Effects of resistance training on quality of life in postmenopausal women with vasomotor symptoms

OBJECTIVE

Most women experience vasomotor symptoms (VMS) around menopause that may affect quality of life negatively. Effective pharmacological treatment exists but is not recommended for all women, and there is a demand for alternatives to reduce symptoms and improve quality of life. The objective of this study was to investigate the effect of a resistance training intervention on health-related quality of life (HRQoL) in postmenopausal women with VMS.

METHODS

This open randomized controlled trial included 65 postmenopausal women >45 years old with daily VMS. The participants were randomized to 15 weeks of resistance training three times per week or an untreated control group. The Women's Health Questionnaire (WHQ) and Short Form Health Survey (SF-36) were used to assess HRQoL at baseline and after 15 weeks.

RESULTS

The resistance training group improved compared to the control group in the WHQ domains of VMS (p = 0.002), sleep problems (p = 0.003) and menstrual symptoms (p = 0.01) from baseline to post intervention. No significant between-group differences were found in SF-36 summary scores, or in any of the domains.

CONCLUSION

In postmenopausal women with moderate to severe VMS, resistance training three times per week for 15 weeks improved menopause-specific HRQoL.

Identification of Proteins Associated with the Early Restoration of Insulin Sensitivity After Biliopancreatic Diversion

CONTEXT

Insulin resistance (IR) is a risk factor for type 2 diabetes, diabetic kidney disease, cardiovascular disease and nonalcoholic steatohepatitis. Biliopancreatic diversion (BPD) is the most effective form of bariatric surgery for improving insulin sensitivity.

OBJECTIVE

To identify plasma proteins correlating with the early restoration of insulin sensitivity after BPD.

DESIGN

Prospective single-center study including 20 insulin-resistant men with morbid obesity scheduled for BPD. Patient characteristics and blood samples were repeatedly collected from baseline up to 4 weeks postsurgery. IR was assessed by homeostatic model assessment for insulin resistance (HOMA-IR), Matsuda Index, and by studying metabolic profiles during meal tolerance tests. Unbiased proteomic analysis was performed to identify plasma proteins altered by BPD. Detailed plasma profiles were made on a selected set of proteins by targeted multiple reaction monitoring mass spectrometry (MRM/MS). Changes in plasma proteome were evaluated in relation to metabolic and inflammatory changes.

RESULTS

BPD resulted in improved insulin sensitivity and reduced body weight. Proteomic analysis identified 29 proteins that changed following BPD. Changes in plasma levels of afamin, apolipoprotein A-IV (ApoA4), and apolipoprotein A-II (ApoA2) correlated significantly with changes in IR.

CONCLUSION

Circulating levels of afamin, ApoA4, and ApoA2 were associated with and may contribute to the rapid improvement in insulin sensitivity after BPD.

Tissue-specific genes as an underutilized resource in drug discovery

Tissue-specific genes are believed to be good drug targets due to improved safety. Here we show that this intuitive notion is not reflected in phase 1 and 2 clinical trials, despite the historic success of tissue-specific targets and their 2.3-fold overrepresentation among targets of marketed non-oncology drugs. We compare properties of tissue-specific genes and drug targets. We show that tissue-specificity of the target may also be related to efficacy of the drug. The relationship may be indirect (enrichment in Mendelian disease and PTVesc genes) or direct (elevated betweenness centrality scores for tissue-specifically produced enzymes and secreted proteins). Reduced evolutionary conservation of tissue-specific genes may represent a bottleneck for drug projects, prompting development of novel models with smaller evolutionary gap to humans. We show that the opportunities to identify tissue-specific drug targets are not exhausted and discuss potential use cases for tissue-specific genes in drug research.

Human hepatic gene expression signature of non-alcoholic fatty liver disease progression, a meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is a wide-spread chronic liver condition that places patients at risk of developing cardiovascular diseases and may progress to cirrhosis or hepatocellular carcinoma if untreated. Challenges in clinical and basic research are caused by poor understanding of NAFLD mechanisms. The purpose of current study is to describe molecular changes occurring in human liver during NAFLD progression by defining a reproducible gene expression signature. We conduct a systematic meta-analysis of published human gene expression studies on liver biopsies and bariatric surgery samples of NAFLD patients. We relate gene expression levels with histology scores using regression models and identify a set of genes showing consistent-sign associations with NAFLD progression that are replicated in at least three independent studies. The analysis reveals genes that have not been previously characterized in the context of NAFLD such as HORMAD2 and LINC01554. In addition, we highlight biomarker opportunities for risk stratification and known drugs that could be used as tool compounds to study NAFLD in model systems. We identify gaps in current knowledge of molecular mechanisms of NAFLD progression and discuss ways to address them. Finally, we provide an extensive data supplement containing meta-analysis results in a computer-readable format.

