The menopause in Europe

Most women in developed countries will live a third of their lives after the menopause. Vasomotor symptoms (hot flushes, night sweats, irritability, sleep disturbances, mood swings), and urogenital complications (atrophic vaginal irritation and dryness, dyspareunia) occur frequently during this period of life, but their severity and duration may vary widely between individuals. The menopause also induces accelerated bone loss and is the principal risk factor for osteoporosis. Hormone replacement therapy (HRT; estrogen or estrogen plus progestogen) alleviates these symptoms and can be administered orally, transdermally, topically, intranasally, or as subcutaneous implants. HRT is also effective for prevention and treatment of postmenosausal osteoporosis throughout the time that it is used. It is not surprising that HRT use has increased substantially during the past decade. Nevertheless, there are still considerable variations in use between different countries within the European community. This presentation will analyze: the frequency of menopausal symptoms among women in different European countries and the factors that influence them; the frequency of other postmenopausal women's health issues in Europe; the use of HRT in Europe as well as the type of HRT and its evolution during the last decade; and possible reasons explaining heterogeneity between countries.

The secondary fungal metabolite gliotoxin targets proteolytic activities of the proteasome

BACKGROUND

The fungal epipolythiodioxopiperazine metabolite gliotoxin has a variety of toxic effects such as suppression of antigen processing, induction of macrophagocytic apoptosis and inhibition of transcription factor NF-kappaB activation. How gliotoxin acts remains poorly understood except that the molecule's characteristic disulfide bridge is important for immunomodulation. As this fungal metabolite stabilizes the NF-kappaB inhibitor IkappaBalpha in the cytoplasm, we decided to investigate its molecular mechanism of action.

RESULTS

We show that gliotoxin is an efficient, noncompetitive inhibitor of the chymotrypsin-like activity of the 20S proteasome in vitro. Proteasome inhibition can be reversed by dithiothreitol, which reduces gliotoxin to the dithiol compound. In intact cells, gliotoxin inhibits NF-kappaB induction through inhibition of proteasome-mediated degradation of IkappaBalpha.

CONCLUSIONS

Gliotoxin targets catalytic activities of the proteasome efficiently. Inhibition by gliotoxin may be countered by reducing agents, which are able to inactivate the disulfide bridge responsible for the inhibitory capacity of gliotoxin.

Bringing together nursing and law: a fitting combination in today's health care environment

Blending careers is an exciting alternative to choosing one profession or another. In this article, the author relates her experiences as a nurse to her current choice of profession, the law. The author used the same principles and interventions developed while nursing in dealing with clients experiencing personal injuries, working on the estate of a client's deceased family member, or helping a client with the many issues that arise with the end of a marriage. The marriage of nursing and law has been a successful partnership. One career builds on the experience and education of the other, allowing the practitioner to offer clients a total package of legal and health care delivery assistance.

Osteoporosis management

About 40% of women who reach the age of 50 are expected to suffer from osteoporosis during their remaining life. The morbidity associated with hip, spinal and wrist fractures, resulting from osteoporosis, and the mortality resulting from hip fractures justify the development of prevention strategies. Optimal management of osteoporosis consists of maximizing peak bone mass in early adulthood and preventing the rapid bone loss that occurs soon after the menopause. Peak bone mass will be reached in most women if adequate nutrition is taken and exercise is encouraged, while major risk factors are avoided. At the menopause, prescription of hormone replacement therapy (HRT) constitutes the primary prevention strategy. There are, however, questions that remain unanswered or debated. What is the optimal dose of HRT, when should it be started, and for how long should it be maintained? In women who do not, or may not, take HRT, and who have osteoporosis, alternative therapeutic options include diphosphonates (e.g., alendronate) and Selective Estrogen Receptor Modulators (such as raloxifene). Other treatments to restore bone strength in women with established disease may also reduce the risk of fractures. Some of them, such as calcitonin, may not be cost effective. Others have produced conflicting data (fluoride) and others are still under evaluation (PTH or strontium). In sunlight-deprived, vitamin D-deficient elderly nursing home residents, dietary supplementation of calcium and vitamin D has been shown to prevent bone loss and fractures. Strategies to avoid falls should also be encouraged for these patients.

Prescription attitudes among gynecologists towards two particular risk factors of osteoporosis: the patient's age and her bone mineral density

OBJECTIVE

The present report assesses, among Belgian gynecologists, the effect of age and bone mineral density on osteoporosis prescription strategy in postmenopausal women.

METHODS

Charts of postmenopausal women were summarized. We constructed cases by modifying some parameters. Ten years of age were added or subtracted to the real age of the patient. The bone mineral density (BMD) result was also modified (three levels: normal BMD, osteopenia, osteoporosis). A total of 612 cases were constructed. Twelve cases were sent out of these 612 files to every Belgian gynecologist (n = 1010). For each chart the gynecologists were asked whether they would treat the patient with HRT. They were also asked whether they would prescribe other therapies than HRT and if so, which ones.

