A double-blind, randomized, comparative study evaluating clinical effects of two sequential estradiol-progestogen combinations containing either desogestrel or medroxyprogesterone acetate in climacteric women.

OBJECTIVES: The aim of this study was to compare a new sequential estradiol-desogestrel (E2-DSG) hormone replacement regimen (Liseta) with one of the standard treatments i.e. estradiol valerate-medroxyprogesterone acetate (E2V-MPA) combination (Klimalet) regarding the alleviation of climacteric symptoms, vaginal bleeding pattern and the occurrence of adverse experiences. METHODS: In a multicenter study performed in Denmark, a total of 376 perimenopausal women with climacteric symptoms were randomly allocated to oral sequential treatment with either E2-DSG (1.5 mg E2 for 24 days with 0.15 mg DSG for the last 12 days followed by a placebo tablet for 4 days) (n = 186) or with E2V-MPA (2 mg E2V for 21 days with 10 mg MPA for the last 10 days) (n = 190). Treatments were administered, using a double-blind, double-dummy technique for 6 cycles of 28 days. RESULTS: Three hundred and seventeen women, 158 in the E2-DSG and 159 in the E2V-MPA group, completed six treatment cycles. Both treatments reduced menopausal symptoms rapidly and to a similar extent. Hot flushes were present in 88% of the women in both groups. After six treatment cycles, hot flushes were no longer present in 71 and 62% of the women in the E2-DSG and E2V-MPA group, respectively. Perspiration decreased from 80 to 65% in the E2-DSG group and from 82 to 63% in the E2V-MPA group. Mood disturbances were present in 82% of the women in the E2-DSG at baseline, and in 52% after six cycles. In the E2V-MPA group the corresponding figures were 68 and 42%, respectively. The bleeding pattern was comparable in both treatment groups. Regular withdrawal (expected) bleeding appeared in 90-92% and in 85-90% of the women in cycles 1-5 with E2-DSG and E2V-MPA, respectively. Irregular bleeding (including spotting) occurred in 15.2% of the women receiving E2-DSG and in 20.1% of the women treated with E2V-MPA in cycle 6. In both treatment groups there was a tendency of a slight decrease in blood pressure. Adverse events were in less than 10% in each group the reason to discontinue treatment. CONCLUSIONS: Both treatments effectively alleviated menopausal complaints and presented good cycle control. Bleeding pattern and mood disturbances appeared to be more favorable influenced by E2-DSG.

[Problem-based medical teaching]. / Problembaseret laegevidenskabelig undervisning.

A possible method of improving teaching at faculties of Health Sciences is the so-called problem-based teaching method. A student is presented with a (clinical) medical case, which is to be investigated. By means of this method, the student himself will, under guidance, formulate his individual lack of knowledge, goals, priorities, methods, and evaluation. Educational observations show that the learning process is better when the problem-solving takes place among a group of students. A tutor acts as a catalyst for the process and gives feed-back through the problem-solving. He is therefore not an intermediary of knowledge to the group, but primarily refers the student to literature or knowledge experts at the faculty. International studies have not proven any unequivocal improvement in the students' ability to pass exams or to work as doctors, but both teachers and students seem to be more satisfied with the teaching method, which has stimulated the wish to study. The use at other faculties has not caused any large increase in expenditures. This should result in an increased use of problem-based teaching in medical education.

[Technique of induced abortion, abrasion and vacuum extraction. Clinical trial of Ambu Twin Pump 1000]. / Teknik ved abortus provocatus, vabrasio og vakuumekstraktion. Klinisk afprøvning af Ambu Twin Pump 1000.

Ambu Twin Pump 1000 is a suction pump designed for pharyngeal and tracheal suction in emergency situations. The pump can be operated by foot or by hand. The object of this test was to evaluate the applicability of the pump in performing legal abortion (before 13th. week), suction curettage and vacuum extraction, in places where electricity is not available; thus especially for use in Third World countries. The evaluation of the pump concerned the suction capacity, the stability on the support and finally ease of dismantling and cleaning. It is concluded that Ambu Twin Pump 1000 are easy to use and has sufficient suction capacity for the mentioned purposes. For induced abortion the pump was provided with a 200 ml reservoir for cleaning purposes.