Risk of postnatal depression or suicide after in vitro fertilisation treatment: a nationwide case-control study

OBJECTIVE

To examine whether women who undergo in vitro fertilisation (IVF) treatment are at greater risk of postnatal suicide or postnatal depression (PND) requiring psychiatric care, compared with women who conceive spontaneously.

DESIGN

Case-control study using data from national registers.

SETTING

Sweden during the period 2003-2009.

POPULATION

Cases were 3532 primiparous women who had given birth following IVF treatment. An aged-matched control group of 8553 mothers was randomly selected from the medical birth register.

METHODS

Logistic regression analyses were performed with PND as the outcome, and with known risk factors of PND as well as IVF/spontaneous birth as covariates.

MAIN OUTCOME MEASURES

Postnatal depression (PND), defined as diagnoses F32-F39 of the tenth edition of the International Classification of Diseases (ICD-10), within 12 months of childbirth.

RESULTS

Initial analyses showed that PND was more common in the control group than in the IVF group (0.8 versus 0.4%; P = 0.04); however, these differences disappeared when confounding factors were controlled for. A history of any psychiatric illness (P = 0.000; odds ratio, OR = 25.5; 95% confidence interval, 95% CI = 11.7-55.5), any previous affective disorder (P = 0.000; OR = 26.0; 95% CI = 10.5-64.0), or specifically a personality disorder (P = 0.028; OR = 3.8; 95% CI = 1.2-12.7) increased the risk of PND. No woman in either group committed suicide during the first year after childbirth.

CONCLUSIONS

Whereas mothers who receive IVF treatment are not at increased risk of PND, the risk is increased among mothers with a history of mental illness.

TWEETABLE ABSTRACT

A Swedish study on 3532 women showed that IVF treatment does not increase the risk of postnatal depression.

AlGaAs/GaAs/InGaAs pnp-type vertical-cavity surface-emitting transistor-lasers

We report on the design, fabrication and analysis of vertical-cavity surface-emitting transistor-lasers (T-VCSELs) based on the homogeneous integration of an InGaAs/GaAs VCSEL and an AlGaAs/GaAs pnp-heterojunction bipolar transistor (HBT). Epitaxial regrowth confinement, modulation doping, intracavity contacting and non-conducting mirrors are used to ensure a low-loss structure, and a variety of design variations are investigated for a proper internal biasing and current injection to ensure a wide operating range. Optimized devices show mW-range output power, mA-range base threshold current and high-temperature operation to at least 60°C with the transistor in its active mode of operation for base currents well beyond threshold. Current confinement schemes based on pnp-blocking layers or a buried tunnel junction are investigated as well as asymmetric current injection for reduced extrinsic resistances.

Hormone therapy might be underutilized in women with early menopause

STUDY QUESTION

Are Swedish women age 40-44 years with assumed early menopause 'undertreated' by hormone therapy (HT)?

SUMMARY ANSWER

Many women with probable early menopause discontinue their HT after a short period of time. Thus, they fail to complete the recommended replacement up to age 51-52 years, the average age of menopause.

WHAT IS KNOWN ALREADY

Spontaneous early menopause occurs in ∼5% of women age 40-45 years. Regardless of the cause, women who experience hormonal menopause due to bilateral oophorectomy before the median age of spontaneous menopause are at increased risk of cardiovascular disease, neurological disease, osteoporosis, psychiatric illness and even death.

STUDY DESIGN, SIZE, DURATION

The study is descriptive, and epidemiological and was based on the use of national registers of dispensed drug prescriptions (HT) linking registers from the National Board of Health and Welfare and Statistics Sweden from 1 July 2005 until 31 December 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study population consisted of 310 404 women, 40-44 years old on 31 December 2005 who were followed from 1 July 2005 until 31 December 2011.

MAIN RESULTS AND THE ROLE OF CHANCE

Only 0.9% of women 40-44 years old started HT during the study period. A majority of these women used HT <1 year.