RESULTS

The chance to have an osteoporosis prevention or treatment prescribed increased when BMD decreased (respectively 57.4% for normal BMD, 73.1% for osteopenia cases and 89.4% for osteoporosis cases; P < 0.001). HRT was the most frequently prescribed medication (67% of the cases), but its prescription rate does not reflect only osteoporosis prevention. Nevertheless, for similar cases with osteopenia, the HRT prescription rate increased by a factor 1.25 and for similar cases with osteoporosis, HRT prescription rate increased by a factor 1.39. Calcium was the 2nd most frequent prescribed regimen. It was prescribed in 17% of the cases. A 3.4-fold increase for osteopenia cases and 7.6-fold increase for osteoporosis cases was observed, compared to women with normal BMD. When calcium was prescribed, it was in association with HRT in 64% of the osteopenia cases and in 76% of osteoporosis cases. Other drugs were less often prescribed. For the "younger age group", that is, with a mean age of 55 years, a prescription rate of 82.9% for any osteoporosis regimen was reached, whereas in the age group that was 10 years older a 20% lower prescription rate was reached (62.6%, P < 0.001). This was mostly due to a decrease in HRT prescription.

CONCLUSIONS

Prescription of medication known to reduce osteoporosis occurred more often in cases with low BMD. In the older patients with osteoporosis, gynecologists prescribed HRT less frequently. This was not compensated by a higher prescription rate of other medication.

Inducible degradation of IkappaBalpha by the proteasome requires interaction with the F-box protein h-betaTrCP

Activation of NF-kappaB transcription factors requires phosphorylation and ubiquitin-proteasome-dependent degradation of IkappaB proteins. We provide evidence that a human F-box protein, h-betaTrCP, a component of Skp1-Cullin-F-box protein (SCF) complexes, a new class of E3 ubiquitin ligases, is essential for inducible degradation of IkappaBalpha. betaTrCP associates with Ser32-Ser36 phosphorylated, but not with unmodified IkappaBalpha or Ser32-Ser36 phosphorylation-deficient mutants. Expression of a F-box-deleted betaTrCP inhibits IkappaBalpha degradation, promotes accumulation of phosphorylated Ser32-Ser36 IkappaBalpha, and prevents NF-kappaB-dependent transcription. Our findings indicate that betaTrCP is the adaptor protein required for IkappaBalpha recognition by the SCFbetaTrCP E3 complex that ubiquitinates IkappaBalpha and makes it a substrate for the proteasome.

Managing the climacteric

HRT taken for a sufficient duration may reduce the occurrence of osteoporosis and of cardiovascular disease by up to 50% and possibly also reduce incidence and lessen severity of Alzheimer's disease. Nevertheless, it is often only prescribed when women request it to relieve climacteric symptoms. Furthermore, many physicians prescribe it for only limited periods of time and few are willing to prescribe it to women in their sixties. As with any long-term prevention strategy, the uptake of HRT is much lower than the prescription rate, since the medication is often abandoned due to side effects or due to lack of motivation. But HRT is often abandoned also due to fear of cancer. While physicians may be aware of some beneficial effects of HRT, they often have no time to inform their patients of them. Alternatively, some of the beneficial effects such as cardioprotection or a reduced incidence of Alzheimer's may be less known. Likewise, HRT-related side effects or risks such as breast cancer or thromboembolic diseases should be discussed prior to HRT prescription. Women need to be informed about these potential risks, and this should be done by their physician. Surveys have shown that many women feel that they receive insufficient information from their physician. The quality of the relationship between physician and patient probably has a large influence on HRT acceptance, but very few studies have been conducted to assess specifically factors influencing the prescription and the continuation rate of HRT. Simple strategies may be among the most effective ones; these include listening to patients' fears, complaints and questions, and taking the time to answer them. The role of a practice nurse in such a setting may be also very important.

[Pharmacoeconomics of menopause treatments: epidemiological data and hormonal and non-hormonal prescription attitude of Belgian gynecologists]

In an economic analysis one has not only to consider costs induced by hormonal substitution therapy (HRT) but also its impact health. Different therapy costs will be considered and related to potential benefits on health. HRT decreases the incidence of symptoms of the menopause, the risk of osteoporosis and perhaps the incidence of coronary hearth disease and the risk of Alzheimer disease but probably increases the incidence of breast cancer. For a majority of women, the favorable impact seems to dominate, increasing their life expectancy.

Educating patients about the benefits and drawbacks of hormone replacement therapy

Hormone replacement therapy (HRT) influences many aspects of health: climacteric symptoms, osteoporosis, cardiovascular disease, breast and endometrial cancer, thrombosis and emboli, and Alzheimer's disease. A decision to use HRT may depend on a woman's individual views of the menopausal transition, the postmenopause and its consequences. It is therefore useful that the health provider inquiries about and discusses these issues in a cultural and family context. Health providers and patients should be thoroughly informed about the symptoms associated with hormonal deprivation, the associated risks of osteoporosis and cardiovascular disease, and the potential of HRT to prevent these afflictions. Recent studies suggest that HRT might be particularly beneficial in women who have an increased risk for cardiovascular disease (because of left ventricular hypertrophy, diabetes mellitus, hypertension or hypercholesterolaemia, or because they smoke) or osteoporosis. In women who are undecided about HRT, a low bone mineral density measurement might help convince them to start using, or to continue using, HRT. There is also a need to discuss with the patient the effect of HRT on cancer risk. In most instances, women can be reassured about the risk of endometrial cancer. The risk of breast cancer should be carefully considered and discussed with each patient before beginning HRT. In most cases, HRT should not be withheld because of fears about breast cancer, because the protective effects of HRT against cardiovascular disease and osteoporosis outweigh the possible increased risk of breast cancer. When HRT is prescribed, individual regiments should be discussed with the patient, who must be warned of the possible adverse effects. In older women, HRT can be started at half the normal dosage and tolerability assessed before increasing the dosage further.

