Biomedical subjects
L Nilas
Publications and source records attributed to L Nilas.
[Problem-based learning in medical education. Experiences from a department of gynecology].
INTRODUCTION: Problem-based learning (PBL) is an educational method based on a clinical problem, where students define their learning objectives, research these objectives, and report back. The aim of the present study was to compare PBL with other learning methods during a pregraduate clinical course. METHODS: PBL was applied to six groups of students (n = 35) during a pregraduate clinical course in obstetrics and gynaecology and compared with other learning methods, such as traditional lectures, participation in the clinical work of the department, and a training course in communication and clinical skills with simulated patients and phantoms. The learning methods were scored on a scale from zero to five. RESULTS: The educational methods were evaluated differently (p < 0.01). PBL reached a score of at least four more often (33/35) than did traditional lectures (25/34), p < 0.05. Most of the students enjoyed PBL, although they found it time consuming. Twenty-one preferred the mixture of PBL and lectures, whereas 13 preferred more PBL and one solely preferred lectures. DISCUSSION: The present study shows that it is possible to implement PBL sessions in clinical courses and the method is positively evaluated by both students and teachers.
Postpartum Clostridium sordellii infection associated with fatal toxic shock syndrome.
Clostridium bacteria are anaerobic Gram positive spore-form-ing bacilli, known to cause distinct clinical syndromes such as botulism, tetanus, pseudomembranous colitis and myonecrosis. The natural habitats of Clostridium species are soil, water and the gastrointestinal tract of animals and humans. In 5-10% of all women, Clostridium species are also found to be normal inhabitants in the microbial flora of the female genital tract. In case of a non-sexually transmitted genital tract infection, Clostridium species are isolated in 4-20%, and clostridium welchii seems to be the most common isolate. Clostridium sordellii is rarely encountered in clinical specimens (1% of Clostridium species), but it has been described as a human pathogen with fatal potential. Two toxins, a lethal and a hemorrhagic (that antigenically and pathophysiologically appear similar to Clostridium difficile toxins B and A, respectively) are responsible for this potential. Reviewing the obstetric literature, only six cases of postpartum endometritis caused by C. sordellii, are described - all being fatal. In addition, one lethal case of spontaneous endometritis resulting from C. sordellii is reported. The clinical aspects of these cases include: - sudden onset with influenza-like symptoms in previously healthy women - progressive refractory hypotension - local and spreading tissue edema - absence of fever Laboratory findings include: - marked leukocytosis - elevated hematocrit. This paper reports the seventh fatal postpartum C. sorlellii associated toxic shock syndrome - the first recognized in Scandinavia.
Two-dimensional gel analysis of human endometrial proteins: characterization of proteins with increased expression in hyperplasia and adenocarcinoma.
In the search for new markers of human endometrial hyperplasia and adenocarcinoma the method of quantitative two-dimensional gel electrophoresis was applied to study the protein expression profiles of metabolically [(35)S]-methionine-labelled proteins of endometrial explants. Approximately 1700 protein spots were resolved by the two-dimensional gel electrophoresis, and the expression pattern of each of these proteins was assessed for increased expression during hyperplasia or adenocarcinoma. In total, six protein spots showed increased expression in hyperplasia, 19 in carcinoma, and eight in both hyperplasia and carcinoma. Twelve of these 33 differentially expressed proteins were identified by peptide mass mapping combined with sequence database searching. Among the identified proteins were proteins involved in cellular transport and chaperoning, i.e. heat shock protein 27 kDa protein, heat shock 70 kDa protein, heat shock cognate 71 kDa protein, and serotransferrin. Other identified proteins were: regulatory chain protein of cAMP-dependent protein kinase, prohibitin, and heterogeneous nuclear ribonucleoprotein A2/B1. Finally we identified proteins associated with the cytoskeleton, vimentin and tropomyosin isoform 3, and the glycolytic pathway, alpha enolase, and phosphoglycerate kinase. The remaining unidentified proteins were either not contained in the database and must be assumed to be novel proteins, or were present in too low amounts to allow characterization.
[Breech delivery. Selection by X-ray pelvimetry].
An attempt was made to evaluate the possible benefit of selecting women for vaginal breech delivery at term by radiological pelvimetry. Information from medical records on 276 singleton breech deliveries were analysed. A total of 188 breech presentations were diagnosed before the onset of labour, pelvimetry was performed in 74 women, where pelvic dimensions too small for recommendation of vaginal breech delivery were found in 30 cases. The overall rate of caesarean section was 78%, among diagnosed patients it was 84% and 64% among undiagnosed breech presentations. Rates of morbidity (low Apgar score and admission to the neonatal care unit) did not differ significantly between infants delivered vaginally or by elective caesarean section. The material, however, is too small for valid conclusions regarding safety of vaginal delivery of term breech in women selected by criteria including estimate of pelvic size.