[Methods in the evaluation of medical students]. / Metoder i evalueringen af laegevidenskabelige studenter.

The achievements of medical students are decisively dependent on the method of evaluation during their education. Frequent testing of these achievements by well-defined (cross-specialized) problems (involving cases) enables the student to quickly correct own knowledge- or skills-deficiencies, while the relevance of the curriculum is further visualized. A differentiated panel of tests evaluates both the students individual study methods and her ability to make clinical inquiry, diagnoses and application of practical skills. An insufficient individual performance graded by known minimal specific standards entails a feedback session with a counsellor who pin-points defects in the student's knowledge and suggests methods for correction. This form of evaluation is expected to be costly, but is a necessity to improve the quality of the graduating medical students.

[Cesarean section under epidural anesthesia. A questionnaire study]. / Kejsersnit i epidural anaestesi. En spørgeskemaundersøgelse.

Seventy-four women selected at random who had been subjected to Caesarean section replied to questions about their satisfaction with epidural anaesthesia at various stages during the intervention. General discomfort increased during the intervention and pain contributed most to this. 96% of the women would recommend the method to others.

Female chronic pelvic pain is highly prevalent in Denmark. A cross-sectional population-based study with randomly selected participants.

Background and purpose Female chronic pelvic pain is a significant clinical problem that burdens the health care services and work productivity, and leads to disability and reduced quality of life among the women affected. A recent systematic review reported worldwide prevalence rates for female chronic pelvic pain ranging from 2.1% to 24%. Our aim was to assess the prevalence, characteristics, and factors associated with chronic pelvic pain among women living in Denmark, and to compare these findings with a pain-free reference group. Secondly, we evaluated the impact of pain on daily life in women suffering from chronic pelvic pain. Methods A cross-sectional postal survey of the prevalence of chronic pelvic pain was undertaken in a randomly selected general female population in Denmark (N = 2500). Inclusion criteria were: (a) ≥18 years of age and (b) living in the Capital region or the region of Zealand in Denmark. Statistical analyses included prevalence percentage rates, chi-square tests, Mann-Whitney tests, and unpaired T-tests. Logistic regression analysis was used to identify the significant independent variables and to estimate their simultaneous impact on chronic pelvic pain. The results were expressed as odds ratio and 95% confidence intervals. All tests were two-tailed and significance levels were set at p < 0.05. Results 1179 (48%) women living in representative areas of Denmark responded. The prevalence of chronic pelvic pain was 11% (n = 130) in women ≥18 years with a prevalence of 13.6% (n = 87) in women of reproductive age; 6.2% (n = 73) women experienced at least moderate average pain intensity (numerical rating scale ≥4). Self-reported diagnosis of irritable bowel syndrome (20%), bladder pain syndrome/interstitial cystitis (3%), vulvodynia (9%), endometriosis (8%), and pelvic surgery in the preceding 6 months (5%) were more prevalent in cases compared to pain-free reference subjects (p = 0.00). Chronic pelvic pain interfered with daily life "all the time" in 5% of the women, "sometimes" in 72.3%, and "not at all" in 22.7%. Factors independently associated with chronic pelvic pain were age, country of birth, and former pelvic trauma or pelvic surgery (p < 0.05). No association was found between chronic pelvic pain and selected socio-demographic factors (residential area, educational level, cohabitation status and employment status). Conclusions Female chronic pelvic pain appears highly prevalent (11%) in Denmark (6.2% with moderate to severe pain). Women of reproductive age had a slightly increased prevalence (13.6%). Although the reported prevalence is based on 48% (N = 1179) of the invited sample, dropout analyses found that respondents did not deviate from non-respondents. Therefore, we considered the reported prevalence rate representative for the total sample and generalisable to the general female population in Denmark. This study was cross-sectional, and relied on association-based analyses. Consequently, causality between age groups, country of birth, former pelvic surgeries and pelvic traumas and experiences of chronic pelvic pain remains unknown. Implications In order to improve prevention and treatment of chronic pelvic pain in Denmark, high quality, population-based cohort studies and randomised clinical trials are essential. The demand for trustworthy chronic pelvic pain prevalence estimates might also inspire political attention and hereby facilitate funding for further development of treatment and research.

Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study.

