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.

Risk of cancer after use of fertility drugs with in-vitro fertilisation

BACKGROUND

We investigated the incidence of invasive cancer of the breast, ovary, and uterus in a cohort of patients who had undergone in-vitro-fertilisation (IVF) treatment and examined whether cause of infertility or exposure to fertility drugs to induce superovulation was associated with an increased cancer risk.

METHOD

Ten Australian IVF clinics provided data for women who had been referred for IVF before Jan 1, 1994. The frequencies of invasive breast, ovarian, and uterine cancer were assessed by record linkage to population-based cancer registries and the national death index. The observed number of cancers was compared with the expected number calculated by application of age-standardised general-population cancer rates to the cohort. Standardised incidence ratios (SIRs) were derived from the ratio of observed to expected cases.

FINDINGS

The cohort consisted of 29,700 women: 20,656 were exposed to fertility drugs and 9044 were not. 143 breast cancers, 13 ovarian cancers, and 12 cancers of the uterus occurred among these women. For breast and ovarian cancer the incidence was no greater than expected (SIR 0.91 [95% CI 0.74-1.13] for breast cancer and 0.88 [0.42-1.84] for ovarian cancer in the exposed group and 0.95 [0.73-1.23] for breast cancer and 1.16 [0.52-2.59] for ovarian cancer in the unexposed group). The incidence of uterine cancer was no higher than expected in the exposed group (1.09 [0.45-2.61]) but was significantly higher in the unexposed group (2.47 [1.18-5.18]). Women with unexplained infertility had significantly more cancers of the ovary and uterus than expected (2.64 [1.10-6.35] and 4.59 [1.91-11.0], whole cohort). Analysis of cancer incidence within 12 months of exposure to fertility drugs with IVF showed that incidence was significantly higher than expected for breast and uterine cancer (1.96 [1.22-3.15] and 4.96 [1.24-19.8]).

INTERPRETATION

Women who have been exposed to fertility drugs with IVF seem to have a transient increase in the risk of having breast or uterine cancer diagnosed in the first year after treatment, though the incidence overall is no greater than expected. Unexplained infertility was associated with an increased risk of a diagnosis of ovarian or uterine cancer.

Neuroendocrine responses to levodopa in multiple system atrophy (MSA)

Hypothalamic dopaminergic pathways are involved in the regulation of growth hormone and prolactin release from the anterior pituitary. Neuroendocrine studies in patients with multiple system atrophy (MSA), in whom there is a reported loss of hypothalamic dopamine, are few and contradictory. We therefore studied the neuroendocrine responses to 250 mg levodopa (plus 25 mg carbidopa) in subjects with MSA (n = 15), and compared them with age- and sex-matched healthy control subjects (n = 8). There were no significant differences in basal or post-levodopa levels of growth hormone (GH), growth hormone-releasing hormone (GHRH), glucose, insulin-like growth factor (IGF-1), or thyroid-stimulating hormone (TSH) between the groups. In patients with MSA, basal levels of prolactin were elevated (21.1 +/- 5.2 ng/mL [mean +/-standard error]) compared with control subjects (12.1 +/- 1.7, p <0.05), and after L-dopa there was increased variability in prolactin response with less suppression compared with control subjects. In conclusion, in patients with MSA, the GHRH and GH responses to L-dopa were preserved and were similar to responses in age-matched control subjects. In contrast, there was impaired dopaminergic suppression of prolactin secretion. In patients with MSA this may represent a selective dysfunction, rather than generalized loss, of tubero-infundibular dopaminergic neurones.

Contribution of nitric oxide to exercise-induced hypotension in human sympathetic denervation

