Breast cancer: diagnosis, treatment and prognosis

This article reviews staging of breast cancer and treatment protocols for the disease, then examines several different types of breast cancer. Each type is described in terms of its mammographic, sonographic and histologic appearance, along with its treatment and prognosis. The author concludes with a discussion of magnetic resonance imaging's role in breast cancer detection and treatment planning.

Modelling the potential impact of population-wide periconceptional folate/multivitamin supplementation on multiple births

OBJECTIVE

To develop a model of the impact of population-wide periconceptional folate supplementation on neural tube defects and twin births.

DESIGN

A hypothetical cohort of 100,000 pregnancies > or =20 weeks, plus terminations of pregnancy after prenatal diagnosis before 20 weeks.

METHODS

Application of pooled data on the relative risks for neural tube defects and twins following periconceptional folate from meta-analysis of the randomised trials.

MAIN OUTCOME MEASURES

1. Pregnancies with a neural tube defect (i.e. terminations of pregnancy, perinatal deaths, and surviving infants); 2. twin births (i.e. preterm births, perinatal deaths, postneonatal deaths, birth defects, cerebral palsy); 3. numbers needed to treat.

RESULTS

The change in neural tube defects would be 75 fewer terminations (95% CI -47, -90), 30 fewer perinatal deaths (95% CI 18, -35), and 13 fewer surviving infants with a neural tube defect (95% CI -8, -16). The change in twinning would be an additional 572 twin confinements (95% CI -100, +1587), among whom there would be 63 very preterm twin confinements (95% CI -11, +174), 54 perinatal and postneonatal deaths (95% CI -9, +149), 48 surviving twins with a birth defect (95% CI -8, +133), and nine with cerebral palsy (95% CI -2, +26). The numbers needed to treat for the prevention of one pregnancy with a neural tube defect is 847, for the birth of one additional set of twins is 175, for the birth of one additional set of very preterm twins is 1587, and for the birth of an additional twin with any of the following outcomes (perinatal death, postneonatal death, survival with a birth defect, or survival with cerebral palsy) is 901.

CONCLUSIONS

Monitoring rates of neural tube defects and twinning is essential as supplementation or fortification with folate is implemented.

L-threo-dihydroxyphenylserine (L-threo-DOPS; droxidopa) in the management of neurogenic orthostatic hypotension: a multi-national, multi-center, dose-ranging study in multiple system atrophy and pure autonomic failure

This study was designed to determine the efficacy and tolerability of increasing doses of L-threo-dihydroxyphenylserine (L-threo-DOPS) in treating symptomatic orthostatic hypotension associated with multiple system atrophy (MSA) and pure autonomic failure (PAF). Following a one-week run-in, patients (26 MSA; 6 PAF) with symptomatic orthostatic hypotension received increasing doses of L-threo-DOPS (100, 200 and 300 mg, twice daily) in an open, dose-ranging study. Incremental dose adjustment (after weeks two and four of outpatient treatment) was based on clinical need until blood pressure (BP), and symptoms improved. Final dosage was maintained for six weeks. With L-threo-DOPS, systolic BP decrease was reduced during orthostatic challenge (-22+/-28 mm Hg reduction from a baseline decrease of 54.3+/-27.7 mm Hg, p = 0.0001, n = 32; supine systolic BP at final visit was 118.9+/-28.2 mm Hg). By the end of the study, 25 patients (78%) improved, and in 14 patients (44%) orthostatic hypotension was no longer observed. Decreased orthostatic systolic BP decrease occurred in 22% (7/32), 24% (6/25) and 61% (11/18) of patients treated with 100, 200, and 300 mg L-threo-DOPS twice daily, respectively. An improvement occurred in symptoms associated with orthostatic hypotension, such as light-headedness, dizziness (p = 0.0125), and blurred vision (p = 0.0290). L-threo-DOPS was well tolerated, with the 2 serious adverse events reported being a possible complication of the disease under study, and with no reports of supine hypertension. In conclusion, L-threo-DOPS (100, 200, and 300 mg, twice daily) was well tolerated. The dosage of 300 mg twice daily L-threo-DOPS seemed to offer the most effective control of symptomatic orthostatic hypotension in MSA and PAF.

