Complications after benign hysterectomy, according to procedure: a population-based prospective cohort study from the Danish hysterectomy database, 2004-2015.

OBJECTIVE: To compare the risk of complications associated with benign hysterectomy according to surgical procedure. DESIGN: Register-based prospective cohort study. SETTING: Danish Hysterectomy Database, 2004-2015. POPULATION: All Danish women with benign elective hysterectomy (n = 51 141). METHODS: Multivariate log-binomial regression to compute relative risks (RRs) stratified by calendar period, and adjusted for age, height, weight, smoking habits, use of alcohol, comorbidity, indications, uterine weight and adhesions. Multiple imputation and 'intention to treat' analyses were performed. MAIN OUTCOME MEASURES: Major (grades III-V) and minor (grades I-II) Clavien-Dindo modified complications within 30 days. RESULTS: Overall, major complications occurred in 3577 (7.0%) hysterectomies and minor complications occurred in 4788 (9.4%). The proportions of major and minor complications according to type of hysterectomy were: 10.3 and 9.6% for abdominal hysterectomy (AH); 4.1 and 12.1% for laparoscopic hysterectomy (LH); and 4.9 and 8.0% for vaginal hysterectomy (VH) for non-prolapse, and 2.3 and 6.4% for prolapse. In multivariate analyses, compared with VH for non-prolapse, the risk of major complications was higher for AH (RR 1.82, 95% CI 1.63-2.03) but lower for both LH (RR 0.78, 95% CI 0.68-0.90) and VH for prolapse (RR 0.55; 95% CI 0.41-0.75). For LH, the risk of major complications reduced from a RR of 0.96 (95% CI 0.75-1.22) in the time period 2004-2009 to an RR of 0.72 (95% CI 0.60-0.87) between 2010 and 2015. CONCLUSION: Laparoscopic hysterectomy and VH for uterine prolapse are associated with fewer major complications, and AH is associated with more major complications, compared with VH performed in the absence of uterine prolapse. TWEETABLE ABSTRACT: Laparoscopic hysterectomy has fewer major complications compared with vaginal hysterectomy, in the absence of uterine prolapse.

Randomized trial to examine procedure-to-procedure transfer in laparoscopic simulator training.

BACKGROUND: Laparoscopic simulation has become a standard component of surgical training, but there is limited knowledge regarding skills transfer between procedural tasks. The objective was to investigate the specificity of procedural simulator training. METHODS: This was randomized single-centre educational superiority trial. Surgical novices practised basic skills on a laparoscopic virtual reality simulator. On reaching proficiency, participants were randomized to proficiency-based training. The intervention group practised two procedures on the simulator (appendicectomy followed by salpingectomy), whereas the control group trained on only one procedure (salpingectomy). The main outcomes were number of repetitions and time to proficiency for the second procedure. RESULTS: Ninety-six participants were randomized, of whom 74 per cent were women, with a median age of 26 years. The intervention group needed significantly fewer attempts than the control group to reach proficiency in the second procedure: median (i.q.r.) 22 (17-34) versus 32 (26-41) attempts, which corresponded to 24·1 per cent fewer attempts as assessed by multivariable analysis (P = 0·004). The intervention group required significantly less time than the control group to reach proficiency: median (i.q.r.) 88 (63-127) versus 131 (101-153) min respectively, corresponding to a difference of 31·1 min as assessed by multivariable analysis (P = 0·001). CONCLUSION: Practising two procedures, compared with only one, reduced the number of attempts and time to reach proficiency in the second procedure. Skills transfer is seen between two tasks in laparoscopic simulator training; however, task specificity is still present when practising procedures. REGISTRATION NUMBER: NCT02069951 (http://www.clinicaltrials.gov).

Five-year follow up of a randomised controlled trial comparing subtotal with total abdominal hysterectomy.