The cardiovascular, catecholamine, and nitrate/nitrite (NO) responses to bicycle exercise were measured in 14 normal subjects (controls) and two groups with sympathetic denervation; 14 with peripheral autonomic failure (pure autonomic failure [PAF]); and 13 with central autonomic failure (multiple system atrophy [MSA]). With exercise, blood pressure increased in control subjects by 40 +/- 7/24 +/- 5 mm Hg (p < 0.001) and fell in PAF by 24 +/- 8/24 +/- 5 mm Hg (p < 0.02 and p < 0.007) and MSA by 31 +/- 7/11 +/- 3 mm Hg (p < 0.005 and p < 0.04). With exercise, the increase in heart rate was greater in control subjects (60 +/- 3 to 111 +/- 4/min; p < 0.0001) than in PAF (69 +/- 3 to 86 +/- 4/min; p < 0.0001) and MSA (70 +/- 4 to 90 +/- 4; p < 0.001). Resting plasma noradrenaline levels were similar in controls (291 +/- 51 pg ml(-1)) and MSA (257 +/- 49 pg ml(-1)), but lower in PAF (82 +/- 14 pg ml(-1)). With exercise, plasma noradrenaline increased in controls but was unchanged in PAF and MSA. Resting NOx was similar in controls (50 +/- 5 nmol/L; range, 23.3-87.6 nmol/L) and PAF patients (59+/-8 nmol/l; range, 19.3-116.4 nmol/L), but was higher in MSA patients (87 +/-14 nmol/L; p <0.025, range 15.4-157.2 nmol/L). With exercise, NOx was unchanged in control subjects and increased by 10% and 17% in PAF and MSA, respectively; these changes were not statistically significant. This study suggests that circulating changes in NOx levels do not exert a major role in exercise-induced hypotension in subjects with sympathetic denervation.

Abnormal suppression of arginine-vasopressin by clonidine in multiple system atrophy

In normal man, the centrally active alpha2-adrenoceptor agonist clonidine reduces arginine-vasopressin (AVP) secretion, probably by presynaptic inhibition of noradrenergic neuron terminals in the supraoptic nucleus. A lesion of noradrenergic pathways in animals abolishes this response to clonidine. At postmortem in multiple system atrophy (MSA) there is marked loss of hypothalamic noradrenergic innervation. We hypothesized that the AVP response to clonidine in MSA may be abnormal and therefore studied the AVP response to clonidine (2 microg/ kg iv) in 10 subjects with MSA and compared them to six healthy age-matched control subjects. Basal levels of AVP were similar in controls and MSA. Following clonidine there was a significantly greater fall in controls than MSA (-47 +/- 4% vs -25 +/- 6%; p < 0.05). There was a similar fall in mean arterial pressure (MAP) and plasma catecholamines in both groups, with no change in plasma osmolarity, excluding these as a contributary factor. In conclusion, there is an abnormal AVP response to clonidine in MSA, which probably represents loss of functional noradrenergic innervation of the supraoptic nucleus.

Fatty acid analysis of blood serum, seminal plasma, and spermatozoa of normozoospermic vs. asthenozoospermic males

Docosahexaenoic acid (DHA; 22:6n-3) is found in extremely high levels in human ejaculate with the majority occurring in the spermatozoa. However, the relative concentration of DHA and other fatty acids, in blood serum, seminal plasma, and spermatozoa of asthenozoospermic vs. normozoospermic individuals is not known. We analyzed the phospholipid fatty acid composition of blood serum, seminal plasma, and spermatozoa of normozoospermic men and asthenozoospermic men in order to determine if DHA levels, as well as the levels of other fatty acids, differed. The serum phospholipid DHA levels were similar in the two groups, suggesting similar intakes of dietary DHA. On the other hand, seminal plasma levels of DHA (3.0 vs. 3.7%) and total polyunsaturated fatty acids (PUFA) (11.8 vs. 13.5%) were significantly lower in asthenozoospermic vs. normozoospermic men, respectively, while 18:1 (19.0 vs. 16.8%) and monounsaturated fatty acids (MUFA) (24.2 vs. 21.7%) were significantly higher in the asthenozoospermic vs. the normozoospermic men. Spermatozoa from asthenozoospermic men had higher levels of 18:1, 20:0, 22:0, 22:1, and 24:0 than sperm from normozoospermic men, and lower levels of 18:0 and DHA (8.2 vs. 13.8%). Furthermore, total MUFA (19.3 vs. 16.5%) was higher and total PUFA (19.0 vs. 24.0%), n-3 fatty acids (9.3 vs. 14.6%), and the ratio of n-3 to n-6 fatty acids (1.0 vs. 1.6) were lower in the asthenozoospermic men. Therefore, in asthenozoospermic individuals, lower levels of DHA in the seminal plasma, but not in the blood serum, mimic the decreased concentrations of DHA in the spermatozoa. This suggests that the lower concentrations of spermatozoon DHA in these individuals are due not to dietary differences but to some type of metabolic difference in the asthenozoospermic men.