The metabolic, catecholamine and cardiovascular effects of exercise in human sympathetic denervation

The cardiovascular and metabolic responses to supine leg exercise were measured in 9 healthy subjects (controls) and in 19 subjects with two primary forms of autonomic failure (11 with peripheral sympathetic denervation [pure autonomic failure; PAF], 8 with central sympathetic failure [multiple system atrophy; MSA]). With exercise, blood pressure increased in controls and fell markedly in subjects with PAF and MSA. Blood pressure returned to baseline in controls, but remained low in the PAF and MSA groups. With exercise, heart rate increased more in controls than the PAF and MSA groups. Resting plasma noradrenaline concentrations in controls and in subjects with MSA were similar, but were lower in subjects with PAF. With exercise, plasma noradrenaline concentrations increased in controls and were unchanged in subjects with PAF; there was no significant increase in the MSA group. Resting plasma lactate, pyruvate and lactate/pyruvate ratios were similar in all three groups. With exercise, lactate concentrations increased until 2 minutes post exercise in all groups. Pyruvate concentrations after 9 minutes' exercise were higher in controls than in the PAF group but were similar to the MSA group; thereafter, concentrations increased similarly in all groups. The lactate/pyruvate ratio increased until 2 minutes post exercise in all groups. Resting plasma free fatty acids, and beta-hydroxybutyrate were similar in all groups. Plasma glycerol concentrations in control and MSA subjects were similar; concentrations were lower in PAF subjects. With exercise, plasma free fatty acids and glycerol concentrations remained unchanged in all groups; beta-hydroxybutyrate concentrations decreased less in control subjects than in PAF and MSA subjects. In conclusion, there were similar concentrations of plasma free fatty acids, glycerol and beta-hydroxybutyrate in control, PAF and MSA subjects; this could indicate up-regulation of beta-receptors in AF, or that sympathetic activity plays a smaller role in lipolysis. Plasma lactate and pyruvate concentrations increased similarly in all groups, despite marked differences in BP; this suggested an impairment of production or clearance of lactate in AF. A role for lactate-induced vasodilatation, not compensated for by sympathetic vasoconstriction, remains speculative.

Reducing waiting times for sleep apnoea hypopnoea syndrome and snoring using a questionnaire and home oximetry: results of a second audit cycle

As a result of a previous audit on the management of sleep apnoea hypopnoea syndrome (SAHS) which showed long waiting times that were primarily due to unnecessary interspecialty referrals, a change in practice was adopted. All referrals are now sent a questionnaire about symptoms suggestive of SAHS, the Epworth Sleepiness Scale score and their body mass index (BMI) which when returned are categorized into having a high, intermediate or low risk of SAHS. Those patients with a high probability have home overnight oximetry and those with intermediate probability have video oximetry. Those with a low probability are referred directly to ENT. We audited the first 100 patients referred. All were General Practitioner referrals to either ENT or respiratory medicine. Only two patients had a low probability score and were seen directly in ENT. Following sleep study analysis, 10 patients were referred directly to ENT with no respiratory medicine follow-up and nine were discharged back to the General Practitioner with no apnoea or snoring. Eighty-one patients were followed up by respiratory medicine. Of these, 49 received a trial of nasal continuous positive airway pressure (nCPAP) and six were referred to ENT. Therefore the majority justified an investigation to exclude SAHS in the first instance and an unnecessary initial ENT appointment was avoided. We have reduced the average waiting times to sleep study by approximately 90 days and to nCPAP trial by 32 days, mostly due to decreased delays in interspeciality referrrals. We have also demonstrated a greater than 50 per cent reduction in ENT clinic visits, a small increase in the number of sleep studies but no increase in respiratory clinic workload.