OBJECTIVES: To compare the rates of urinary incontinence (UI) and other complications of subtotal abdominal hysterectomy (SAH) with total abdominal hysterectomy (TAH) at 5 years after surgery. DESIGN: Randomised clinical trial with central, computer-generated randomisation. SETTING: Danish multi-centre trial performed in 11 departments of gynaecology. POPULATION: Women referred with benign uterine diseases scheduled for abdominal hysterectomy. METHODS: Women were randomised to either SAH (n = 161) or TAH (n = 158). Follow-up data were collected from participants using postal questionnaires sent out 5 years after surgery. Complications of hysterectomy were further examined by scrutinising registered discharge summaries following hospitalisation. Intention-to-treat and per-protocol analyses were conducted. Potential bias caused by missing data was handled using multiple imputation. MAIN OUTCOME MEASURES: The primary outcome was UI. Secondary outcomes included constipation, prolapse of the vaginal vault or cervical stump, satisfaction with sexual life, pelvic pain, postoperative complications and vaginal bleeding. RESULTS: The response rate was 234/319 (73.4%). A significantly higher proportion of respondents had urinary incontinence 5 years after SAH 34/113 (30.1%) than TAH 21/119 (17.6%) (RR 1.71, 95% confidence interval 1.06-2.75, P = 0.026). This difference reduced after multiple imputation to account for missing data (RR 1.37, 95% confidence interval 0.99-1.89, P = 0.052). Eleven of the 101 women (11%) in the SAH group still experienced vaginal bleeding. No other differences were found between the two types of abdominal hysterectomy. AUTHORS' CONCLUSIONS: A smaller proportion of women suffered from UI after TAH than after SAH 5 years postoperatively. Around one in ten women continued to experience vaginal bleeding 5 years after SAH.

Socio-demographic factors, comorbidity and diagnostic delay among women diagnosed with cervical, endometrial or ovarian cancer.

This study investigates the association between socio-demographic factors, comorbidity and diagnostic delay among gynaecological cancer patients. A questionnaire was sent to 1052 women diagnosed with cervical, endometrial or ovarian cancer between October 2006 and December 2007 in Denmark. Long patient delays were associated with diagnosis with a greater risk of experiencing long delays among women diagnosed with cervical and endometrial cancer as opposed to ovarian cancer. The risk of experiencing long GP referral delays was associated with residential area, with a greater risk of long delays in rural vs. urban areas. Long gynaecologist appointment delays were associated with younger age, while long secondary care delays were associated with living in a capital area and having comorbidity. Long total delays were associated with diagnosis with greater risk of experiencing long delays among women diagnosed with cervical and endometrial cancer as opposed to ovarian cancer, and with working as opposed to being retired. In conclusion, this study found that socio-demographic factors and comorbidity play a role in the probability of experiencing long delays. If delays in diagnosis are to be reduced, there must be increased recognition of the significance of symptoms among patients and interventions aimed at ensuring timely care by specialists.

Risk indicators for dystocia in low-risk nulliparous women: a study on lifestyle and anthropometrical factors.

We examined background information and course of labour from a cohort of 2,810 low-risk nulliparas to identify possible lifestyle and anthropometrical risk indicators for dystocia. Criteria for dystocia: cervical dilatation <2 cm over 4 h during labour's active phase, or no descent during 2 h (3 h with epidural) in the descending phase, or no progress for 1 h during the expulsive phase. After adjustments, athletics or heavy gardening > or =4 h per week appeared protective for dystocia (OR 0.63, CI 0.45-0.89), contrary to a non-significant finding of intensive physical training (OR 1.57, CI 0.84-2.93). Caffeine intake of 200-299 mg/day was associated with dystocia (OR 1.37, CI 1.04-1.80); also high maternal age (OR 2.25, CI 1.58-3.22), small stature (OR 2.18, CI 1.51-3.15) and pre-pregnancy overweight (OR 1.28, CI 1.02-1.61). No association was found between dystocia and alcohol intake, smoking, night sleep and options for resting during the day.

Sports and leisure-time physical activity in pregnancy and birth weight: a population-based study.

We examined the association between sports and other leisure-time physical activities during pregnancy and birth weight of babies born after 37 completed weeks of gestation. All Danish-speaking pregnant women attending routine antenatal care at the Department of Obstetrics, Aarhus University Hospital, Denmark, from August 1989 to September 1991 were invited to participate in the study. A total of 4458 healthy women who delivered after 37 completed gestational weeks participated in this study. The associations between sports (0, 1-2, 3+ h/week) or leisure-time physical activity (sedentary, light, and moderate to heavy) and birth weight were examined by linear and logistic regression and adjusted for potential confounding factors such as smoking, parity, schooling, pre-pregnancy body mass index and gestational age. The results showed that pregnant women who practiced sports or were moderate to heavy leisure-time physical active during the early second or the early third trimester gave birth to infants with a similar birth weight as inactive women. The proportion of newborns with a low (<2500 g) or a high birth weight (>/=4500 g) was also unchanged. In conclusion, in this large population-based study, we found no association between sports and leisure-time physical activity and low-birth weight, high-birth weight, or average-birth weight.