Expression of monocyte chemoattractant protein-1 cDNA in vascular smooth muscle cells: induction of the synthetic phenotype: a possible clue to SMC differentiation in the process of atherogenesis

In the arterial wall, smooth muscle cells (SMC) normally exist in a quiescent, differentiated state, representing the contractile phenotype. During the development of atherosclerosis SMC change towards the synthetic phenotype going along with proliferation, chemotactic response and increased monocyte binding. Expression of monocyte chemoattractant protein-1 (MCP-1), a potent chemoattractant for monocytes, has been shown to be among the earliest events in atherogenesis. We investigated the effect of MCP-1 on differentiated and dedifferentiated SMC. Differentiation of SMC was induced using Matrigel as a matrix for cultivation. MCP-1 was expressed in SMC by means of a recombinant adenovirus. Expression of MCP-1 led to dedifferentiation of SMC as demonstrated by induction of cytokeratin 18, a marker for the synthetic phenotype. Concurrently, migration was only detectable in MCP-1 expressing cells, whereas SMC infected with a control virus, coding for the nuclear-targeted lacZ gene showed no migration. The expression of intercellular adhesion molecule-1 (ICAM-1) could be demonstrated in synthetic SMC and was induced after infection of differentiated cells with recombinant adenovirus, coding for MCP-1 (AdMCP-1). Expression of ICAM-1 was associated with a tenfold higher monocyte binding compared to lacZ infected cells. Our data suggest that MCP-1 plays an important role for SMC in the functional switch from the contractile to the synthetic phenotype in the course of atherogenesis.

Effects of HMG-CoA reductase inhibition on PDGF- and angiotensin II- mediated signal transduction: suppression of c-Jun and c-Fos in human smooth muscle cells in vitro

Hydroxymethylglutaryl-Coenzyme A (HMG-CoA) reductase inhibitors were shown to be effective in primary and secondary prevention of coronary heart disease. The beneficial effect of statins is generally attributed to their cholesterol lowering activity. However recent work points to additional cholesterol independent effects of these drugs on cellular signal transduction. In this study it was investigated whether HMG-CoA reductase inhibition could affect induction of the transcription factors c-Jun and c-Fos in smooth muscle cells, which play an important role in atherogenesis. SMC were preincubated for 12 h with or without lovastatin (5 microM) and subsequently stimulated with platelet derived growth factor (PDGF, 10 ng/ml) or angiotensin II (0.1 microM) for 1, 2, 4 and 12 h or with phorbol myristate acetate (100 pM) for 2 h. Stimulation in the absence of the HMG-CoA reductase inhibitor led to a significant induction of c-Jun and c-Fos. Lovastatin inhibited, PDGF-, angiotensin II- and PMA-mediated induction. Concomitant addition of mevalonate, farnesylpyrophosphate and geranylgeranylpyrophosphate prevented the effects of HMG-CoA reductase inhibition resulting in rescued expression of c-Jun and c-Fos. The suppression of these transcription factors was associated with a complete growth arrest. Viability was not affected by pretreatment with the HMG-CoA reductase inhibitor. The data demonstrate that lovastatin can suppress PDGF- and angiotensin II-mediated induction of c-Jun and c-Fos protein in human SMC. This inhibitory effect may prevent activation of numerous growth factor- and cell cycle- genes. Whether these findings contribute to the effects of statins in atherosclerosis remains to be further investigated.

Hu23F2G, an antibody recognizing the leukocyte CD11/CD18 integrin, reduces injury in a rabbit model of transient focal cerebral ischemia

Neutrophils are known to mediate injury in acute ischemic stroke especially during reperfusion. Migration of neutrophils into regions of ischemic injury involves binding to the endothelial cell's intercellular adhesion molecule (ICAM-1) through the leukocyte integrin, CD11/CD18. We studied the potential for neuroprotection with a humanized antibody that binds to and blocks the functions of the CD11/CD18 integrin in a rabbit model of transient focal ischemia. Fifteen New Zealand White rabbits underwent transorbital occlusion of the left middle cerebral, anterior cerebral, and internal carotid arteries using aneurysm clips for 2 h, followed by 6 h of reperfusion. Treatment with a maximally saturating dose (4 mg/kg) of a humanized CD11/CD18 monoclonal antibody (Hu23F2G, ICOS Corp., Bothell, WA) (n = 8) or placebo (n = 7) was administered 20 min after occlusion and given as a single intravenous bolus. Hemispheric ischemic neuronal damage (IND) as seen on hematoxylin- and eosin-stained sections was significantly reduced in Hu23F2G-treated animals by 57% (Hu23F2G: 15 +/- 6.9%; placebo: 35 +/- 5%; mean +/- SEM, P < 0.05, t-test). Immunohistochemical staining with neutrophil elastase confirmed the presence of neutrophils within regions of IND in control brains. Treatment with Hu23F2G resulted in marked reduction of neutrophil infiltration. (No. of neutrophils/IND area: Hu23F2G 36.1 +/- 36.7 cm-2, placebo 460.6 +/- 101.8 cm-2, P = 0.001. ) Antagonism of neutrophil migration at the level of the CD11/CD18 integrin reduces ischemic injury in experimental stroke.