Life expectancy among people with cerebral palsy in Western Australia

This report describes trends, predictors, and causes of mortality in persons with cerebral palsy (CP) using individuals identified by the Western Australian Cerebral Palsy Register and born between 1958 and 1994. Two thousand and fourteen people were identified (1154 males, 860 females), of whom 225 had died by 1 June 1997. Using date-of-death data, crude and standardized mortality rates were estimated and predictors of mortality sought using survival analysis stratified by decade of birth, description of impairments, and demographic and perinatal variables. For those born after 1967, the cause of death profile was examined over time. Mortality exceeded 1% per annum in the first 5 years and declined to age 15 years after which it remained steady at about 0.35% for the next 20 years. The strongest single predictor was intellectual disability, but all forms of disability contributed to decreased life expectancy. Half of those with IQ/DQ score <20 survived to adulthood, increasing to 76% with IQ/DQ score 20-34, and exceeding 92% for higher scores. Severe motor impairment primarily increased the risk of early mortality. Despite there being 72 persons aged from 25 to 41 years with severe motor impairment in our data set, none had died after the age of 25 years. Infants born after more than 32 weeks' gestation were at significantly higher risk of mortality than very preterm infants, accounted for by their higher rates of intellectual disability. No improvements in survival of persons with CP were seen over the study period despite advances in medical care, improved community awareness, and the increasing proportion of very preterm births among people with CP. This may be the result of improved neonatal care enabling the survival of infants with increasingly severe disabilities.

Age- and gender-related growth hormone responses to intravenous clonidine in healthy adults

The alpha(2)-adrenoceptor agonist clonidine stimulates growth hormone (GH) release in both animals and humans. It has been used to test for GH deficiency in children, to assess central alpha(2)-adrenoceptor function in adults and to determine the pathophysiological basis and to confirm diagnosis in neurological diseases with autonomic failure. The dose and mode of administration, however, may be important, as in some studies in adults oral clonidine has minimal effects on GH. We report our experience following intravenous (i.v.) clonidine (2 microg/kg) in 98 normal adults on the neuroendocrine (GH, insulin, glucose and catecholamine) and cardiovascular (blood pressure) responses. In males between 25 and 89 years and females between 25 and 64 years there was a significant rise in GH secretion (P < 0.05) after clonidine. Males showed an age-sensitive secretory pattern, with the greatest response between 25 and 35 years (P < 0.02). Younger males (< 45 years) had significantly higher peak GH levels post-clonidine than younger females < 45 years (P < 0.03). No sex-related change was observed in older subjects (< 45 years). Clonidine caused a significant fall in plasma noradrenalin and adrenalin in all age-sex groups (P< 0.001). There were no significant changes in glucose or insulin. There were no effects of age on the fall in blood pressure induced by clonidine. In conclusion, i.v. clonidine stimulated GH in all age groups and there was a marked sexually dimorphic pattern in adults < 45 years. The results overall suggest that i.v. clonidine-GH testing provides a reliable method for investigation of central alpha(2)-adrenergic function in adult humans.

Designing a library: everyone on the same page?

Excerpts are presented from an interview by the Bulletin of the Medical Library Association buildings projects editor with four academic health sciences library directors: one who had recently completed a major library building project and three who were involved in various stages of new building projects. They share their experiences planning for and implementing library-building programs. The interview explores driving forces leading to new library buildings, identifies who should be involved, recalls the most difficult and exciting moments of the building projects, relates what they wished they had known before starting the project, assesses the impact of new library facilities on clients and services, reviews what they would change, and describes forces impacting libraries today and attributes of the twenty-first century library.

Phosphorylation of cytokeratin 8 and 18 in human vascular smooth muscle cells of atherosclerotic lesions and umbilical cord vessels

