The purpose of this study was to compare 136 frontier and 148 urban patients with chronic heart failure who were aged 60 years and older. Medical records from 2000 to 2002 were reviewed from a regional tertiary hospital in Montana. While the two groups did not differ with respect to New York Heart Association functional class and number of comorbid conditions, the frontier sample was more likely to be male, married, and younger. Frontier patients were more depressed and scored significantly lower on quality-of-life measures. Among those who had died, frontier patients survived an average of 7.7 months, in contrast to urban patients who survived an average of 13.4 months following index hospitalization. Frontier patients have few available health care services and providers may not treat patients as expertly or aggressively as urban providers. Frontier patients tend to be isolated due to illness, lack of transportation, travel distances, and weather-related barriers. Many may be falling through the cracks.

Our belief that plasma proteins participate actively in the complex internal protein metabolism of the body should be adequate reason for our continued interest in blood plasma protein regeneration. It appears that the plasma can contribute protein readily to body tissues or body stores, but only in small amounts and with difficulty can the body contribute protein to the blood plasma--for example in fasting. Theterm "dynamic equilibrium" has been used to express the ebb and flow between plasma, organ, and tissue proteins. When reserve stores are exhausted the blood plasma production depends almost wholly upon food factors coming into the body from the intestine (16, 13, 9).Reserve stores under ordinary conditions are adequate to tide the body over any emergency call for new formed plasma proteins. A study of the reserve stores is in progress and it is probable that the stores of materials from which plasma proteins can be fabricated are distinct from the stores of hemoglobin building material.Infection can inhibit the formation of hemoglobin in anemia (17) and in like fashion it can inhibit the formation of plasma protein (Tables 3 and 3-a and Chart A below) during plasmapheresis. The mechanism of this interesting reaction is discussed below.