Objective assessment of surgical competence in gynaecological laparoscopy: development and validation of a procedure-specific rating scale.

OBJECTIVE: The purpose of this study was to develop a global- and a procedure-specific rating scale based on a well-validated generic model (objective structured assessment of technical skills) for assessment of technical skills in laparoscopic gynaecology. Furthermore, we aimed to investigate the construct validity and the interrater agreement (IRA) of the rating scale. We investigated both the gamma coefficient (Kendall's rank correlation), which is a measure of the strength of dependence between observations, and the kappa value for each of the ten individual items included in the rating scale. DESIGN: Prospective cohort, observer-blinded study. SETTING: Departments of Obstetrics and Gynaecology in Zealand, Denmark. POPULATION: Twenty one gynaecologists or gynaecological trainees. MATERIAL AND METHODS: Twenty-one video recordings of right side laparoscopic salpingectomies were collected prospectively, eight from novices (defined as <10 procedures), seven from intermediate experienced (20-50 procedures) and six from experts (> 200 procedures). All operations were performed by the same operative principles and using a standardised technique. The recordings were analysed by two independent, blinded observers. MAIN OUTCOME MEASURES: Construct validity of the rating scale based on operative performance (median of total score) and interrater reliability. RESULTS: There were significant differences between the three groups: median score of novices 24.00 versus intermediate 29.50 versus expert 39.50, P < 0.003) The IRA was 0.83 overall. The gamma correlation coefficient was 0.91. The kappa values varied from 0.510-0.933 for each of the individual items of the rating scale. CONCLUSIONS: The procedure-specific rating scale for laparoscopic salpingectomy is a valid and reliable tool for assessment of technical skills in gynaecological laparoscopy.

Objective assessment of gynecologic laparoscopic skills using the LapSimGyn virtual reality simulator.

BACKGROUND: Safe realistic training and unbiased quantitative assessment of technical skills are required for laparoscopy. Virtual reality (VR) simulators may be useful tools for training and assessing basic and advanced surgical skills and procedures. This study aimed to investigate the construct validity of the LapSimGyn VR simulator, and to determine the learning curves of gynecologists with different levels of experience. METHODS: For this study, 32 gynecologic trainees and consultants (juniors or seniors) were allocated into three groups: novices (0 advanced laparoscopic procedures), intermediate level (>20 and <60 procedures), and experts (>100 procedures). All performed 10 sets of simulations consisting of three basic skill tasks and an ectopic pregnancy program. The simulations were carried out on 3 days within a maximum period of 2 weeks. Assessment of skills was based on time, economy of movement, and error parameters measured by the simulator. RESULTS: The data showed that expert gynecologists performed significantly and consistently better than intermediate and novice gynecologists. The learning curves differed significantly between the groups, showing that experts start at a higher level and more rapidly reach the plateau of their learning curve than do intermediate and novice groups of surgeons. CONCLUSION: The LapSimGyn VR simulator package demonstrates construct validity on both the basic skills module and the procedural gynecologic module for ectopic pregnancy. Learning curves can be obtained, but to reach the maximum performance for the more complex tasks, 10 repetitions do not seem sufficient at the given task level and settings. LapSimGyn also seems to be flexible and widely accepted by the users.

The association between early menopause and risk of ischaemic heart disease: influence of Hormone Therapy.

UNLABELLED: Randomised clinical trials find no protection against development of ischaemic heart disease by use of Hormone Therapy (HT) after the age of 50 years. Observational studies suggest that early menopause is a risk factor for ischaemic heart disease. Yet, a clinical very relevant question is whether HT reduces this risk associated with early menopause. OBJECTIVE: To analyse whether early menopause based on various causes are independent risk factors for ischaemic heart disease, and to investigate whether the risks are modified by use of HT. METHODS: In a prospective cohort study questionnaires were mailed to Danish female nurses above 44 years of age in 1993. Information on menopause, use of HT and lifestyle was obtained. In total 19,898 (86%) nurses fulfilled the questionnaire, among them 10.533 were postmenopausal with definable menopausal age, free of previous ischaemic heart disease, stroke or cancer. Through individual linkage to national register incident cases of ischaemic heart disease were identified until end of 1998. RESULTS: Menopause below both age 40 and 45 was associated with an increased risk of ischaemic heart disease, seeming most pronounced for women who had an early ovariectomy but also among spontaneous menopausal women. Generally HT did not reduce the risk except for the early-ovariectomised women, where no increased risk of ischaemic heart disease for HT users was found. CONCLUSION: We found an increased risk of ischaemic heart disease associated with early removal of the ovaries that might be reduced with HT. The present study need confirmation from other studies but suggests that early ovariectomised women could benefit from HT.