What constitutes cerebral palsy?

Cerebral palsy (CP) is a term of convenience applied to a group of motor disorders of central origin defined by clinical description. It is not a diagnosis in that its application infers nothing about pathology, aetiology, or prognosis. It is an umbrella term covering a wide range of cerebral disorders which result in childhood motor impairment. The precise inclusion criteria vary with the objectives for using the term. For meaningful comparison of rates of CP, as performed by and between CP registers, it is important that the rates should be generated using the same criteria. As generally understood there must be motor impairment, and this impairment must stem from a malfunction of the brain (rather than spinal cord or muscles). Furthermore, the brain malfunction must be non-progressive and it must be manifest early in life. For the purposes of comparisons of rates across time even when the condition meets all the above criteria, it must not historically have been excluded from the category of CP. This paper addresses the problem of standardizing the inclusion criteria for selecting people included on CP registers with particular reference to this last criterion.

Is baby too warm? The use of infant clothing, bedding and home heating in Victoria, Australia

Overheating of infants has been associated with a raised risk for sudden infant death syndrome (SIDS). Data on the use of heating, bedding and clothing and other measures affecting the thermal environment of 4 week old infants were collected at a home interview for infants of women born in Australia (Anglo-Celtic background), in Southern Europe, in Asia and of women who had a planned out-of-hospital birth. These groups have different risks of SIDS not explained by the classic social and perinatal risk factors nor associated with the currently promoted 'new' risk factors. Thermal insulation of the infant's bedding and clothing and excess thermal insulation (for any observed room temperature) were calculated. Bed sharing differed significantly between the groups as did the use of a sheepskin, tucking in firmly, the closing of doors and windows and the use of heating in the infant's room. After stratifying by bed sharing practice and season of interview, it was found that bed sharing infants had more thermal insulation than those sleeping alone irrespective of season of interview. Infants sleeping alone in the Asian-born and Southern European-born groups were kept warmer than infants in the other two groups. Cultural factors appear to affect the thermal environment in which infants are raised. Some bed sharing infants in all four groups were inappropriately warm, particularly in colder weather, but this was more likely in the Asian-born (low risk) group than in the home birth (high risk) group. These results do not explain the differences in SIDS incidence between the groups.

Maternal corticotropin-releasing hormone is increased with impending preterm birth

The objective of this study was to test the hypothesis that maternal CRH concentrations are elevated in women experiencing threatened preterm labor who subsequently give birth within 24 h compared to those in women who do not. We also characterized the changes in maternal plasma cortisol, ACTH, corticosteroid binding capacity (CBC), and CRH concentrations in 28 healthy pregnant women between 20-38 weeks gestation. Overall, maternal plasma CRH concentrations were significantly greater (P < 0.05) in those women giving birth within 24 h (1343.3 +/- 143.9 pg/mL; n = 81) compared to those in women who did not (714.5 +/- 64.8 pg/mL; n = 144) or those in normal subjects. This difference was present between 28-36 weeks, but not 24-28 weeks gestation. The ratio of maternal cortisol to CBC was also significantly greater (P < 0.05; 0.65 +/- 0.04; n = 82) in women giving birth within 24 h than in those who did not (0.55 +/- 0.02; n = 136). This difference was significant at all gestational ages studied. Elevated CRH concentrations and bioavailability of free cortisol may both be implicated in the pathogenesis of preterm labor in some women. Further prospective clinical trials are warranted to determine the positive and negative predictive values of maternal CRH concentrations and/or the ratio of cortisol/CBC for identifying women with threatened preterm labor destined to give birth within 24 h.

Adverse outcome after multiple pregnancy

There is increasing interest in the outcomes of multiple pregnancies as their numbers rise, mainly owing to advances in fertility-enhancing techniques. In addition, the numbers of multiple births surviving the perinatal period is increasing with the increasing survival of very tiny babies. In order to investigate these outcomes or to evaluate procedures that may improve them, it is important to consider a number of methodological issues that affect the comparability of data both between and within populations. How a birth and a multiple birth are defined, data sources, whether multiple pregnancies or individual births are being counted and the identification of multiple gestations by zygosity and chorionicity will all affect the reported outcome rates. In light of this, perinatal mortality and neurodevelopmental disabilities are examined as adverse outcomes of multiple pregnancies.