Engineering of betabellin-15D: a 64 residue beta sheet protein that forms long narrow multimeric fibrils

The betabellin target structure is a beta-sandwich protein consisting of two 32 residue beta-sheets packed against one another by interaction of their hydrophobic faces. The 32 residue chain of betabellin-15S (HSLTAKIpkLTFSIAphTYTCAV pkYTAKVSH, where p=DPro, k=DLys, and h=DHis) did not fold in water at pH 6.5. Air oxidation of betabellin-15S provided betabellin-15D, the 64 residue disulfide bridged two-chain molecule, which also remained unfolded in water at pH 6.5. By circular dichroic spectropolarimetry, the extent of beta structure observed for betabellin-15D increased with the pH and ionic strength of the solution and the betabellin-15D concentration. By electron microscopy, in 5.0 mM MOPS and 0.25 M NaCl at pH 6.9, betabellin-15D formed long narrow multimeric fibrils. A molecular model was constructed to show that the dimensions of these betabellin-15D fibrils are consistent with a single row of beta-sandwich molecules joined by multiple intersheet H-bonds.

Ecological studies of relation between hospital policies on neonatal vitamin K administration and subsequent occurrence of childhood cancer

OBJECTIVE

To investigate the possible link between neonatal administration of intramuscular vitamin K and childhood cancer.

DESIGN

Ecological studies comparing incidence of cancer in groups of children classified by the vitamin K policy in operation at their hospital of birth.

SETTING

Selected large maternity units in England, Scotland, and Wales.

SUBJECTS

Children born in these units in varying periods between 1966 and 1991.

MAIN OUTCOME MEASURES

Cancer occurring among these children before age 15 years identified by using the National Registry of Childhood Tumours. Ratios of observed to expected numbers of these conditions calculated for hospitals where the policy was to give all babies intramuscular vitamin K (non-selective) and where the policy was to use this treatment only for a selected minority of babies at increased risk of vitamin K deficiency bleeding (selective).

RESULTS

These ratios were calculated for children born in 94 hospitals with varying vitamin K policies. A raised risk was occasionally associated with vitamin K, but the overall results were not significant, and there was no evidence to support the previously suggested doubling of the risk of childhood cancer.

CONCLUSIONS

On the basis of the results reported here it is unlikely that there is a greatly increased risk of childhood cancer attributable to intramuscular vitamin K given to newborns, if indeed there is any.

Case-control studies of relation between childhood cancer and neonatal vitamin K administration

OBJECTIVE

To investigate the possible link between neonatal administration of intramuscular vitamin K and childhood cancer.

DESIGN

Matched case-control study.

SETTING

Selected large maternity units in England and Wales.

SUBJECTS

Children with cancer born 1968-85, diagnosed 1969-86; controls matched for sex, month of birth, and hospital of birth.

MAIN EXPOSURE MEASURES

Neonatal administration of vitamin K, length of gestation, birth weight, type of delivery, admission to special care baby unit.

RESULTS

After exclusion of cases with missing notes or unknown hospital vitamin K policy, 597 cases and matched controls were studied. Written records on the use of vitamin K were available for only about 40% of these, and to avoid possible bias from selective recording it was assumed that the stated hospital policy was followed. The association between cancer generally and intramuscular vitamin K was of borderline significance (odds ratio 1.44, P = 0.05); the association was strongest for leukaemia. There was, however, also an effect of abnormal delivery, which could explain some of the findings.

CONCLUSIONS

The lack of consistency between the various studies so far published, including this one, and the low relative risks found in most of them suggest that the risk, if any, attributable to the use of vitamin K cannot be large, but the possibility that there is some risk cannot be excluded. A comparison of the predicted consequences of various policies shows that even a 10% increase would imply that prophylaxis using the commonly recommended 1 mg intramuscular dose should be restricted to babies at particularly high risk of vitamin K deficiency bleeding; alternatively a lower dose might be given to a larger proportion of those at risk.

Detection of CBFbeta/MYH11 fusion transcripts in patients with inv(16) acute myeloid leukemia after allogeneic bone marrow or peripheral blood progenitor cell transplantation

We evaluated the occurrence of the CBFbeta/MYH11 fusion transcripts by PCR analysis in 10 patients with inv(16)(p13;q22) acute myeloid leukemia (AML) who underwent allogeneic bone marrow transplantation (BMT) (n = 5), peripheral blood progenitor cell transplantation (PBPCT) (n = 3), or autologous transplantation (n = 2). In addition to the analysis of minimal residual disease (MRD), the chimerism status of patients after allogeneic transplant was studied by PCR. The CBFbeta/MYH11 fusion transcript was not detectable in six of seven patients who remained in remission after allogeneic BMT or PBPCT. Two of these patients in remission were monitored for 50 months and 64 months post-BMT. One patient in remission was PCR-positive for CBFbeta 3 months post-BMT in a single BM sample, but not in a simultaneously examined blood sample, suggesting that analyses from BM samples are more sensitive than those from blood samples. Sequential PCR assays performed 6 and 12 months post-BMT obtained from the same patient were negative. Another patient with a positive PCR assay 3 months post-allogeneic PBPCT, remained PCR positive for the CBFbeta/MYH11 fusion transcript when tested 6 months post-PBPCT. A chimerism analysis by PCR revealed a mixed chimerism status in this patient. He relapsed 7 months post-transplant. Before transplant, in all nine patients who were in complete remission of AML (eight patients in 1CR, one patient in 2CR), the CBFbeta/MYH11 transcript was detectable. In one patient in relapse, the fusion transcript was not only detectable in blood and bone marrow, but also in a cerebrospinal fluid sample prior to transplant. Two patients who received autologous BMT were monitored for CBFbeta/MYH11 transcripts 3 months after BMT. The CBFbeta/MYH11 was detected in these patients. Both patients subsequently relapsed 3 months and 23 months post-autologous BMT. The results study show that analysis of the CBFbeta/MYH11 fusion transcript by PCR seems to be a suitable method for monitoring minimal residual disease in AML patients with inv (16).

