6″-Modifed α-GalCer-peptide conjugate vaccine candidates protect against liver-stage malaria

Self-adjuvanting vaccines consisting of peptide epitopes conjugated to immune adjuvants are a powerful way of generating antigen-specific immune responses. We previously showed that a Plasmodium-derived peptide conjugated to a rearranged form of α-galactosylceramide (α-GalCer) could stimulate liver-resident memory T (T_RM) cells that were effective killers of liver-stage Plasmodium berghei ANKA (Pba)-infected cells. To investigate if similar or even superior T_RM responses can be induced by modifying the α-GalCer adjuvant, we created new conjugate vaccine cadidates by attaching an immunogenic Plasmodium-derived peptide antigen to 6″-substituted α-GalCer analogues. Vaccine synthesis involved developing an efficient route to α-galactosylphytosphingosine (α-GalPhs), from which the prototypical iNKT cell agonist, α-GalCer, and its 6″-deoxy-6″-thio and -amino analogues were derived. Attaching a cathepsin B-cleavable linker to the 6″-modified α-GalCer created pro-adjuvants bearing a pendant ketone group available for peptide conjugation. Optimized reaction conditions were developed that allow for the efficient conjugation of peptide antigens to the pro-adjuvants via oxime ligation to create new glycolipid-peptide (GLP) conjugate vaccines. A single dose of the vaccine candidates induced acute NKT and Plasmodium-specific CD8⁺ T cell responses that generated potent hepatic T_RM responses in mice. Our findings demonstrate that attaching antigenic peptides to 6″-modifed α-GalCer generates powerful self-adjuvanting conjugate vaccine candidates that could potentially control hepatotropic infections such as liver-stage malaria.

Candidate vaccines comprised of peptide antigen conjugated to 6″-modified α-GalCer analogues generate potent hepatic T_RM responses in mice with a single dose inducing protective immunity against malaria in a Plasmodium sporozoite challenge model.

"Not there yet": Examining community support from the perspective of people with dementia and their partners in care

People with dementia can live meaningful and engaged lives with the appropriate social and physical supports in place. There has been relatively little research, however, on the experiences and desires of people with dementia themselves as they negotiate informal and formal support in rural and small town settings. In this article, we draw on semi-structured interviews with 46 community-dwelling people with dementia and 43 partners in care in rural Ontario, Canada to examine how people with dementia relate to and within their communities as well as their perceptions of community support services. We identify the continued contributions of people with dementia to their own care and the care of others as well as common social, cultural, and organizational factors related to delayed service use and refusal to use particular services. We argue that care is "not there yet" for people in the earlier stages of dementia and that more attention needs to be paid to what people with dementia can offer their communities as well as the role of culture and gender in developing support. Our findings make an important contribution to understanding the experience of dementia in rural and small town Canada, which is relevant to rural healthcare and community support in other industrialized countries.

The Elderly, Economic Dependency, and Local Government Revenues and Expenditures

The relationships among the elderly population, economic conditions relative to the working age population, and local government revenues and expenditures are complex. With Ontario, Canada in 1986 as a case study, these relationships are explored through a series of models. The geographic distribution of the elderly population and its economic dependency are projected to the year 2006. Given the current relationships and the projections, the implications for various levels of government are discussed.

'Gentle caring experience'. Seeking alternative health care in Canada

The starting point for this paper is a review of the literature, which seeks to explain the use of alternative medicines, therapies and practices in developed countries. Using the Statistics Canada 1996-97 National Population Health Survey--Health File, we then examine the profile of alternative service users. Our analysis shows that use of alternative health care is still limited to a relatively small segment of Canadians whose profile is similar to those in other developed countries. Women are more likely than men to use alternative medicines, therapies and practices, as are those who have higher incomes and are better educated. To move what has been an essentially empirical discussion forward, we explore critiques of conventional medical practice and propose that the analysis of alternative health care be situated within the geographies of consumption.

