months, the frequencies of which were determined by the need for clinic attendance. Specimens were taken from several sites on each ulcer using sterile preweighed filters. Wound margins were traced and sites recorded for each collection. Sample sites were evaluated for severity as improving, static, or deteriorating according to subsequent wound progression. Specimens were analyzed for levels of proenzyme and active forms of matrix metalloproteinases 2 and 9, neutrophil elastase, and type I collagen C propeptide. There was an overall trend of greater expression of all markers with increasing severity of wound site, this being highly significant for pro-matrix metalloproteinase-9 (p = 0.006). For samples collected simultaneously from improving and deteriorating regions of the same wound, paired data analysis showed statistically significant differences for pro-matrix metalloproteinase-9 (p < 0.001), neutrophil elastase (p < 0.005) and activated matrix metalloproteinase-9 (p < 0.05). Taken overall, these data show the potential of markers of collagen biochemistry as predictors of repair in venous ulcers; in particular pro-matrix metalloproteinase-9 and neutrophil elastase were found to be accurate prognostic indicators of subsequent healing. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The influence of the cruciate ligaments in spontaneous osteoarthritis (OA) is not understood, although ligament rupture is known to cause secondary OA. Additionally, femoral notch narrowing at the anterior cruciate ligament (ACL) insertion site is associated with disease severity, but it is unknown whether ligament deterioration precedes or follows osteophyte formation. We examined cruciate ligament mechanics and metabolism and the intercondylar notch width in OA-prone Dunkin-Hartley (DH) guinea pigs at ages up to and including the age at OA onset (24 weeks), and compared the data with those in age-matched controls (Bristol strain 2 [BS2] guinea pigs). METHODS: Guinea pigs were assessed at 3, 6, 9, 12, 16, 20, 24, and 36 weeks of age. ACLs were mechanically tested, and the intercondylar notch width index (NWI) was determined. Cruciate ligament metabolism was determined by measuring the following markers of collagen turnover: matrix metalloproteinase 2 (MMP-2), tissue inhibitor of metalloproteinases 2, C-terminal type I procollagen propeptide (PICP), and the immature collagen-derived crosslink dihydroxylysinonorleucine (DHLNL). RESULTS: DH guinea pigs had significantly laxer ACLs than did BS2 guinea pigs, at 12, 16, and 24 weeks. We observed elevated levels of pro and active MMP-2, PICP, and DHLNL in the cruciate ligaments of DH animals at most ages, compared with BS2 guinea pigs. The NWI in DH animals was significantly lower than that in BS2 guinea pigs at 24 and 36 weeks. CONCLUSION: In DH guinea pigs, laxer ACLs, which are associated with increased collagen turnover, may cause joint instability and predispose these animals to the early onset of OA. Decreased intercondylar notch width in the DH animals indicates that bone remodeling at the ACL insertion site is a response to elevated ACL laxity. [ABSTRACT FROM AUTHOR]