The carboxy-terminus of I kappaB alpha determines susceptibility to degradation by the catalytic core of the proteasome

The Rel/NF-kappaB family of transcription factors controls the expression of a wide variety of genes that are implicated in immune and inflammatory responses and cellular proliferation. Disregulation of NF-kappaB is associated with cellular transformation and the maintenance of a high anti-apoptotic threshold in transformed cells. NF-kappaB activity is in turn regulated by its sequestration in the cytoplasm by the inhibitor I kappaB. I kappaB alpha, the most abundant and well-characterized member of the I kappaB multiprotein family, is rapidly degraded in response to multiple physiologic stimuli. In the present study we show that not only the amino-terminus, but also the carboxy-terminus of I kappaB alpha contain transferable signals that must be simultaneously present in an unrelated protein to render it susceptible to activation-induced, proteasome-mediated degradation. We show here that I kappaB alpha amino-terminal modifications occur independently of the carboxy-terminus. Moreover, we present evidence indicating a critical role for the carboxy-terminal region in facilitating proteolysis by the catalytic core of the proteasome. When incubated with 20S proteasome extracted from rat liver, I kappaB alpha was quickly degraded while a deletion mutant lacking the carboxy-terminus was resistant to proteolysis. Likewise, chimeric proteins of beta-galactosidase with the I kappaB alpha carboxy-terminus were degraded in vitro independently of the presence of the I kappaB alpha amino-terminus, whereas chimeric proteins lacking the I kappaB alpha carboxy-terminus were stable. Our results identify the carboxy-terminus of I kappaB alpha as a domain critical for degradation through interaction with an as yet unidentified component of the proteasome.

Postoperative radiotherapy of spinal and intracranial ependymomas: analysis of prognostic factors

PURPOSE

Postoperative radiation therapy adds significantly to disease control and survival of patients with ependymoma. However, much controversy exists about the radiation treatment policy. We report the long-term results of a cohort of 56 patients with primary intracranial and spinal ependymomas. Special effort has been taken to define prognostic indicators as a basis for future treatment strategies.

PATIENTS AND METHODS

Between November 1963 and May 1995, 56 patients with histological proven ependymoma were referred to our clinic for further treatment following surgery. Thirty patients had a high grading tumor and 26 had low grade tumors. Seventeen patients had supratentorial tumors and 24 had infratentorial tumors. Fifteen patients suffered from localized spinal tumors.

RESULTS

The mean survival time for all patients was 77 months. Five- and 10-year survival probabilities were 60 and 51%, respectively. The mean progression free survival (PFS) probability for all patients was 67 months with corresponding 5- and 10-year PFS probabilities of 53 and 39%, respectively. On univariate analysis initial performance status, age and tumor grade were significant for survival probability. Concerning PFS radiation dose was significant with improved survival with doses > 45 Gy. On multivariate analysis, tumor grade and initial performance status proved to be the only independent prognostic factors.

CONCLUSIONS

Tumor grade, age, initial performance status and radiation dose are significant factors for the clinical course of patients and have to be taken into account for the urgently needed prospective trials.

Efficiency and productivity of a sheathed fiberoptic sigmoidoscope compared with a conventional sigmoidoscope

PURPOSE

The aim of this study was to measure and compare time and productivity between a new sheathed flexible sigmoidoscope and a traditional fiberoptic flexible sigmoidoscope relative to labor and cost analysis.

METHODS

Two flexible sigmoidoscopes, the Vision Sciences sigmoidoscope using a protective sheath covering requiring removal and replacement between procedures and a conventional flexible sigmoidoscope requiring meticulous cleaning using a washer and high-level disinfection, were compared. Sigmoidoscope preparation was defined as the average time between the procedures (reprocessing, start to finish) and was measured by an independent nonmedical timekeeper JG). The parameter recorded was scope reprocessing time.

RESULTS

Ten procedures were performed using the sheathed flexible sigmoidoscope system compared with nine using a conventional sigmoidoscope. Scope performance and endoscopic visualization for both systems were comparable. The average reprocessing time was 46.8 minutes for the conventional sigmoidoscope vs. 4.9 minutes for the sheathed sigmoidoscope (P < 0.0001). The average time saved was 9.5 times greater with the sheathed flexible sigmoidoscope system than with the conventional sigmoidoscope.

CONCLUSION

The almost tenfold difference in the time saved using the sheathed flexible sigmoidoscope system represents increased productivity and potentially decreased overall labor cost. By reducing endoscope turnover time, this new sheathed system can reduce or even eliminate the need for backup endoscopes and endoscope washers and potentially allow better use of nursing staff.

Factors influencing the prescription of hormone replacement therapy

OBJECTIVE

To assess the effects of age, bone mineral density, risk of cardiovascular disease, and of breast cancer on the prevalence of hormone replacement therapy (HRT) prescriptions.