Expression of cytokeratins (CK) is considered a hallmark of the state of epithelial differentiation. CK also occur in certain vascular smooth muscle cells (VSMC), inferring an association with a less differentiated phenotype. Recently, CK posttranslational modification was shown to occur in epithelial cells in stress, mitosis or apoptosis. The aim of this study was to determine potential CK phosphorylation patterns in human VSMC. Tissue samples of normal peripheral and coronary arteries, atherosclerotic lesions and umbilical cord vessels were evaluated by immunofluorescence microscopy applying antibodies specific for cytokeratins 8 and 18, specific cytokeratin phosphorylation sites, Ki-67-antigen as a proliferation marker and nick end labeling (TUNEL) to detect apoptosis. All samples contained cytokeratin-positive VSMC but diverse phosphorylation patterns. The C-terminal serine 431 of cytokeratin 8 (CK8Ser-431) was phosphorylated in the vast majority of CK-expressing VSMC of coronary artery lesions. Only a subset of these cells demonstrated phosphorylation of CK18Ser-33 or, to an even lesser extent, CK8Ser-73. DNA fragmentation occurred predominantly in samples containing cells with phosphorylated CK8Ser-431 domains. In contrast, occluded peripheral lesions exhibited little or no phosphorylation. Neonatal VSMC in umbilical cord vessels contain abundant phosphorylated CK domains, again predominantly CK8Ser-431, but also CK18Ser-33. Again, only single cells were found to be proliferating or to contain DNA fragmentation. Thus, abundant CK phosphorylation in VSMC of atherosclerotic lesions suggests a specific functional response to cell stress and a possible relation to apoptosis.

Physiological, pharmacological and neurohormonal assessment of autonomic function in progressive supranuclear palsy

The clinical features of progressive supranuclear palsy (PSP) overlap with other parkinsonian syndromes, including multiple system atrophy (MSA). Autonomic dysfunction is a characteristic of MSA, but has also been described in PSP. We therefore report results from a series of physiological studies of cardiovascular autonomic function in 35 PSP and 20 MSA subjects, and 26 age-matched healthy control subjects. The response to growth hormone-clonidine testing, a neuropharmacological assessment of central adrenoceptor function, was also assessed in 14 PSP and 10 MSA subjects, and compared with 10 controls. None was on medication which may have affected the results. Orthostatic hypotension did not occur in PSP subjects or controls, unlike MSA subjects. Overall there was no evidence of sympathetic vasoconstrictor failure in PSP subjects, unlike MSA subjects, although the pressor response to mental arithmetic was reduced. Cardiac parasympathetic function was affected in only a minority (three of 35) of PSP subjects and was abnormal in MSA subjects. After clonidine administration, growth hormone rose in PSP subjects (median increase 4.3; interquartile range 1.8-7.8 mU/l) and controls, unlike MSA subjects (0.9; 0.3-2.4 mU/l; P < 0.005, Mann-Whitney U-test). In conclusion, in PSP subjects, responses to both physiological and pharmacological tests provided evidence against widespread autonomic dysfunction; this differed markedly from MSA subjects. Thus, cardiovascular autonomic dysfunction should be an exclusionary feature in the diagnosis of PSP.

Comparison of pharmacokinetics of a conjugated equine estrogen preparation (premarin) and a synthetic mixture of estrogens (C.E.S.) in postmenopausal women

OBJECTIVE

To compare the pharmacokinetics and relative bioavailabilities of key estrogen components of Premarin (Wyeth-Ayerst, Canada) with those of a generic conjugated estrogen preparation, C.E.S. (synthetic mixture of estrogens; ICN, Montreal, Canada) in healthy postmenopausal women.

METHODS

We conducted a randomized, single-dose, two-treatment, three-period crossover study in 41 postmenopausal women. After an oral dose (2 x 0.625 mg) of Premarin or C.E.S., plasma concentrations of unconjugated and total estrone (E(1)), equilin (Eq), 17beta-estradiol (17beta-E(2)), 17beta-dihydroequilin (17beta-Eq), Delta(8)-esterone (Delta(8)-E(1)) and Delta(8),17beta-estradiol (Delta(8),17beta-E(2)) were measured over 72 hours using gas chromatography and mass spectroscopy.