Different cerebrovascular effects of medroxyprogesterone acetate and norethisterone acetate in the New Zealand White rabbit.

OBJECTIVE: The lack of a cardioprotective effect of hormone replacement therapy (HRT), as suggested by the Heart and Estrogen/progestin Replacement Study (HERS) and Women's Health Initiative (WHI) may in part be explained by the progestin used. The aim of this study was to elucidate the effect of different progestins on cerebrovascular reactivity in an animal model. METHODS: Fifty-six ovariectomized New Zealand White rabbits were randomized into seven groups receiving hormone treatment for 4 weeks: medroxyprogesterone acetate (MPA) (10 mg/day); norethisterone acetate (NETA) (3 mg/day); conjugated equine estrogens (CEE) (1.25 mg/day); 17beta-estradiol (E2) (4 mg/day); MPA + CEE (10 mg/day + 1.25 mg/day); NETA + E2 (3 mg/day + 4 mg/day); or placebo. Segments from the basilar and posterior cerebral arteries were mounted in myographs for tension recordings. Concentration-response curves to potassium, acetylcholine, sodium nitroprusside, L-NAME (N(omega)-nitro-L-arginine methyl ester), calcium and endothelin-1 were established. RESULTS: Treatment with MPA caused a significant increase in vasoconstriction, expressed as E(max) (mN/mm, mean +/- SEM; p < 0.05), in response to potassium (3.18 +/- 0.19 vs. 2.47 +/- 0.19) and calcium (4.00 +/- 0.22 vs. 3.34 +/- 0.14) in the posterior cerebral artery, and to endothelin-1 (6.88 +/- 0.69 vs. 5.22 +/- 0.30) in the basilar artery, when compared with NETA. This difference was neutralized in the groups receiving the combined treatment of MPA + CEE and NETA + E2. No overall differences were seen between CEE and E2. CONCLUSIONS: In rabbit cerebral arteries, MPA treatment causes a higher development in arterial tension compared with NETA, indicating that different progestins may display different cerebrovascular effects. However, when accompanied by estrogens, as in the case of HRT, this difference is eliminated.

Breast cancer with different prognostic characteristics developing in Danish women using hormone replacement therapy.

The aim of this study is to investigate the risk of developing prognostic different types of breast cancer in women using hormone replacement therapy (HRT). A total of 10 874 postmenopausal Danish Nurses were followed since 1993. Incident breast cancer cases and histopathological information were retrieved through the National Danish registries. The follow-up ended on 31 December 1999. Breast cancer developed in 244 women, of whom 172 were invasive ductal carcinomas. Compared to never users, current users of HRT had an increased risk of a hormone receptor-positive breast cancer, but a neutral risk of receptor-negative breast cancer, relative risk (RR) 3.29 (95% confidence interval (CI): 2.27-4.77) and RR 0.99 (95% CI: 0.42-2.36), respectively (P for difference=0.013). The risk of being diagnosed with low histological malignancy grade was higher than high malignancy grade with RR 4.13 (95% CI: 2.43-7.01) and RR 2.17 (95% CI: 1.42-3.30), respectively (P=0.063). For breast cancers with other prognostic characteristics, the risk was increased equally for the favourable and non favourable types. Current users of HRT experience a two- to four-fold increased risk of breast cancer with various prognostic characteristics, both the favourable and non favourable types. For receptor status, the risk with HRT was statistically significantly higher for hormone receptor-positive breast cancer compared to receptor-negative breast cancer.

Acute effects of tibolone on cerebral vascular reactivity in vitro.