METHODS

Seventeen charts of postmenopausal women were summarized. For each chart, we constructed 36 different cases by modifying the age (two levels), the bone mineral density (three levels), the cardiovascular risk (three levels), and the breast cancer risk (two levels). Twelve cases of these 612 files were sent to each Belgian gynecologist (n = 1010).

RESULTS

Overall, HRT was prescribed in 67% of the cases. It was prescribed in 54.6% of women who had a normal bone mass, 67.9% of women with a low bone mass, and 79.0% of those with osteoporosis (P < .001). The prescription rate was higher in younger women (mean +/- standard deviation 55 +/- 4 years) than in their peers who were 10 years older (79.3% versus 55.2%; p < .001). No significant variation was observed in relation to the cardiovascular risk profile or to breast cancer risk.

CONCLUSION

Osteoporosis is associated with an increased rate and older age with a decreased rate of HRT prescription, whereas no difference is observed in association with cardiovascular or breast cancer risk.

Analysis of the DNA sequence of a 34,038 bp region on the left arm of yeast chromosome XV

We report the DNA sequence of a 34,038 bp segment of Saccharomyces cerevisiae chromosome XV. Subsequent analysis revealed 20 open reading frames (ORFs) longer than 300 bp and two tRNA genes. Five ORFs correspond to genes previously identified in S. cerevisiae, including RPLA2, PRE6, MSE1, IFM1 and SCM2 (TAT2, TAP2, LTG3). Two putative proteins share considerable homology with other proteins in the current data libraries. ORF O2145 shows 41.2% identity with the glycophospholipid-anchored surface glycoprotein Gas1p of S. cerevisiae and ORF O2197 has 53.2% identity to chromosome segregation protein Dis3p of Schizosaccharomyces pombe.

The brittle bone: how to save women from osteoporosis

For a woman, the risk of suffering an osteoporotic fracture during her lifetime is higher than the combined risk of breast, endometrial, and ovarian cancer. It is important to reduce the number of osteoporosis-related fractures. Therefore, it is necessary to emphasize various interventions and attitudes which will decrease both the risk of falling and that of breaking bones. Strategies should be followed to reach adulthood with an optimal bone mass through improved diet and exercise during childhood. Programs that identify women with the lowest bone mass at the time of menopause may be useful, since prophylactic measures against osteoporosis such as hormone replacement therapy (HRT) can be offered to them. Identification of women at risk can be achieved through bone densitometry; a decrease of each standard deviation of bone mineral mass below mean values predicts a doubling of the fracture risk. Some data suggest that physicians are more willing to prescribe HRT specifically to women with the lowest bone mass, and that the latter are more likely to stay on therapy for longer periods of time. The decision to use HRT should be taken by the patient after proper information of all benefits (diminished climacteric symptoms, decrease of cardiovascular risk) and potential risks (possible enhanced breast cancer risk, appearance of side effect). In women who do not want to take HRT, or for whom contraindications exist, alternative medications, such as calcium, vitamin D and biphosphonates can be considered, depending on fracture risk. For older and institutionalized women, programs should be developed to decrease the risk of falling. Likewise, it may be possible to reduce the consequences of a fall, for instance by promoting the development of energy-absorbing hip pads, which reduce fracture risk.

Effect of bone density evaluation on hormone replacement therapy prescription

OBJECTIVES

This study evaluates whether Bone Mineral Density (BMD) results influence HRT prescription.

METHODS

Successive charts of 29 postmenopausal women were summarised. For each chart, 3 'simulated cases' were created by modifying the BMD result (based on the Z-score) in order to have 4 groups with the same clinical story but a wide range of BMD values (Group I = Z-score > 0, Group II = Z-score between 0 and -1, Group III = Z-score between -1 and -2 and Group IV = Z-score < -2). The obtained cases were presented to 10 gynaecologists who were asked whether HRT should be prescribed. The gynaecologists were not aware of the above-mentioned manipulation.

RESULTS

The overall treatment rate was 74.2%, ranging from 65% for women with the highest BMD (Group I), 73% for Group II, 79% for Group III and 80% for Group IV, i.e. women with the lowest BMD (Friedman analysis of variance; chi-square 17.2; P < 0.001). In approximately a third of the patients (11/29), there was agreement for initiation of therapy, regardless of the BMD. Most of these women presented other indications and no contra-indications for therapy. The prescription frequency of the 10 gynaecologists varied between 63% and 87%; Cochran Q Statistic 39.2; P < 0.0001). For some physicians, a trend to increase prescription was observed in relation to the BMD result, but a statistical difference could only be reached for one physician (P < 0.05). Furthermore, for some physicians no modification whatsoever could be observed.

CONCLUSIONS

BMD appears to be a determinant factor for HRT prescription in only a limited proportion of the patients and a small number of the physicians. From an epidemiological point of view, BMD measurements may be useful in order to help deciding women to start HRT, especially those who are reluctant or to those who present relative contra-indications, provided that their physicians are aware of the usefulness of these investigations.