The impacts of distance to hospital on families with a child with a chronic condition

Children with chronic conditions and their families face many similar challenges that can be stressful for the family including, daily caregiving activities, financial difficulties caused by unexpected expenses, and increased use of health services to treat and help manage the condition. Many of these families, in addition to facing daily caregiving responsibilities, must travel substantial distances to access some of the necessary aspects of their child's health care. In this study, the Burke et al. (1994-1996) data of repeatedly hospitalized children and their families are used to explore a geographical dimension of family impact, distance. Outcome measures from the Feetham Family Functioning Survey and the Questionnaire on Resources and Stress are analyzed using exploratory and multivariate analysis. Results show that distance to hospital plays a role in the two areas of family life regarding relationships within the immediate family, and issues surrounding the ability to maintain the child in the family home. The implications of the results for family, health care intervention, and government policies and guidelines are discussed.

Gender, poverty and location: how much difference do they make in the geography of health inequalities?

It is often said that women live longer than men, but suffer more illnesses throughout their lives. It has also been demonstrated in various studies of women's health that measures of health and health behaviour vary over different geographic scales. Added into this mix is the fact that historically more women than men in relative terms are found on the lower rungs of the socio-economic ladder. What has not been so well-developed is our understanding of the connections among health, gender, poverty and especially location. In 1998, Statistics Canada released the second wave of the National Population Health Survey (NPHS-2). Included with the NPHS-2 public use microdata file are measures of health status, gender, income and location which can be analyzed in the form of logistic regression models. Results are reported which provide a better understanding of the relative roles that gender, poverty and location play in the geography of inequalities.

Activity limitation and chronic conditions in Canada's elderly, 1986-2011

Together with all other developed countries, Canada's population is experiencing a significant increase in the proportion that is elderly. This paper examines basic linkages between individual ageing, the prevalence of various chronic health conditions, functional limitation and the receipt of help in activities of daily living (ADL) and instrumental activities of daily living (IADL) for the Canadian population using recent data from the National Population Health Survey (NPHS) as well as the Health and Activity Limitation Surveys (HALS) and the two General Social Surveys (GSS) with health data. Presented are age- and sex-specific prevalence of chronic conditions and logistic regression is used to assess the impacts of different chronic conditions on the receipt of help for IADL and ADL. The importance of gender and living alone in influencing the receipt of help and also of use of formal agencies is presented using additional data from HALS. Findings from these analyses are also used to project changes in the distribution of health status defined by disability and receipt of help with IADL/ADL and, secondarily, by chronic condition. These analyses imply increases in demand for a range of health related services which will be 50 to 100% greater than the growth in the total elderly population.

Not-So-New Public Management and the Denial of Geography: Ontario Health-Care Reform in the 1990s

New public management (NPM) has become the mantra for public sector restructuring in OECD nations. We critically examine NPM in the context of recent public sector restructuring initiatives in the province of Ontario, Canada. Two NPM-inspired reform mechanisms employed by the Ontario government—the benchmarking of hospital-utilization indicators and the offloading of a greater share of patient-care responsibilities to the private sector—are examined as they impact on the economically disadvantaged city of Thunder Bay in the province's remote Northwestern region. We argue that the health reforms pursued by the Ontario government are focused on a one-dimensional notion of efficiency which denies important socioeconomic and health-service-environment dimensions that account for local differences in health-services utilization. Although this type of reform approach achieves short-term cost savings, we question whether the longer term effects on health and social services are efficient and equitable from a systemwide perspective. Ultimately, we question whether NPM will solve the problems inherent in publicly supported health and social services or will generate a new set of problems linked to the belief in the primacy of market mechanisms.

The health of Canada's elderly population: current status and future implications

The growing size of Canada's elderly population and its use of health care services has generated much discussion in policy circles and the popular press. With data from the National Population Health Survey, undertaken in 1994-95, the authors examine the health status of Canada's elderly population using 3 sets of measures: level of activity limitations, prevalence of chronic illnesses and self-assessment of overall health. They also analyse the utilization of physician and institutional services. The profile of this population the authors develop is in many respects not much different from that of the remaining adult population, until the age of 75. People aged 75 and over are much more likely than other adults to have health problems and use health care services. Also, elderly women living alone and with low income are identified as an especially vulnerable group who need access to medical and nonmedical services if they are to remain in the community. Using Statistics Canada projection data the authors discuss some aspects of the elderly population's health status in the future. Their look into the future raises issues about the preparedness of health care providers and our health care system to meet the challenges of tomorrow's elderly population.