OBJECTIVE: To evaluate the acute effects of tibolone and its metabolites on cerebral vascular reactivity in vitro. METHODS: Ring segments of the posterior cerebral artery from female rabbits were mounted in myographs for isometric tension recordings. Concentration-response curves with tibolone, 3alpha-OH-tibolone, 3beta-OH-tibolone, Delta(4) isomer and 17beta-estradiol were obtained before and after addition of the NO blocker N(omega)-nitro-L-arginine methyl ester (L-NAME, 10(-4) mol/l) or the potassium-channel blocker tetraethylammonium chloride (TEA, 10(-2) mol/l). Additionally, the effects of the hormones on the concentration-response curves with calcium were examined. RESULTS: Tibolone and its metabolites induced a concentration-dependent relaxation comparable to that of 17beta-estradiol (area under the curve (AUC); tibolone vs. 17beta-estradiol: 242 vs. 251; p < 0.05, analysis of variance). L-NAME increased the AUC for all substances compared with controls (p < 0.05, Student's t test), except for 17beta-estradiol. Preincubation with TEA induced no changes. The concentration-dependent contraction curves with calcium were shifted rightward by all hormones. CONCLUSIONS: The study demonstrates that the acute relaxation induced by tibolone and its metabolites in cerebral arteries in vitro is comparable to that with 17beta-estradiol, and seems to be mediated by inhibition of voltage-gated calcium channels and possibly partly by a nitric oxide-dependent mechanism.

New animal model for the study of postmenopausal coronary and cerebral artery function: the Watanabe heritable hyperlipidemic rabbit fed on a diet avoiding phytoestrogens.

OBJECTIVE: To evaluate the effect of estrogen replacement therapy (ERT) on the functional characteristics of coronary and cerebral arteries in a new rabbit model for postmenopausal vascular function. METHODS: Female ovariectomized Watanabe heritable hyperlipidemic (WHHL) rabbits were randomized to treatment for 16 weeks with either 17 beta-estradiol or placebo. The chow used was semi-synthetic, thereby avoiding the influence of phytoestrogens. Ring segments of cerebral and coronary arteries were mounted for isometric tension recordings in myographs. The passive and active length-tension relationships for electromechanical (high potassium), pharmacomechanical (histamine) and combined electro- and pharmacomechanical (high potassium plus histamine) contraction were evaluated. RESULTS: Treatment with 17 beta-estradiol significantly changed the active length-tension relationship for the electromechanical response in the proximal coronary arteries. No changes were observed for the passive length-tension relationships. CONCLUSIONS: Long-term treatment with 17 beta-estradiol lowered the electromechanical tonus of atherosclerotic coronary arteries proximally, where the atherosclerosis is most developed. This could be one of the mechanisms behind the putative protective effect of hormone replacement therapy against ischemic heart disease. The study presents a promising new animal model for the investigation of postmenopausal coronary and cerebral artery function. The data correspond well with epidemiological observations in postmenopausal women.

Substantial variability in postoperative treatment, and convalescence recommendations following vaginal repair. A nationwide questionnaire study.

BACKGROUND: Postoperative care and convalescence recommendations following vaginal surgery are generally not evidence based. The aim of this study was to describe pre and postoperative treatment, and advice and restrictions for the convalescence period, given by Danish hospital-employed gynecologists, and gynecologists in private practice, to patients undergoing vaginal repair. METHOD: In 1999 all Danish gynecologists (n=433) received a tested questionnaire about postoperative treatment and convalescence recommendations following vaginal repair. Non-responders received one reminder. OUTCOME MEASURES: Pre and postoperative treatment, and expected hospital stay. Furthermore, lifting restrictions, sick leave, and convalescence before resumption of defined activities. RESULTS: The overall response rate was 82%. The expected postoperative hospital stay was median 3 days (range, 1-7) following anterior repair, and 2 days (range, 1-7) following posterior repair. The recommended sick leave was median 6 weeks (range, 2-12) for patients with work with heavy lifts. There were substantial differences in recommendations. Recommended lifting restrictions were median 3 kg (range, 0-20) for median 4 weeks (range, 1-12), and the recommended time till recommencement of sexual intercourse was median 4 weeks (range, 0-12). The recommended convalescence was median 4-5 weeks for strenuous activities, and median 1-2 weeks for non-strenuous activities, with ranges from 0-24 weeks. The overall, great variance could not be explained by demographic differences between gynecologists. CONCLUSION: Postoperative treatment, and convalescence recommendations given by Danish gynecologists following vaginal repair, show substantial variability and are based on individual viewpoints. Evidence based guidelines and consensus are desirable.

Obesity and sarcopenia after menopause are reversed by sex hormone replacement therapy.