Bone sialoprotein expression in primary human breast cancer is associated with bone metastases development

Breast cancer metastasizes to bone more frequently than to any other organ, and over 80% of advanced breast cancer patients develop bone metastases. Our recent demonstration that human breast cancer cells express bone sialoprotein (BSP), a bone matrix protein, provides a possible clue for the selective affinity of breast cancer cells for bone. We tested the hypothesis that detection of BSP in primary human breast cancer could be a potential indicator of the ability of breast cancer cells to metastasize to bone. BSP expression was evaluated in the primary breast cancers of 39 patients using immunoperoxidase and two specific anti-BSP antibodies. None of these patients presented clinically or scintigraphically detectable bone metastases at the time of surgery. In the course of their disease, 22 patients developed clinically diagnosed bone metastases. Expression of BSP in breast cancer cells from patients who developed bone metastases was significantly higher (p = 0.008, according to the Mann-Whitney test) than in patients with no bone involvement. No association was found between BSP expression in the primary breast lesions and axillary lymph node metastases. BSP expression was significantly increased in infiltrating ductal carcinoma compared with infiltrating lobular carcinoma (p = 0.0023). No correlation was found between immunoreactivity to BSP antibodies and estrogen receptor (ER) status, progesterone receptor (PR) status, or age. Our data suggest that BSP could help to identity which women will develop bone metastases and provide new bases for the understanding of the molecular mechanism(s) responsible for breast cancer cells osteotropism.

Principal cancers among women: breast, lung and colorectal

The major variations in the pattern and level of cancer throughout the world reflect for the most part differences in the environment. It is generally agreed that carcinogenesis may arise as a result of chemical, physical, biologic, and genetic insults to cells. In addition, specific external factors may initiate and/or support malignant transformation, such as smoking, occupational and environmental chemicals, radiation, dietary factors, and specific viruses. Furthermore, endogenous compounds, such as steroid sex hormones, may be promoters for carcinogenesis of hormone-dependent tissue. Although some cancers seem to be related to inherited traits, research generally does not support the notion of group or inherited differences in cancer statistics. The leading causes of cancer death in females in 1991 in the United states were lung cancer (52,068), breast cancer (43,583), and colorectal cancer (29,017). According to the American Cancer Society, this year 182,000 women will be diagnosed with breast cancer, 73,900 with lung cancer, and 66,000 with colorectal cancer. Even with our knowledge about the influence of life style and environmental causes of cancer, little progress has been made. In breast cancer, only 25 to 30% can be attributed to known risk factors. Lung cancer in females, on the other hand, once a rare disease, turns out to be the leading cause of cancer death among women in industrialized countries, mostly due to smoking.

Osteoporosis prevention and treatment with sex hormone replacement therapy

Oestrogen deficiency is by far the major factor contributing to the high rate of osteoporotic fractures in women. The anti-osteoporotic effect of estrogen may be explained by its property to regulate cytokine secretion and thus balance bone remodeling. In oestrogen deficiency, increased resorption and remodeling will occur leading to osteoporosis. It has been extensively shown that oestrogen replacement therapy (ERT) prevents postmenopausal bone loss and reduces fracture risk by half, provided that an appropriate dose is used. In order to optimize osteoporosis prevention, ERT should be started a early as possible in menopause and be maintained as long as possible. ERT may also be effective in elderly osteoporotic patients in preventing bone loss and, reducing fracture risk. The acceptance of ERT, however, at an older age has not been thoroughly evaluated. A reduction of cardiovascular disease and of climateric symptoms are among other benefits of ERT. So far, only few postmenopausal women are treated with ERT. ERT without progestins has been repeatedly found associated with an increased risk of developing endometrial cancer, but the cyclic addition of progestins protects from endometrial hyperplasia and carcinoma. Combined oestrogen-progestin therapy is as efficient as estrogen therapy alone, but not more so. Since progestins may oppose some of the beneficial effects of estrogens, the lowest dose with the least metabolic impact should be prescribed. Women who have had a hysterectomy, should probably be treated by estrogen replacement therapy only. Meta-analyses concerning breast cancer associated with ERT found a very moderately increased risk (RR = 1.06). Therefore ERT prescription should be discussed openly with women considering all risks and benefits. In women who have suffered from breast cancer, a bone sparing effect of tamoxifen has been shown.

[Compliance with hormone replacement therapy]

Hormone Replacement Therapy (HRT) after menopause reduces climacteric symptoms and increases the quality of life. If correct dosage is used, bone loss can be prevented and fracture frequency reduced. Epidemiological studies also suggest a decreased cardio-vascular mortality among HRT users. A high proportion of post-menopausal women should therefore be treated using long-term therapy, but currently only a small proportion of women use HRT in Belgium, (around 14%). Further their compliance is particularly low. Fear of cancer and drug-related side effects, such as unaccepted bleeding are often mentioned causes of low compliance. Education of both physicians and patients, regarding HRT seems to be a crucial issue. The physician's attitude towards HRT is often reported as negative. Osteoporosis prevention and related bone mass measurements may have a favorable effect on compliance, but this is not well established. Establishing a confidential relationship with patients and the involvement of nursing counseling are strategies which may improve compliance. The use of easy-to-take medications supported by calendar blisters or reminders, may facilitate chronic use of medication. Future research needs to investigate the physician's and the patient's decision-making process.

Overview of the clinical usefulness of bone mineral measurements in the prevention of postmenopausal osteoporosis

Bone mass measurements might be useful in two ways in prevention of postmenopausal osteoporosis: the decision to start HRT, or other therapy, could be based on such measurements; and, possibly, compliance to treatment would be enhanced. Bone density measurement appears to have sufficient predictive value for osteoporotic fracture, especially when density is measured by dual-energy X-ray absorptiometry. However, choice of skeletal site for the measurement cannot be made with certainty, although a vertebral site may be best early in menopause; and in women with osteophytes or scoliosis, and with older women, the femur or wrist may be preferred. With respect to enhancement of patients' compliance to HRT, as well as clinicians' willingness to prescribe treatment, it has not yet been clearly shown that bone mass measurements have a significant effect. This topic involves economic efficiency and should be evaluated by considerations of economics weighted against medical efficacy.