Lack of influence of simple premenopausal hysterectomy on bone mass and bone metabolism.
OBJECTIVE: Our purpose was to investigate the influence of premenopausal hysterectomy on bone mass. STUDY DESIGN: A cross-sectional study was performed on 69 women who had premenopausal hysterectomy and 427 women with natural menopause 50 to 59 years old. Bone mineral density was measured in the distal forearm by single-energy x-ray absorptiometry. Body composition and bone mineral density in the anteroposterior spine, proximal femur, and total body was measured by dual-energy x-ray absorptiometry. Bone turnover was determined by plasma osteocalcin, serum alkaline phosphatase, and fasting urinary calcium corrected for creatinine excretion. RESULTS: Women who had undergone premenopausal hysterectomy had similar bone mineral densities compared with women with an intact uterus in all compartments, apart from a 6% to 11% higher bone mineral density (p < 0.05 to 0.001) in the proximal femur. The women who had undergone premenopausal hysterectomy had 2% to 11% more fat (significant for arm fat, p < 0.05), 9% to 13% lower serum follicle-stimulating hormone levels (p < 0.01), 10% to 13% higher serum estradiol levels (not significant), and 8% to 9% lower osteocalcin levels (p < 0.05 to 0.07). This bone mineral density difference could thus be explained by extragonadal sex hormone production. CONCLUSION: Premenopausal hysterectomy did not reduce ovarian function and increase bone turnover and bone loss.
Dual energy X-ray absorptiometry of the spine--decubitus lateral versus anteroposterior projection in osteoporotic women: comparison to single energy X-ray absorptiometry of the forearm.
We investigated the discriminatory ability of dual energy X-ray absorptiometry (DXA) of the lumbar spine in the anteroposterior vs. decubitus lateral projection in 53 elderly women with at least one vertebral fracture and 63 age-matched women without fracture. Twenty-three premenopausal healthy women served as a reference group. Spine measurements were compared to forearm measurements by single energy X-ray absorptiometry (SXA). Bone mineral density (BMD) of the women with fractures was 16% lower in the AP projection and 17% lower in the decubitus lateral projection compared to age-matched women without fractures. t-Scores (deviation from normal premenopausal values in SDs) were -2.1 to -2.3 in the women without fractures, and -3.9 (AP projection), -3.1 (lateral projection) and -3.8 (forearm) in the women with vertebral fractures. t-Scores as well as z-scores for bone mineral content of the vertebral body and the vertebral posterior elements (both measured with the lateral projection) were similar. ROC analysis showed no significant difference between the AP and the lateral projection of the spine. When subjects with vertebral endplate sclerosis (about 25% in each group, with considerably elevated spinal BMD) were excluded, it did not significantly change the diagnostic abilities for fractures. We found no diagnostic advantage of the lateral projection as compared to the AP projection or forearm measurement. Future studies will reveal whether absorptiometry in the lateral projection can be improved by supine lateral scanning.
[The postmenopausal ovary--should it be preserved?].
Oophorectomia per occasionem is often performed in connection with hysterectomy in peri- and postmenopausal women as prophylaxis against ovarian cancer. Reviewing published articles has shed little light on whether the postmenopausal ovaries have an endocrine function, and whether such a function may have physiological importance. Population studies of healthy women, comparisons of oophorectomized and non-oophorectomized postmenopausal women and measurements of ovarian venous gradients have shown that the postmenopausal ovaries contribute substantially to the production of androgens, and produce about half the body's circulating testosterone. In a number of women there is a continued significant oestrogen production in the ovaries during the first five to ten years following menopause. After this period the ovarian contribution to the total oestrogen production is very small. To what extent the continued androgen production could have physiological importance cannot be decided by reviewing the literature. Androgens seem to have importance for sexual function, but could possibly also have negative effects in the form of an increased risk of cardiovascular disease. We lack both epidemiological investigations and in-vitro perfusion studies of human ovaries in order to illuminate the physiological function of the postmenopausal ovary. In deciding on oophorectomia per occasionem in the postmenopausal woman the possible advantages of continued ovarian hormonal production must be weighed against the risk of later development of ovarian cancer, which is 2%, identical to that of the risk in the background population.
Bleeding pattern and climacteric symptoms during different sequential combined HRT regimens in current use.