BACKGROUND: No current standardized set of pelvic floor muscle (PFM) outcome measures have been specifically tested for their applicability in a general female chronic pelvic pain (CPP) population. We aimed to compare PFM function between a randomly selected population-based sample of women with CPP and age-matched pain-free controls using multiple standardized intravaginal examination measures recommended by the International Continence Society. METHODS: This was a cross-sectional, population-based and controlled study with randomly selected participants among women in Denmark. We reported blinded findings from a set of standardized vaginal PFM examination manoeuvres in 50 female participants (24 with CPP, 26 pain free). A preliminary pilot study ensured the intra- and intertester reliability of the test procedure. PFM outcomes were resting tone, relaxation capacity, strength, surface electromyographic activity and mechanosensitivity. Statistical analyses included unpaired t-tests, Fisher's exact tests and Mann-Whitney tests. RESULTS: The examination protocol was a reliable and predictable clinical measurement of associated PFM dysfunction in female CPP. Women with CPP had higher PFM resting tone and decreased maximal PFM strength and relaxation capacity compared with pain-free controls. Enhanced PFM pressure-pain sensitivity measured by palpometry during examination was also associated to CPP. CONCLUSION: This controlled, single-blinded study with randomly selected participants provides new population-based information regarding associated PFM dysfunction in women with CPP using multiple intravaginal examination methods. However, to identify women with CPP who will benefit from a physiotherapeutic specialized intervention, future prospective randomized controlled trials using these reliable and predictive outcomes are needed.

Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review.

Background and purpose Chronic pelvic pain (CPP) is a debilitating condition among women with a major impact on health-related quality of life, work productivity and health care utilisation. The exact prevalence of chronic pelvic pain is not known, but 3.8% is commonly suggested. Musculoskeletal dysfunction is frequently cited as a possible aetiology. Physiotherapy is therefore recommended as one treatment modality. The aim of this systematic review was to source and critically evaluate the evidence for an effect of physiotherapy on pain, physical activity and quality of life in the treatment of female CPP. Methods Electronic databases, conference proceedings, text books and clinical guidelines were searched for quantitative, observational, and prospective clinical intervention studies of female chronic pelvic pain where physiotherapy was a sole or significant component of the intervention. Trial inclusion, data extraction according to predefined criteria and risk of bias assessment were performed by two independent authors. Methodological quality of the included clinical intervention studies was assessed using The Cochrane Collaboration's tool for assessing risk of bias. Review Manager (RevMan) version 5.0 was used for data analysis. Effect estimates (relative risk, mean difference and mean change) with 95% confidence intervals were calculated for the above outcomes. For significant outcomes the numbers needed to treat were calculated. Results The search strategy identified 3469 potential articles. Of these, 11 articles, representing 10 studies, met the inclusion criteria. There were 6 randomised clinical trials, 1 cohort study and 3 case series. Methodological quality was dependent on study type. Accordingly, level of evidence was judged higher in randomised clinical trials than in the other study types. Physiotherapy treatments varied between studies and were provided in combination with psychotherapeutic modalities and medical management. This did not allow for the 'stand-alone' value of physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions, outcome measures and times of follow-up, prevented meta-analysis. Narrative synthesis of the results, based on effect estimates and clinically relevant pain improvement, disclosed some evidence to support an effect of multidisciplinary intervention and Mensendieck somatocognitive therapy on female chronic pelvic pain. Conclusion Chronic pelvic pain in women is a major health care problem with no specific therapies and poor prognosis. There seems to be some evidence to support the use of a multidisciplinary intervention in the management of female chronic pelvic pain. Somatocognitive therapy is a new approach that appears to be promising and randomised clinical trials are underway in order to establish its evidence base. Implications Based on the findings of this review, recommendations for physiotherapy in chronic pelvic pain clinical guidelines, textbooks and narrative reviews should be interpreted with caution due to the lack of a sufficient evidence base. Only small and largely non-randomised studies have been undertaken of physiotherapeutic interventions and this greatly limits the available evidence on which to base clinical practice. High quality randomised clinical trials are therefore urgently needed.

Skin oxygen tension, skin oxygen consumption, and skin blood flow measured by a tc-pO2 electrode.