Osteoporosis prevention with sex hormone replacement therapy

It was suggested as long ago as 1941 that there might be a connection between the menopause and osteoporosis. Since then, abundant data have confirmed that hypothesis as well as showing that such osteoporosis may be prevented by estrogen supplementation (ERT--estrogen replacement therapy). In estrogen deficiency, increased bone resorption takes place in the process of bone remodeling, leading to bone loss. The bone loss occurs universally but to the greatest extent at sites rich in trabecular bone. There are uncertainties concerning extent of bone loss at various sites at different ages, effect of ERT at varying sites and different ages, degree of fracture prevention, and relationship between duration of therapy and fracture risk. That optimal fracture risk is not being attained now on a population basis is due to apparently low acceptance of ERT by patients and lack of strenuous effort in that direction by physicians.

A tool for measuring functional outcomes after total hip arthroplasty

PURPOSE

To describe a functional milestone scale (FMS) for measuring functional progression following total hip arthroplasty and to demonstrate that this scale meets accepted standards of scale construction.

METHODS

Inter-observer reliability of the scale was determined for 30 patients using a kappa coefficient of concordance (k) for ordinal data, representing 221 pairs of observations. There were 79, 54, 44, and 44 pairs of observations for transfer, walker, crutch, and stair ambulation, respectively.

RESULTS

The k coefficient ranged from 0.82 to 0.91. Agreement between therapists was almost perfect according to the criteria of Feinstein.

CONCLUSIONS

The FMS exhibits substantial inter-observer reliability and moderate to substantial validity. We have demonstrated its clinical applications as well as showing it to be a useful management and research tool.

Liposome-based flow-injection immunoassay for determining theophylline in serum

We developed a method for quantitatively determining theophylline in serum, using a heterogeneous immunoassay called flow-injection immunoanalysis. The reaction involves competition between serum theophylline and theophylline-labeled liposomes. Separation occurs on a solid-phase reactor column containing immobilized antibody to theophylline incorporated in a flow-injection system. Subsequent lysis of the bound liposomes provides sensitive detection of the analyte. Effective regeneration of the immobilized antibody activity allows the reactor to be reused for hundreds of sequential samples. Comparison of the results of the flow-injection immunoassay method with results obtained with a commercially available fluorescence polarization method showed an excellent correlation.

Liposome-based flow-injection immunoassay for determining theophylline in serum

We developed a method for quantitatively determining theophylline in serum, using a heterogeneous immunoassay called flow-injection immunoanalysis. The reaction involves competition between serum theophylline and theophylline-labeled liposomes. Separation occurs on a solid-phase reactor column containing immobilized antibody to theophylline incorporated in a flow-injection system. Subsequent lysis of the bound liposomes provides sensitive detection of the analyte. Effective regeneration of the immobilized antibody activity allows the reactor to be reused for hundreds of sequential samples. Comparison of the results of the flow-injection immunoassay method with results obtained with a commercially available fluorescence polarization method showed an excellent correlation.

[The effect of topical heparin on histamine-induced wheals. A double-blind study]

Since it is difficult to demonstrate the effectiveness of heparin-containing ointments in the treatment of thrombophlebitis under clinical conditions, a double-blind experimental trial was performed in 18 volunteers. To produce a reproducible inflammation, ten drops of a histamine solution containing 10 mg histamine/100 ml, were applied to an area measuring 4 x 7 cm2 on both forearms of each test subject. Under each drop, the skin was pricked five times. Ten minutes after induction of inflammation, one forearm of each subject was treated in a double-blind randomized manner with an ointment containing heparin (50,000 IU heparin/100 g), the other arm being treated with the heparin-free ointment base. As a criterion of the effectiveness of the ointment, the course of the temperature of the forearms was measured using thermography. Ten minutes after application of the histamine solution, the temperature increased by a mean of about 3 degrees centigrade. After 30 minutes' treatment with heparin-containing ointment, the temperature then decreased by 1.77 degrees C, while that of the forearms treated with heparin-free ointment base decreased by only 1.14 degrees C. The difference was statistically significant (p less than 0.001). Sixty minutes after treatment the differences were still significant at p = 0.012. This study thus demonstrates the effectiveness of heparin-containing ointment in the treatment of histamine-induced inflammation.

Does tourniquet use during anterior cruciate ligament surgery interfere with postsurgical recovery of function? A review of the literature

This article explores the issue of whether use of a tourniquet during arthroscopically assisted repair of the anterior cruciate ligament (ACL) slows the postoperative recovery of function. A tourniquet is customarily used to provide a bloodless field, thus enabling the surgeon to visualize the joint clearly. However, there is increasing evidence that tourniquets cause muscle and nerve damage that can have long-term consequences for the recovery of function following surgery. The two randomized trials that investigated tourniquet use during meniscectomy reached contradictory conclusions about the effects of the tourniquet. There have been no randomized trials of tourniquet use during the longer and more complex ACL surgery. This article reviews the pertinent literature and suggests some clinical implications of the available information.