Four sequential combined oestrogen and progestogen regimens were compared in terms of bleeding pattern and relief of climacteric symptoms. Treatment was with either 2 mg 17 beta-oestradiol with 1 mg norethisterone acetate [E2 + NETA]; 2 mg oestradiol valerate with 75 micrograms levonorgestrel [E2V + LNG]; 2 mg oestradiol valerate with 10 mg medroxyprogesterone acetate [E2V + MPA]; or 1.5 mg 17 beta-oestradiol with 150 micrograms desogestrel [E2 + DG]. A placebo-controlled study lasting 12-24 months was completed by 143 healthy early postmenopausal women. Bleeding lengths were not substantially different; in all regimens the majority of women were bleeding for 3-6 days. Bleeding onset showed differences when related to the 11th day of progestogen addition; in the regimen with E2V + LNG, 21% of the women women were bleeding before the 11th day of progestogen addition 26% on, and 53% after that day. In the regimen with E2V + MPA, 56% of the women were bleeding before the 11th day, 28% on, and 17% after that day, whereas in the regimen with E2 + DG, 15% of the women were bleeding before the 11th day, 5% on, and 80% after that day. All regimens reduced climacteric symptoms to the same extent. Breast tenderness occurred in all the regimens, except in the E2 + DG. Conclusively, the differences between the responses to treatment were not conspicuous. However, our data indicate that one regimen (E2 + DG) resulted in optimal bleeding control, optimal effect on climacteric symptoms, and no production of breast tenderness.
[Ovarian function after premenopausal hysterectomy].
In Denmark, about 6000 hysterectomies are performed annually, and about 75% are performed on benign indications in women less than 50 years of age. When deciding on oophorectomia per occasionem, the risk of disease in the retained ovaries must be weighed against the advantages of continued ovarian function. The literature about ovarian function after hysterectomy consists predominantly of older, retrospective and uncontrolled investigations describing earlier menopause, increased frequency of climacteric symptoms and increased risk of benign ovarian cysts. Hysterectomy is followed by histological changes in the retained ovaries, but a significant reduction in the ovarian hormone production is not documented. Several studies have indicated that hysterectomy is followed by an increased risk of ischaemic heart disease, but the literature is equivocal. A possible explanation for the altered ovarian function after hysterectomy is reduced ovarian blood supply caused by the operation, but the existence of a direct endocrine function of the uterus can not be excluded. Solid prospective studies of the ovarian function following hysterectomy are needed.
Nutrition and fitness in the prophylaxis for age-related bone loss in women.
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Calcium intake and osteoporosis.
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Assessment of the physiological bone loss in women, with special emphasis on the menopausal changes.
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Influence of menopause on serum lipids and lipoproteins.
The influence of the menopause on serum lipids and lipoproteins was examined longitudinally at 6-week intervals for 2-3 years in pre-menopausal women undergoing the menopause. Serum lipid and lipoprotein profiles were also examined cross-sectionally in 4 groups of pre-menopausal, peri-menopausal and post-menopausal women, who were followed up longitudinally at 3-monthly examinations for 1-2 years. The results covering 1360 examinations and 270 woman-years are reported here. Serum concentrations of total cholesterol (P = 0.001), low-density-lipoprotein (LDL) cholesterol (P = 0.001) and triglycerides (P less than 0.05) increased significantly as a consequence of the menopause and all increases occurred within 6 months of cessation of menstrual periods. High-density-lipoprotein (HDL) cholesterol decreased significantly (P less than 0.05) as a consequence of the menopause, but the decline occurred gradually over the 2 years preceding cessation of menses. In addition to the menopausal changes, serum concentrations of total cholesterol and LDL-cholesterol increased gradually in the pre-menopausal and post-menopausal years, but were significantly related to biological age only in the pre-menopausal groups (P less than 0.05). Serum triglycerides and HDL-cholesterol levels remained virtually unchanged in the pre-menopausal as well as the post-menopausal groups and were only influenced by the actual menopause. Serum lipids and lipoproteins are thus significantly altered as a consequence of the menopause. The result is a more atherogenic lipid profile which may partly explain the increased risk of cardiovascular disease observed in post-menopausal women.
The pathophysiology of peri- and postmenopausal bone loss.