OBJECTIVE: Menopause is linked to an increase in fat mass and a decrease in lean mass exceeding age-related changes, possibly related to reduced output of ovarian steroids. In this study we examined the effect of combined postmenopausal hormone replacement therapy (HRT) on the total and regional distribution of fat and lean body mass. RESEARCH METHODS AND PROCEDURES: Sixteen healthy postmenopausal women (age: 55 +/- 3 years) were studied in a placebo-controlled, crossover study and were randomized to 17beta estradiol plus cyclic norethisterone acetate (HRT) or placebo in two 12-week periods separated by a 3-month washout. Total and regional body composition was measured by DXA at baseline and in the 10th treatment week in both periods. Changes were compared by a paired Student's t test. RESULTS: The change in body weight during HRT was equal to the change during placebo (-24.6 g vs. -164 g, p = 0.42), but relative fat mass was significantly reduced (-0.5% vs. +1.24%, p < 0.01). During HRT, compared with during placebo, lean body mass increased (+347 g vs. -996 g, p < 0.01) and total fat mass decreased (-400 g vs. +836 g, p = 0.06). Total bone mineral content increased (+28.9 g vs. -4.4 g, p = 0.04) and abdominal fat decreased (-185 g vs. +253 g, p = 0.04) during HRT compared with placebo. DISCUSSION: HRT is linked to the reversal of both menopause-related obesity and loss of lean mass, without overall change in body weight. The increase in lean body mass during HRT is likely explained by muscle anabolism, which in turn, prevents disease in the elderly.

Fast track hysterectomy.

OBJECTIVE: To identify factors limiting early discharge after laparoscopically assisted vaginal hysterectomy (LAVH) and abdominal hysterectomy, in a fast track setting with emphasis on information, treatment of pain, early mobilization, and early food intake. STUDY DESIGN: A prospective, descriptive study of 32 unselected women allocated to either abdominal hysterectomy (n=16) or LAVH (n=16). The patients received the same information, care, and advice for the perioperative period except for an assumed 1-day hospital stay in the LAVH-group and 2 days in the abdominal group. RESULTS: Patients were discharged median 1 day (1-3) after LAVH and 2 days (2-4) after abdominal hysterectomy. Work was resumed median 23 days after abdominal hysterectomy and 28 days after LAVH (P > 0.05). CONCLUSIONS: The study questions the previously proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy. Further studies with active rehabilitation are needed to demonstrate real differences between laparoscopic and open hysterectomy.

17beta-Estradiol but not the phytoestrogen naringenin attenuates aortic cholesterol accumulation in WHHL rabbits.

The effects of 17beta-estradiol (17beta-E(2)) or the phytoestrogen naringenin on spontaneous atherosclerosis were studied in 36 ovariectomized homozygous Watanabe heritable hyperlipidemic (WHHL) rabbits receiving a semisynthetic control diet; this diet added 0.0040% 17beta-E(2;) or 0.20% naringenin, for 16 weeks. The uterine weight was increased (P < 0.001) and the concentration of estrogen receptor alpha was decreased (P < 0.001) in the 17beta-E(2) group compared with the controls. Total plasma cholesterol and triglycerides were not different from those in the controls. In lipoproteins, HDL cholesterol was increased (P < 0.01), and LDL triglyceride and IDL triglyceride were lowered (P < 0.05). The oxidation (as concentration of malondialdehyde) was increased in LDL (P < 0.05) but not in plasma. The cholesterol accumulation was decreased (P < 0.05) in the ascending aorta and in the total aorta but the ratio of intima to media and area of intima in ascending, thoracic, and abdominal aorta were not significantly different. In the naringenin group the only differences, compared with the control group, were increased HDL cholesterol (P < 0.001) and decreased activity of glutathione reductase (P < 0.05). In conclusion, 17beta-E(2), but not naringenin, attenuated aortic cholesterol accumulation independently of plasma and LDL cholesterol. Further, these results support previously suggested pro-oxidant ability of 17beta-E(2) toward LDL and a possible connection between the pro-oxidant nature of 17beta-E(2) and its antiatherogenic effect.

[Laparoscopic surgery--an update of current status]. / Laparoskopisk kirurgi--en statusvurdering.

Recent developments have allowed most intra-abdominal procedures to be performed by the laparoscopic technique. Potential clinical advantages are supported by the reduced pathophysiological changes demonstrated in the surgical stress response, as compared with open surgery. However, a critical assessment of randomised, controlled studies and meta-analyses comparing laparoscopic and open surgery has not convincingly shown that laparoscopic surgery improves the outcome, except in a few operations. Because the concept of minimal invasive surgery is based on well-documented pathophysiological advantages, future randomised studies comparing laparoscopic and open surgery should include a revision of perioperative care regimens with early rehabilitation, in order to demonstrate more significant benefits of laparoscopic surgery.