Twenty-four-hour profiles of growth hormone, prolactin and cortisol in the chronic vegetative state

The 24-h profiles of growth hormone (GH), prolactin (PRL) and cortisol were obtained from 11 patients in the chronic vegetative state in order to gain more insight into the neuroendocrine alterations caused by widespread suprahypothalamic brain damage. Age and sex-matched normal subjects served as a control group. Patients had fewer high-amplitude GH peaks (greater than 20 mU/l: 6 peaks/24 h vs 21 peaks/24-h in controls) and a (non-significant) tendency towards higher basal GH concentrations. PRL concentrations were higher in patients (296 +/- 212 (SD) vs 120 +/- 28 mU/l). Cosinor analysis also showed that 24-h rhythmicity was preserved, but acrophases were more dispersed. A nocturnal PRL acrophase occurred in only three of 11 patients but in 10 of 11 control subjects. The number of PRL peaks was the same in patients and controls. Cortisol concentrations were also higher in patients (298.3 +/- 114.6 vs 193.6 +/- 97.4 nmol/l) with a preserved circadian rhythm. The acrophases, however, were likewise more dispersed. There was no difference in the number of cortisol peaks between patients and controls, but the mean peak duration was shorter in patients (75.4 +/- 28.1 vs 109.5 +/- 28.2 min). The stage of remission was negatively correlated with the 24-h mean and the mean peak amplitude of PRL. No patient showed a normal organization of sleep stages. On visual analysis there was no apparent association between EEG patterns and hormonal parameters. These results suggest that the endocrine hypothalamus is essentially intact in the chronic vegetative state. The observed changes may be due to an altered input from extrahypothalamic brain structures.

Serum enzyme, myoglobin and muscle strength relationships in polymyositis and dermatomyositis

Strength of the quadriceps and hamstring groups was biomechanically assessed in terms of isometric torque production in 14 patients with inflammatory myopathy. Eleven had polymyositis and 3, dermatomyositis. Determinations of serum creatine kinase, lactate dehydrogenase, transaminase, and myoglobin were simultaneously obtained over an average period of observation of 1.8 years. In certain individual patients, there were significant correlations between laboratory indices and strength during the entire course of illness. In others, this was not the case. In the total group of patients, absolute values of the laboratory indices did not correlate well with strength except in the case of serum myoglobin, where there a significant inverse relationship. Logarithmic transformations of the laboratory data increased the inverse correlations. High strength and low myoglobin were related to high prednisone dose. Since laboratory guides are not always related to disease activity, quantitative assessment of muscle strength is necessary.

[Malignant fibrous histiocytoma. Prognostic value of the histological findings]

Surgical specimens after excision of malignant fibrous histiocytomas from 41 patients were classified histologically according to subtype; semiquantitatively by cell content, mitosis count, necrosis tendency and cell polymorphism; and "subjective grading". There was no significant difference in survival time between storiform-pleomorphic and myxoid subtypes. The marked scatter in the storiform-pleomorphic subtype reflects the inhomogeneity of this group. Analysis of the individual semiquantitative criteria gave better results. Cases with many mitoses, many necroses, marked cell polymorphism and high cell content had significantly shorter survival times than those with less marked changes. "Subjective grading" was also of prognostic value. However, overlapping of prognostic factors and limitations due to tumour biology allow of only a rough orientating prediction based on histological assessment of malignancy grade.

Torque-velocity relationships of the knee extensor and flexor muscles in individuals sustaining injuries of the anterior cruciate ligament

Muscle deficits in 58 patients with chronic anterior cruciate ligament (ACL) insufficiency were evaluated after completion of a 6 month rehabilitation program. Quadriceps and hamstring torques were measured on a modified Cybex II isokinetic dynamometer. Twenty-nine of our patients were tested just prior to undergoing ACL reconstruction, and patients who were continuing to tolerate their conditions served as controls. For the surgical group, significant quadriceps deficits (P less than 0.01) were found for all speeds and at both the 30 and 60 degrees positions. The nonsurgical group had significant deficits at the 30 degrees position at 180 degrees/sec, and at 60 degrees for the 0 degree/sec and 30 degrees/sec. However, in comparing the two groups no significant differences were noted. Regarding hamstring deficits in the surgical group, significant deficits were seen only at 30 degrees of flexion at 180 degrees/sec. The nonsurgical group had similar deficits. Of interest was the observation that the hamstring:quadriceps (H:Q) ratio was found to be both speed-position dependent. Overall, no correlation was found between the presence of strength deficits following a rehabilitation program and the need for surgery.

Dissociation of light onset and wake onset: effect on rhesus monkey growth hormone secretion

Synchronization of GH-secretory episodes occurs at light onset in the rhesus monkey and is later lost during the 24-h day. The stimulus for this synchronization was studied in nine male adult monkeys prepared with chronic jugular catheters. In a first experiment, light onset was delayed by 2 h (from 0600 to 0800 h) on days 2-6 and returned to 0600 h on day 7. The animals were allowed to sleep on during the additional time of darkness. The early morning GH peak was immediately shifted to the new light-onset times, both after introduction of the delay and after its reversal. In a second experiment, the animals were awakened in darkness during a similar light-onset delay. Now the GH peaks constantly occurred at the time of awakening shortly after 0600 h, and no GH peak was seen after light onset at 0800 h. Neither experimental condition had an influence on the patterns of plasma PRL and cortisol. These results suggest that the early morning synchronization of the GH-secretory pattern in the rhesus monkey is triggered by awakening and not by light onset.