Complications of laser resurfacing

The laser demonstrates significant benefits over traditional resurfacing and incisional techniques. Serious complications of laser surgery are easily avoidable provided practitioners and support staff receive proper education and training. The following article describes the more common complications of laser resurfacing followed by a brief discussion of avoidance techniques.

British agencies for adoption and fostering in Scotland--Scottish Medical Advisers' survey

Children in local authority care (The survey was conducted before the term 'in care' was replaced by 'looked after' on The Children (Scotland) Act coming into force in October 1996) come from backgrounds of high incidence of mental illness, substance abuse and learning difficulties and have often suffered from neglect and/or abuse. They have a high incidence of medical problems affecting both physical and mental health. The Committee of the Scottish Section of the Medical Group of British Agencies for Adoption and Fostering (BAAF) were concerned about the provision and co-ordination of medical services for children in local authority care. The aim of the survey was to identify the current and evolving practice among medical advisers across Scotland. Questionnaires were returned from 40 Medical Advisers representing each of the local authorities in Scotland. The responses highlighted a variation in the implementation of practice in clinical services provided to children in care and by whom. It confirmed that difficulties in follow-up did exist and revealed widespread confusion surrounding co-ordination of medical services, absence of procedures and ignorance of legal requirements. The study confirms that involved medical practitioners need to have a pro-active role in co-operating closely with social work colleagues to provide a well co-ordinated service of medical supervision providing a comprehensive assessment of health care needs as part of the overall child care plan.

Distinction of idiopathic Parkinson's disease from multiple-system atrophy by stimulation of growth-hormone release with clonidine

BACKGROUND

Idiopathic Parkinson's disease is a common neurodegenerative disease that is difficult to distinguish from other parkinsonian syndromes such as multiple-system atrophy (MSA). In MSA, autonomic dysfunction is common and is associated with either parkinsonian or cerebellar features, or both. Differentiation of idiopathic Parkinson's disease from MSA is important because prognosis, complications, and response to therapy vary according to disorder. Our aim was to find out whether clonidine/growth hormone (GH) testing distinguishes idiopathic Parkinson's disease from MSA.

METHODS

Clonidine is a centrally active alpha 2-adrenoceptor agonist that raises concentrations of GH in serum in healthy people and those with pure autonomic failure (with peripheral lesions), but not in those with MSA (with a central autonomic deficit). We investigated the effects of clonidine on 14 people with idiopathic Parkinson's disease (without autonomic deficits). 31 people with MSA of the three different clinical forms (parkinsonian, cerebellar, and mixed), 19 people with pure autonomic failure, and 27 healthy participants. In nine people with parkinsonian MSA (MSA-P), the GH response to levodopa was also assessed.

FINDINGS

Clonidine raised serum GH concentrations in patients with idiopathic Parkinson's disease (median increase 8.98 [IQR 6.6-16.6] mU/L), normal participants (13.2 [7.0-18.6] mU/L), and patients with pure autonomic failure (12.5 [5.6-18.2] mU/L). In those with MSA who had central autonomic failure, GH concentrations were unchanged (MSA-P; 0.41 [-0.30 to 2.09] mU/L and cerebellar MSA [MSA-C] 1.67 [0-4.49] mU/L). The GH response to clonidine in idiopathic Parkinson's disease was significantly different from that in MSA-P (p < 0.0002). In MSA-P, the dopamine precursor levodopa raised GH concentrations (from mean 2.7 [SE 1.0] mU/L to mean 18.2 [6.0] mU/L, p < 0.05) and GH-releasing hormone (GHRH) concentrations (from mean 20.6 [3.25] ng/L to mean 68.0 [10.6] ng/L, p < 0.05), excluding dysfunction of pituitary somatotrophs or GHRH neurons as a cause for the absent GH response to clonidine in MSA.

INTERPRETATION

The GH responses to clonidine clearly differentiated idiopathic Parkinson's disease from MSA-C and MSA-P. Together with the levodopa studies they indicated a specific alpha 2-adrenoceptor-hypothalamic deficit in MSA. The clonidine-GH test may provide further insight into central neurotransmitter and alpha 2-adrenoceptor-hypothalamic abnormalities in MSA.