LIMITATIONS, REASONS FOR CAUTION

We do not know the indications that led to the prescription of HT but assume that early onset of menopause was the main reason. Because of the study design-making a retrospective study of registers-we can only speculate on the reasons for most of the women in this group discontinuing HT. Another limitation of this study is that we have a rather short observation time. However, we have up to now only been able to collect and combine the data since July 2005.

WIDER IMPLICATIONS OF THE FINDINGS

As the occurrence of spontaneous early menopause in women age 40-45 is reported to be ∼5%, the fact that <1% of Swedish women age 40-44 are prescribed HT, and can be shown also to have had the medication dispensed at a pharmacy suggests an unexpectedly low treatment rate. Some women with early menopause may have used combined contraceptives as supplementation therapy, but in Sweden HT is the recommended treatment for early menopause so any such women are not following this recommendation. Women who experience early menopause are at increased risk for overall morbidity and mortality, and can expect to benefit from HT until they have reached at least the median age of spontaneous menopause. It is therefore important to individualize the information given these women and to convey new knowledge in this area to gynaecologists and physicians in general as well as the recommendation that women in this group continue HT at least until the average age for spontaneous menopause is reached.

STUDY FUNDING/COMPETING INTERESTS

No competing interests exist.

FKBP5 expression in human adipose tissue increases following dexamethasone exposure and is associated with insulin resistance

OBJECTIVE

To study effects of dexamethasone on gene expression in human adipose tissue aiming to identify potential novel mechanisms for glucocorticoid-induced insulin resistance.

MATERIALS/METHODS

Subcutaneous and omental adipose tissue, obtained from non-diabetic donors (10 M/15 F; age: 28-60 years; BMI: 20.7-30.6 kg/m²), was incubated with or without dexamethasone (0.003-3 μmol/L) for 24 h. Gene expression was assessed by microarray and real time-PCR and protein expression by immunoblotting.

RESULTS

FKBP5 (FK506-binding protein 5) and CNR1 (cannabinoid receptor 1) were the most responsive genes to dexamethasone in both subcutaneous and omental adipose tissue (~7-fold). Dexamethasone increased FKBP5 gene and protein expression in a dose-dependent manner in both depots. The gene product, FKBP51 protein, was 10-fold higher in the omental than in the subcutaneous depot, whereas the mRNA levels were similar. Higher FKBP5 gene expression in omental adipose tissue was associated with reduced insulin effects on glucose uptake in both depots. Furthermore, FKBP5 gene expression in subcutaneous adipose tissue was positively correlated with serum insulin, HOMA-IR and subcutaneous adipocyte diameter and negatively with plasma HDL-cholesterol. FKBP5 SNPs were found to be associated with type 2 diabetes and diabetes-related phenotypes in large population-based samples.

CONCLUSIONS

Dexamethasone exposure promotes expression of FKBP5 in adipose tissue, a gene that may be implicated in glucocorticoid-induced insulin resistance.

GPR120 (FFAR4) is preferentially expressed in pancreatic delta cells and regulates somatostatin secretion from murine islets of Langerhans

AIMS/HYPOTHESIS

The NEFA-responsive G-protein coupled receptor 120 (GPR120) has been implicated in the regulation of inflammation, in the control of incretin secretion and as a predisposing factor influencing the development of type 2 diabetes by regulation of islet cell apoptosis. However, there is still considerable controversy about the tissue distribution of GPR120 and, in particular, it remains unclear which islet cell types express this molecule. In the present study, we have addressed this issue by constructing a Gpr120-knockout/β-galactosidase (LacZ) knock-in (KO/KI) mouse to examine the distribution and functional role of GPR120 in the endocrine pancreas.

METHODS

A KO/KI mouse was generated in which exon 1 of the Gpr120 gene (also known as Ffar4) was replaced in frame by LacZ, thereby allowing for regulated expression of β-galactosidase under the control of the endogenous GPR120 promoter. The distribution of GPR120 was inferred from expression studies detecting β-galactosidase activity and protein production. Islet hormone secretion was measured from isolated mouse islets treated with selective GPR120 agonists.

RESULTS

β-galactosidase activity was detected as a surrogate for GPR120 expression exclusively in a small population of islet endocrine cells located peripherally within the islet mantle. Immunofluorescence analysis revealed co-localisation with somatostatin suggesting that GPR120 is preferentially produced in islet delta cells. In confirmation of this, glucose-induced somatostatin secretion was inhibited by a range of selective GPR120 agonists. This response was lost in GPR120-knockout mice.