Changes in sex hormones and bone turnover were studied longitudinally in 31 women aged 47-54 years who were approaching the menopause. Every 6 weeks for 2-3 years, hormones and biochemical estimates of the bone turnover were determined and the bone mass was measured at two forearm sites by single photon absorptiometry. Spinal bone mass was measured every 6 months. The bone turnover was normal in women aged 47-54 years with regular menstruation, whereas the estimates of bone resorption were high in the women with irregular menstruation. In nine women, who reached the menopause during the study, bone resorption increased significantly, whereas bone formation showed only a small increase. When the results of the nine women were combined with those of 50 women, who had passed a natural menopause within the preceding 3.5 years, the bone resorption indices reached their peak within the first postmenopausal year, whereas bone formation increased until 1.5-2 years after the last menstrual cycle. At the ultradistal forearm site the rate of bone loss was maximal (5% per year) immediately after the menopause and subsequently declined, which suggests that trabecular bone is more sensitive than cortical bone to changes in bone turnover. Spinal bone loss was identical in late peri- and early postmenopausal women. We conclude that bone resorption starts to increase during the last perimenopausal years, with a beginning acceleration in bone loss, which then becomes sharp after the menopause. The changes are related to the decline in oestrogens, but other mechanisms may also play a role.
Regional bone mineral in healthy and osteoporotic women: a cross-sectional study.
Regional bone mineral content and density (BMC and BMD) was measured in six regions (head, arms, chest, spine, pelvis, and legs) using dual photon 153Gd absorptiometry (DPA) in 128 healthy women aged 21-77 years, and in 45 women presenting with Colles' fracture (mean age 65 years), 46 women with vertebral crush or wedge fracture (mean age 68 years), and 27 women with femoral neck-fracture (mean age 74 years). The age-related normal bone loss was generalized, uniformly distributed, and best described by a combination of a premenopausal linear and a postmenopausal exponential regression in all six regions. Looking at BMD, the overall expected bone loss from age 20 to age 80 was approximately 20% in all the regions. When the fracture patients were examined, we found also generalized bone deficit as the prominent feature, amounting to about 20% of the premenopausal level for Colles' and spinal fractures, and about 25% for femoral neck-fracture. However, there was a regional bias in the fracture patients, as the Colles' and spinal fracture patients had a preferential reduction in spinal and pelvic BMD, whereas the patients with femoral neck-fracture had a preferential reduction in pelvic and leg BMD. We conclude that age-related and osteoporotic bone loss is generalized. Furthermore, we propose that regional differences in osteoporotic bone loss are brought about by a simple biological variability of the range of (i) relative amount of trabecular and cortical bone, (ii) rate of loss in the two types of bone tissue, and (iii) time of onset of trabecular relative to cortical bone loss.
Discriminative ability of total body bone-mineral measured by dual photon absorptiometry.
We investigated the discriminative ability of total body bone-mineral expressed as the total body bone-density (TBBD) measured by dual photon absorptiometry (DPA) in 79 healthy premenopausal women, 27 healthy postmenopausal women, and 120 female osteoporotic fracture patients presenting with either Colles' fracture, vertebral fracture or femoral neck-fracture. TBBD was compared to the bone-mineral density of the lumbar spine (BMDspine) also measured by DPA, and to the bone-mineral content of the forearms (BMCforearm) measured by single photon absorptiometry (SPA). TBBD, BMDspine and BMCforearm showed that all the fracture patient groups had significantly reduced bone-mass. Using receiver operating characteristic (ROC) analysis, we found that TBBD had a tendency towards better discriminative ability than BMDspine or BMCforearm with regard to the discrimination between healthy premenopausal women and the three types of osteoporotic fractures (not significant in spinal fracture patients). BMCforearm had an intermediate position, whereas BMDspine had the smallest discriminative ability. TBBD also discriminated better between healthy postmenopausal women and hip-fracture patients than BMDspine or BMCforearm, whereas there was no significant difference between the three methods regarding the discrimination between the healthy postmenopausal women and the Colles' and spinal fracture patients. We conclude that the TBBD measurement by DPA has a discriminative potential which is better than the local spine or forearm measurements.
Lack of seasonal variation in bone mass and biochemical estimates of bone turnover.
Three previous studies have indicated a seasonal variation in bone mineral content, with values during the summer being 1.7% to 7.5% higher than during the winter. We have examined the seasonal influence on both bone mass, biochemical estimates of bone turnover and vitamin D metabolites in 86 healthy women, aged 29-53 years. All participants were followed up for 2 years with examinations every 6 weeks or 3 months. Bone mineral content in the proximal and distal part of the forearm (single photon absorptiometry) did not reveal any significant seasonal variation, whereas bone mineral density of the lumbar spine (dual photon absorptiometry) indicated that the highest values occurred in winter. None of the biochemical parameters showed any statistically significant cyclical changes. Serum concentrations of 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D3 showed a highly significant seasonal variation, whereas the serum 1,25-dihydroxyvitamin D concentration was virtually unchanged. We conclude that seasonal variation in bone mineral content and bone turnover should not be taken into account when interpreting data from longitudinal studies of healthy pre- and postmenopausal women on a sufficient vitamin D nutriture.