Using restriction-site variation of PCR-amplified cpDNA genes for phylogenetic analysis of tribe Cheloneae (Scrophulariaceae)

Data from restriction-site variation of three PCR-amplified chloroplast genic regions (trnK, rps2, and rbcL) were used to assess the utility of PCR-based methodology for phylogenetic reconstruction. Seventeen genera from tribe Cheloneae s.l. (Scrophulariaceae), and one genus each from Solanaceae, Acanthaceae, and Bignoniaceae, representing 32 taxa, were sampled. Phylogenetic reconstruction, based on a combined data set of 138 variable restriction sites, revealed a monophyletic clade of North American Cheloneae, which were not inconsistent with a polyphyletic Scrophulariaceae. Separate analyses of individual genie regions were unable to completely resolve the phylogeny, but were adequate for resolving relationships of major clades among the taxa sampled. We suggest that analysis of PCR-product restriction-site variation is useful for phylogenetic reconstruction above the species level.

Perspectives unifying symptom interpretation

PURPOSE

To introduce the symptom interpretation model (SIM) and facilitate understanding symptoms from an intrapersonal perspective. Determining an individual's interpretation of symptoms is critical to understanding the resulting decisions.

ORGANIZING CONSTRUCT

SIM is based on an illness representation model, knowledge structures theory, and propositions about reasoning. Individuals name and assign meaning to environmental stimuli. Based on this interpretation, behaviors are selected for symptom management.

METHODS

Theory derivation was used to develop SIM for understanding comparisons of known and new symptoms in a behavioral outcomes context.

CONCLUSIONS

Symptom familiarity reinforces patterns about symptom management. SIM enriches understanding of symptom experiences. Comprehensive assessment, including the intraindividual perspective, is essential to successful symptom management.

Breathlessness and exercise capacity in heart failure: the role of bronchial obstruction and responsiveness

The cause of the breathlessness and reduced exercise capacity that occur in patients with chronic heart failure remains obscure. We examined the hypothesis that airway obstruction and bronchial hyper-responsiveness, which are recognised features of chronic heart failure, might contribute to the breathlessness and reduced exercise capacity in this condition. We studied 37 patients (7 female) with chronic heart failure, of mean age 61 years. Each patient underwent: (i) lung function testing with spirometry and expiratory flow volume loops. (ii) Measurement of bronchial responsiveness to methacholine. (iii) Symptom-limited treadmill exercise capacity using both incremental and fixed workload protocols, with measurement of Borg scores for breathlessness. Lung function was not significantly related to either exercise time, or Borg symptom scores in either exercise protocol. Bronchial hyper-responsiveness to methacholine was demonstrated in 12 patients. Exercise time did not correlate with the degree of bronchial hyper-responsiveness in these 12 patients. Group mean exercise time and Borg scores were not significantly different in these 12 patients when compared to the 25 patients in whom bronchial hyper-responsiveness was not found. We conclude that airway obstruction and bronchial hyper-responsiveness are not likely to be important determinants of reduced exercise capacity and breathlessness in chronic heart failure.

The Fort McMurray Demonstration Project in social marketing: health- and safety-related behaviour among oil sands workers

This is the first round in a series of surveys conducted in Fort McMurray as part of the Fort McMurray Demonstration Project in social marketing. This component of the survey was intended to focus on the most prominent group of employed workers in the community and to compare their patterns of response with the community as a whole. Respondents to the survey were overwhelmingly male (96%), married (72.9%) and living in households of two to five persons (87.9%). They were predominantly aged 30-44 (55%) and graduates of high school (53.5%). Younger male workers (below age 30) were more likely to have a high school diploma (78.3%) or some additional technical or vocational training (21.7% compared to 12.5% overall) and to be unmarried or separated. Attitudes toward safety-related behaviours were stronger than for respondents from the community as a whole. Approximately 70-100% of all age groups and both sexes showed strong agreement with attitudes involving child car seats and the unacceptability of drinking and driving. These attitudes include strong advocacy of vigorous enforcement of occupational health and safety standards. However, they showed a variability similar to the community as a whole in behaviour at home compared to work, generally reporting more consistent use of personal protection on the job than in their own homes, particularly hearing protection. Even so, they were much less likely to perform stretching and warm-up exercises prior to exertion than community residents in general. The potential may exist to transfer the technology and attitudes from workplace health and safety to community safety. One possible strategy to accomplish this is to involve workers in this industry directly in community initiatives. This strategy may be generalizable to any community in which there are major employers who place a heavy emphasis on risk control and occupational health and safety.