By use of a combined tc-pO2 skin blood flow sensor E5250 and measurement of cutaneous and subcutaneous blood flows with the 133Xenon washout method it was demonstrated that blood flow in both tissues increases with a factor of 3-4 when the electrode temperature increases from 37 to 45 degrees C. In order to examine the influence of the gas diffusion barrier within the epidermal membrane the stratum corneum of the forearm was removed selectively by stripping with adhesive tape. Stripping increased the oxygen tension values from 10.98 +/- 0.63 kPa to 14.58 +/- 1.03 kPa, and skin oxygen consumption ranged from 0.208 to 0.251 ml O2.(100g.min)-1. The combination of a Clark type electrode with a heat sensor allows determination of oxygen delivery to the skin as well as the oxygen supplying cutaneous blood flow. The distribution of blood flow between nutritional and shunt vessels at various local temperatures remains to be clarified.

Blood flow rate, temperature, oxygen tension and consumption in the skin of adults measured by a heated microcathode oxygen electrode.

Reliable transcutaneous measurements of arterial oxygen tension are based on a maximum skin blood flow rate which is created by heating the skin, typically at an electrode temperature of 44 to 45 degrees C. This increase in skin blood flow rate creates an arterialization of the oxygen tension in the capillaries and the surrounding tissue. The heat conducted to the skin surface is removed by a combination of convection (skin perfusion) and conduction to the deeper layers of the skin. This heat transport to and through the skin surface causes a measurable temperature profile from the electrode surface to the capillary layer. By a blood flow cessation it is possible to change the temperature profile because the convective part of the heat consumption is eliminated and the conductive part can then be measured and subtracted. Using the forearm as measuring area and a heated tc-PO2 electrode several observations were made. The mean temperature gradient over epidermis down to the capillary layer at an electrode temperature of 43, 44, and 45 degrees C was 2.1, 2.4 and 2.7 degrees C, respectively. The change in temperature profile caused by the blood flow cessation enabled primarily an estimation of the skin blood flow rate by temperature measurements, ranging from 0.07 to 0.24 ml.cm-2.min-1. Increasing blood flow rates correlated to increasing tc-PO2 values. By means of a dynamically, thermally shielded tc-PO2 electrode it was possible to determine the skin blood flow rates in the same arbitrary units computed on the basis of the heat dissipation to the skin surface. Furthermore, it was possible to correlate these blood flow estimations to the cutaneous blood flow rates measured by 133Xe washout technique. By increasing the electrode temperature the cutaneous blood flow rates increased from 12 to 50 ml.(100 g)-1.min-1. It was possible to calculate a conversion factor on the basis of the correlation between the heat determinations of the skin blood flow rate and the 133Xe measurements. Using this conversion factor the highest blood flow rate did not exceed 55 ml.(100 g)-1.min-1. The subcutaneous blood flow rate increased accordingly with increasing electrode temperature. It was concluded that the measured heat consumption of the skin is effected by the heat removing capacity of the cutaneous as well as the subcutaneous blood flow. The cutaneous blood flow, however, was considered predominant in the transport of heat from the skin surface. By 50 times of stripping the skin surface, the cornified epidermal membrane was removed. This procedure increased the tc-PO2 values by on an average 3.6 kPa (27.1 mmHg).(ABSTRACT TRUNCATED AT 400 WORDS)

Estimation of blood flow in transcutaneous PO2 measurements.

A method for estimation of the cutaneous blood flow in transcutaneous PO2 measurements is presented. Recordings of electrode and skin temperature make it possible to compute the effect dissipated to the circulating blood. Eighteen measurements were performed on three healthy volunteers at electrode temperature settings from 37.0 degrees C to 45.0 degrees C. The blood-flow estimates ranged from 0.07 to 0.19 ml . cm-2 . min-1. At an electrode temperature of 45.0 degrees C the investigations showed a tc-PO2 value as low as 7 mmHg (0.9 kPa) which, however, corresponded well to the lowest blood-flow estimate determined. The temperature-corrected (37 degrees C) a-PO2-tc-PO2 gradient ranged from 50 mmHg to 95 mmHg (6.7-12.6 kPa). The investigations confirm the importance of simultaneous determinations of cutaneous blood flow, capillary temperature and cutaneous oxygen consumption in order to describe the connection between arterial and cutaneous oxygen tension. The cutaneous blood flow seems in this connection to be the most important parameter.