Access and utilization: a continuum of health service environments

Birch and Abelson [1] argue that non-income based barriers might explain differences in utilization of health services within and between income groups. Databases which contain utilization data rarely allow for the modelling of geographic variation. In the Ontario Health Survey (OHS), individual observations are georeferenced at the Public Health Unit (PHU) scale, but PHUs cannot easily be used because of the large coefficients of variation. To overcome this problem, a cluster analysis is performed to create a service environment variable, which reflects differences in service availability, population size and rurality. Utilization of health services is then modelled as a logistic regression equation where the independent variables are age, sex, service environment and income to test the Birch and Abelson argument. This argument is then extended by controlling for age, health and income status. Based on the modelling results, the importance of geography to access and utilization is assessed.

Modelling migration flows of immigrant groups in Canada

"In this paper, the authors briefly review the findings of an earlier study on the patterns of both regional and metropolitan redistribution of immigrant groups in Canada. Against this backdrop, a hierarchical model of migration for immigrant groups for the period 1981-86 is developed and estimated. The internal redistribution of immigrants through postarrival migration has continued to be focused on metropolitan areas in general and on Toronto, Vancouver, and Montreal in particular. The distribution of previous immigrants plays a significant role over and above that of economic circumstances both in retaining immigrants in a particular city and in attracting members of immigrant groups from other cities."

The end of the second most expensive health care system in the world: some geographical implications

In Canada, there has been an increasingly, vociferous debate over the future of a health care system which is based on 5 principles: comprehensiveness; public administration; universality; portability; and accessibility. In part, this debate is a policy tug-of-war among provincial governments, special interest groups and the public who on one side want to maintain the principles of the health care system and on the other want to control costs within the system. The outcome of this policy tug-of-war is demonstrated through an analysis of the funding of health care in the province of Ontario, Canada in general, and the closure of hospital beds specifically. The analysis shows that in attempting to restructure the system, rationalization and growing spatial inequality are occurring simultaneously. The analysis calls into question the whole strategy of bed closures as a method of controlling health care costs. These conclusions have implications for other national health care systems where hospital bed closures have also been used as a strategy in controlling health care costs.

Contradictions in women's health care provision: a case study of attendance for breast cancer screening

Breast cancer screening facilities operated by the Ontario Breast Screening Program (OBSP) have recently been added to the existing geography of diagnostic mammography facilities in hospitals and private clinics in Eastern Ontario. While diagnostic facilities require a physician's referral for access, the new centres offer mammograms by self-referral. Other work has shown the utilization of mammography screening services to be quite low despite widespread acceptance of early diagnosis through mammographic screening as the best method to lower breast cancer mortality. Major findings are that spatial variation does exist in attendance rates in the townships and census tracts surrounding the screening centre. At the regional level, physician referral patterns and the presence of local diagnostic mammography units appear to affect the uptake of screening at the Kingston facility. The individual level analysis confirms the importance of the primary care physician's referral with two-thirds of the client sample indicating that they were referred for screening by their family physician. The sample of clients are also very mobile women who have comparatively greater access to financial resources than other women of screening age. The results of ecological and individual level analyses of attendance at OBSP's Kingston Centre reveal contradictions in the provision of this service. Spatially, the centres follow a location pattern of a much higher order health facility yet women are expected to include screening as part of their routine care. Attenders at the Centre were found to be of higher socioeconomic status, married and have access to a private automobile. The finding that the primary care physician's referral is an important prerequisite for attendance raises questions about the feasibility of providing health care for women which encourages individual responsibility for health within the existing paternalistic health care system.

Malar augmentation by osteotomy and advancement

We developed a modification of Tessier's zygoma plasty to increase anterior and lateral projection of the malar eminences in 8 patients with malar hypoplasia. The four steps of our modification are: (1) access solely through an intraoral upper sulcus incision; (2) osteotomy of the inferior orbital rim at a more medial site and of the lateral orbital rim more cephalad; (3) careful preservation of both the zygomaticomaxillary buttress and the zygomatic arch; and (4) use of a cranial bone graft alone, as a wedge, to stabilize the rotated zygoma, without the need for plate or screw fixation. Eight patients have undergone this procedure. Follow-up ranged from 4 to 15 months. There have been no complications. All 8 patients have achieved excellent accentuation of their malar eminences, with maintenance of symmetry. The increase in malar eminence projection has improved overall facial form in these patients. The modified Tessier zygoma plasty offers a stable and predictable technique for improving facial form. It provides a very natural correction for deficient malar projection, without introducing visible scars.