RESULTS

After administration of C.E.S., E(1), Eq, and 17beta-Eq appeared in blood at a significantly faster rate (lower t(max)) than after Premarin. The rapid appearance of estrogens after C.E.S. was associated with significantly higher (14-61%) C(max) values. In contrast to the high C(max) values, the area under the curve (AUC)(infinity) of unconjugated and total Eq, and 17beta-Eq were significantly lower after C.E.S., whereas those of E(1) were significantly higher. Although, the t(max) values for 17beta-E(2) were lower and the C(max) values higher after C.E.S., only the C(max) of unconjugated 17beta-E(2) was significantly different after Premarin. Unconjugated and total Delta(8)-E(1) and its main metabolite, Delta(8),17beta-E(2), were detectable in plasma only after administration of Premarin. The geometric mean ratio (GMR) (C. E.S./Premarin) of bioavailability parameters indicated that all C(max) and t(max) values for the unconjugated and total E(1), Eq, 17beta-E(2), and 17beta-Eq fell outside the regulatory requirement that the 90% confidence intervals of GMRs of two products be within 80% and 125%. Similarly, with the exception of total E(1) and total Eq, none of the AUC(t) or AUC(alpha) of the remaining estrogens meets the required regulatory standards of bioequivalence.

CONCLUSIONS

C.E.S. is not bioequivalent to Premarin. Because C.E.S. also is not pharmaceutically equivalent to Premarin, it cannot be assumed to be therapeutically equivalent. Until long-term clinical trials with C.E.S. demonstrate its efficacy, extrapolation of the long-term benefits described for Premarin to C.E.S. would be risky and questionable.

The role of ultrasound in breast imaging

Sonography has become an important tool for evaluating breast abnormalities, including inflammatory processes, hematomas, ductal ectasia, cysts and solid lesions. This article describes protocols for ultrasound imaging of the breast and the sonographic appearance of common breast conditions, with particular attention to differentiating benign from malignant lesions. Ultrasound's role in interventional breast procedures and radiation therapy planning also are discussed.

Cardiac alpha-actin in smooth muscle cells: detection in umbilical cord vessels and in atherosclerotic lesions

Phenotypic modulation of smooth muscle cells (SMC) is a key event during the development of atherosclerotic and restenotic lesions. During this process, the composition of the cytoskeleton is substantially altered, with changes predominantly in actin expression reflecting a shift from smooth muscle alpha-actin to the non-muscle beta-isoform. We now demonstrate that yet another actin isoform, cardiac alpha-actin, is synthesized, de novo, in SMC of various atherosclerotic lesions. Using a highly specific monoclonal antibody against cardiac alpha-actin, we analyzed and compared the accumulation of this actin isoform in diverse SMC by immunofluorescence microscopy and immunoblotting. As expected, cardiac alpha-actin was present in human myocardium but not in healthy SMC of adult aorta, coronary arteries, trabeculae of the spleen, colon, stomach or skeletal muscle. Interestingly, the presence of cardiac alpha-actin was detected in umbilical cord vessels, human myometrium, in atherosclerotic coronary lesions and atherosclerotic lesions from peripheral vascular disease. The distribution of cardiac alpha-actin often paralleled that of cytokeratins 8 and 18, intermediate filament proteins typically found in dedifferentiated SMC. Taken together, the data presented here illustrate the expression of cardiac alpha-actin to be limited to either fetal vessels or those vessels or tissue having suffered damage or atrophy, outside its 'native' environment in the heart. The demonstration of cardiac alpha-actin in SMC of umbilical cord vessels and in atherosclerotic lesions but not in apparently healthy vessels supports the notion that SMC in atherosclerotic lesions exhibit a dedifferentiated phenotype.

Sniff nasal inspiratory pressure as a marker of respiratory function in motor neuron disease

Vital capacity (VC) and maximum mouth pressures are often used to monitor respiratory function in motor neuron disease (MND), but require the use of a mouthpiece. Sniff nasal inspiratory pressure (SNIP) is a simple and reliable means of measuring inspiratory muscle strength; it does not involve the use of a mouthpiece and might therefore be better than VC or mouth pressures for assessing patients with bulbar disease. SNIP, maximum inspiratory (MIP) and expiratory mouth pressure (MEP), VC and arterial carbon dioxide tension (Pa,CO2) were measured in 59 consecutive patients attending a specialist MND clinic. Thirty-one had bulbar involvement on clinical grounds. Both SNIP and VC were inversely related to Pa,CO2 in nonbulbar patients only. Neither MIP nor MEP were related to Pa,CO2. The 10 patients with an elevated Pa,CO2 (>6 kPa) had significantly lower SNIP and VC than normocapnic patients. Sniff nasal inspiratory pressure can be used to monitor respiratory function in motor neuron disease. It is quick and easy for patients to perform, but otherwise appears to offer little advantage over vital capacity measurement. Patients with bulbar disease are often poor at performing sniff nasal inspiratory pressure manoeuvres, possibly because of upper airway collapse or inability to close the mouth completely during the manoeuvre.

Effect of DHA supplementation on DHA status and sperm motility in asthenozoospermic males

The effects of supplementation with docosahexaenoic acid (DHA) on DHA levels in serum, seminal plasma, and sperm of asthenozoospermic men as well as on sperm motility were examined in a randomized, double-blind, placebo-controlled manner. Asthenozoospermic men (n = 28; < or =50% motility) were supplemented with 0, 400, or 800 mg DHA/d for 3 mon. Sperm motility and the fatty acid composition of serum, seminal plasma, and sperm phospholipid were determined before and after supplementation. In serum, DHA supplementation resulted in decreases in 22:4n-6 (-30% in the 800-mg DHA group only) and total n-6 (-6 and -12% in the 400- and 800-mg DHA groups, respectively) fatty acids. Increases were noted in DHA (71 and 131% in the 400- and 800-mg DHA groups, respectively), total n-3 fatty acids (42 and 67% in the 400- and 800-mg DHA groups, respectively), and the n-3/n-6 ratio (50 and 93% in the 400- and 800-mg DHA groups, respectively). In seminal plasma, DHA supplementation resulted in a decrease in 22:4n-6 (-31% in the 800-mg DHA group only) and an increase in the ratio of n-3 to n-6 (35 and 33% in the 400- and 800-mg DHA groups, respectively). There were insignificant increases in DHA and total n-3 fatty acids. In sperm, decreases were noted in 22:4n-6 (-37 and -31% in the 400- and 800-mg DHA groups, respectively). There were no other changes. There was no effect of DHA supplementation on sperm motility. The results show that dietary DHA supplementation results in increased serum--and possibly seminal plasma--phospholipid DHA levels, without affecting the incorporation of DHA into the spermatozoa phospholipid in asthenozoospermic men. This inability of DHA to be incorporated into sperm phospholipid is most likely responsible for the observed lack of effect of DHA supplementation on sperm motility.

Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects

BACKGROUND

Neural tube defects arise during the development of the brain and spinal cord.

OBJECTIVES

The objective of this review was to assess the effects of increased consumption of multivitamins or folate on the prevalence of neural tube defects before pregnancy and in the first two months of pregnancy (periconceptionally).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing periconceptional supplementation by multivitamins with placebo, folate with placebo, or multivitamins with folate; different dosages of multivitamins or folate; prepregnancy dietary advice and counselling in primary care settings to increase the consumption of folate-rich foods, or folate-fortified foods, with standard care; increased intensity of information provision with standard public health dissemination.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Four trials involving 6425 women were included. The trials all addressed the question of supplementation and they were of variable quality. No dissemination trials were identified. Periconceptional folate supplementation reduced the incidence of neural tube defects (odds ratio 0.28, 95% confidence interval 0.15 to 0.53). Folate supplementation did not significantly increase spontaneous abortion, ectopic pregnancy or stillbirth, although there was a possible increase in multiple gestation. Multivitamins alone were not associated with prevention of neural tube defects and did not produce preventive effects when given with folate.

REVIEWER'S CONCLUSIONS

Periconceptional folate supplementation has a strong protective effect against neural tube defects. Information about folate should be made more widely available throughout the health and education systems. Women whose fetuses or babies have neural tube defects should be offered continuing folate supplementation. The benefits and risks of fortifying basic food stuffs, such as flour, with added folate remain unresolved.