Immediate reconstruction of complex cranioorbital fractures in children

Six principles of craniofacial surgery were applied to the treatment of 7 consecutive pediatric patients who sustained complex cranioorbital fractures. These principles are (1) accurate assessment of the deformity, (2) early reconstruction, (3) complete exposure of the involved craniofacial skeleton, (4) accurate anatomical reduction of the fracture fragments, (5) use of rigid internal fixation, and (6) autogenous cranial bone grafting. Patient follow-up ranged from 6 to 52 months; evaluation included serial photographs, three-dimensional computed tomographic imaging, and cephalometric analysis. Application of these 6 craniofacial surgical principles provided definitive management in one operation, with optimal anatomical and functional reconstruction, and resulted in no detectable impairment to subsequent craniofacial growth.

Locating emergency medical services in small town and rural settings

Locating emergency medical services in small town and rural settings presents subtle, but significant differences to those in metropolitan areas. The lack of service mix and unit choice, the measurement of response time in minutes rather than seconds, and the limits of the planning environment are discussed. Using time-distance comparisons and location-allocation techniques within a microcomputing environment, some aspects of planning emergency medical services are illustrated within the context of the Kingston (Ontario) Regional Ambulance Service.

Activism for medical geographers: American, British and Canadian viewpoints

This paper describes some of our personal efforts to launch research projects that address public health issues of interest to geographers in the United States, Canada and Britain. In pressing these agendas we have found through our experiences that there are personal and disciplinary costs associated with activism. We describe the loss of identity with geography; the frustration of trying to persuade bench scientists, corporate representatives, and government officials of the importance of our work; the loss of research time and contact with both our academic colleagues and students.

Ontario's underserviced area program revisited: an indirect analysis

Financial incentive programs are used in various developed and developing countries to effect change in the geographic distribution of physicians. The Underserviced Area Program of Ontario is the longest running financial incentive program in Canada. It is described in detail and analyzed for its effectiveness in solving the problems of the maldistribution of physicians in northern Ontario. Using location quotients as an indirect measure shows that the maldistribution of physicians continues despite the implementation of the program. It is argued that the unidimensional solution of financial incentives cannot be used to solve the multidimensional issue of accessibility to health care in rural and remote areas.

Components of change in the spatial distribution of the elderly population in Ontario, 1976-1986

"Using data from the 1976, 1981, and 1986 [Canadian] Censuses for Ontario, components of change in the elderly population are obtained by cohort survival methods. The significance of rapid metropolitan growth of the elderly compared with the slow growth of the rural elderly is highlighted, while intra-county distributional shifts in the elderly population raise important questions for the next decade." (SUMMARY IN FRE)

Linking the geographical, the medical and the political in analysing health care delivery systems

The models and methodologies used by medical geographers for analysing health care delivery systems are critically reviewed. As a result, it is argued that an intellectual cul-de-sac has been reached because of the lack of linkage in these models and methodologies that explicitly recognize the socio-cultural and political-economic influences in the environment, where the health care delivery system under study exists. Using the example of abortion services in Canada in general, and Ontario specifically for illustrative purposes, a general model for linking the geographical, the medical and the political aspects of health care delivery is proposed.

Artefactual breast disease: a report of three cases

Three cases of suspected artefactual conditions of the breast are presented, one case each of recurrent bleeding, recurrent infection and atypical eczema. Involvement of the breast is rare, but may go undiagnosed in many cases. Patients are usually married and in the second half of their reproductive life. An unusual pattern of disease appearance and behavior, lack of response to treatment, inappropriate affect and a request for mastectomy are helpful in suggesting the diagnosis. A disturbance in personal relationships can often be elucidated by psychiatric assessment. Treatment is difficult and may be limited to suspecting the diagnosis, excluding organic disease and avoiding unnecessary and repetitive surgery.