Frozen shoulder: a 12-month clinical outcome trial

A prospective study was undertaken of 73 patients with frozen shoulder syndrome who were treated with an arthroscopic capsulotomy. All of the patients were assessed for pain, function, and range of motion before surgery and were monitored through to 1-year follow up. Improvement in all parameters was achieved, with pain taking an average of 2.24 weeks to diminish and range of motion improving to within 10% of the other side at an average of 5.5 weeks after surgery. Patients were discharged with a full range of motion and without pain at an average of 8.9 weeks. There was, however, some mild reaggravation of most patients' pain within the postoperative period (mean 4.5 weeks). This pain usually settled with appropriate massage within a 2-week period. In 37% of cases, however, an injection of corticosteroid was required as part of the postoperative management. These cases were usually in that subgroup of patients who still had significant night pain and were in stage 2 or 3 of the disease process at the time of surgery. The postoperative results continued to the 12-month follow-up, with 11% of patients having a recurrence of pain or stiffness. This study has demonstrated that arthroscopic capsulotomy is an effective technique in the management of the frozen shoulder. It also has enabled the authors to document postoperative recovery times, which has given prospective patients realistic time frames of functional expectation in their postoperative recovery.

JNK and c-Jun but not ERK and c-Fos are associated with sustained neointima-formation after balloon injury

BACKGROUND

Formation of neointima after balloon angioplasty is regulated via inducible transcription factors (ITF), such as c-Jun and c-Fos, depending on mitogen activated protein (MAP) kinases, which have been shown to be activated after balloon injury. The precise localization of activated MAP-kinases and concomitant expression of transcription factors in the vessel wall remains to be elucidated. We have now studied the localization and time-dependent expression of MAP-kinases together with corresponding ITFs in the rat carotid angioplasty model.

DESIGN

Animals were sacrificed at 0. 5, 6 and 24 h and 3, 5, 7, 14 and 28 days after injury. Cryocut sections were stained using antibodies directed against c-Jun, phosphorylated c-Jun, c-Fos, c-Jun amino-terminal kinase (JNK), extracellular signal related kinase (ERK), von Willebrand factor, ki67 antigen, and alpha-actin.

RESULTS

c-Jun expression was strongly induced in smooth muscle cells (SMC) 30 min after injury and remained upregulated for 24 h, thereafter dropping to basal levels at day 3. Re-expression was observed at day 7 and 14 but not day 28. Expression patterns of JNK and phosphorylated c-Jun were highly congruent to that of c-Jun. In contrast, c-Fos expression was restricted to 30 min and, less pronounced than c-Jun and JNK, was visible after 7 days. Also, its expression was congruent with the presence of ERK.

CONCLUSIONS

These findings demonstrate a clear association between MAP-kinases and their transcription factor substrates in vivo with a predominant association of JNK and c-Jun with sustained SMC proliferation.

Midwives in Victoria, Australia: a survey of current issues and job satisfaction

OBJECTIVE

To describe demographic and work profiles of registered practising midwives, to assess their job satisfaction and their knowledge of and attitudes to the 1990 Victorian Birthing Services review.

DESIGN

A questionnaire posted in 1995 to a population-based random sample of registered midwives.

PARTICIPANTS

Two hundred and forty midwives currently using their midwifery skills in their work.

SETTING

One thousand names and addresses were randomly selected from a database of midwives registered to practise in Victoria, Australia in 1993.

FINDINGS

There was a 72% response rate to the postal questionnaire. Two hundred and forty practising midwives returned completed questionnaires. Seventy-three per cent were in full time employment, 49% lived in rural Victoria, 80% were born in Australia, more than half were aged 40 or more years and 72% had at least one child. Twenty-six per cent worked in postnatal wards, 9% in each the labour ward and the neonatal nursery, 2% in birthing centres and 12% in out of hospital settings. Eighty per cent were satisfied with their work and interactions with women were the most important aspect. Satisfaction was associated with working in a labour ward, feeling adequately prepared by midwifery education and training, nursing for more than 15 years and having continuing education. Neonatal and rotating positions were significantly associated with dissatisfaction. Less than one-half of the midwives had read some of the Birthing Services Review, and of these only one-half had changed their attitudes or practice. One-third knew little of the imminent changes to the Midwifery Regulations.

CONCLUSION

Although most midwives enjoyed their work there was little evidence of increasing autonomy or involvement in change.