CONCLUSIONS/INTERPRETATION

The results imply that GPR120 is selectively present within the delta cells of murine islets and that it regulates somatostatin secretion.

Plasma frequency and dielectric function dependence on doping and temperature for p-type indium phosphide epitaxial films

The optical properties of p-type InP epitaxial films with different doping concentrations are investigated by infrared absorption measurements accompanied by reflection and transmission spectra taken from 25 to 300 K. A complete dielectric function (DF) model, including intervalence band (IVB) transitions, free-carrier and lattice absorption, is used to determine the optical constants with improved accuracy in the spectral range from 2 to 35 μm. The IVB transitions by free holes among the split-off, light-hole, and heavy-hole bands are studied using the DF model under the parabolic-band approximation. A good understanding of IVB transitions and the absorption coefficient is useful for designing high operating temperature and high detectivity infrared detectors and other optoelectronic devices. In addition, refractive index values reported here are useful for optoelectronic device designing, such as implementing p-InP waveguides in semiconductor quantum cascade lasers. The temperature dependence of hole effective mass and plasma frequency is also reported.

Acupuncture compared with placebo acupuncture in radiotherapy-induced nausea--a randomized controlled study

BACKGROUND

It is not known if verum (real) acupuncture is effective for nausea and vomiting (emesis) during radiotherapy.

PATIENTS AND METHODS

We randomly treated 215 blinded cancer patients with verum: penetrating 'deqi' creating acupuncture (n = 109) or non-penetrating sham needles (n = 106) two to three times per week. The patients documented emesis daily during the radiotherapy period. Primary end point was the number of patients with at least one episode of nausea.

RESULTS

In the verum and the sham acupuncture group, 70% and 62% experienced nausea at least once during the radiotherapy period (relative risk 1.1, 95% CI 0.9-1.4) for a mean number of 10.1 and 8.7 days. Twenty five percent and 28% vomited, and 42% and 37% used antiemetic drugs at least once, respectively. Ninety-five percent in the verum acupuncture group and 96% in the sham acupuncture group believed that the treatment had been effective against nausea. In both groups, 67% experienced positive effects on relaxation, mood, sleep or pain reduction and 89% wished to receive the treatment again.

CONCLUSION

Acupuncture creating deqi is not more effective than sham in radiotherapy-induced nausea, but in this study, nearly all patients in both groups experienced that the treatment was effective for nausea.

A comparison of acupuncture and oral estradiol treatment of vasomotor symptoms in postmenopausal women

OBJECTIVE

To compare the effects of electro-acupuncture with oral estradiol and superficial needle insertion on hot flushes in postmenopausal women.

MATERIAL AND METHODS

Forty-five postmenopausal women with vasomotor symptoms were randomized to electro-acupuncture, superficial needle insertion or oral estradiol treatment during 12 weeks, with 6 months' follow-up. The number and severity of flushes were registered daily and the Kupperman index and a general estimate of climacteric symptoms were completed before, during and after therapy.

RESULTS

In the electro-acupuncture group, the mean number of flushes/24 h decreased from 7.3 to 3.5 (ANOVA, p < 0.001). Eleven of the 15 women had at least a 50% decrease in number of flushes (with a mean decrease of 82%). Superficial needle insertion decreased the number of flushes/24 h from 8.1 to 3.8 (p < 0.001). In seven out of 13 women, the number of flushes decreased by at least 50% (mean decrease 83%). In the estrogen group, the number of flushes decreased from 8.4 to 0.8 (p < 0.001). The decrease in number of flushes persisted during the 24-week follow-up period in all treatment groups. The Kupperman index and the general climacteric symptom score decreased, and remained unchanged 24 weeks after treatment in all groups (p < 0.001). Electro-acupuncture decreased the number of flushes/24 h significantly over time, but not to the same extent as the estrogen treatment. No significant difference in effect was found between electro-acupuncture and the superficial needle insertion.

CONCLUSION

We suggest that acupuncture is a viable alternative treatment of vasomotor symptoms in postmenopausal women and cannot recommend superficial needle insertion as an inactive control treatment.

Effects of acupuncture, applied relaxation, estrogens and placebo on hot flushes in postmenopausal women: an analysis of two prospective, parallel, randomized studies

OBJECTIVE

To assess if transdermal or oral estrogens, acupuncture and applied relaxation decrease the number of menopausal hot flushes/24 h and improve climacteric symptoms, as assessed by the Kupperman index, more than transdermal placebo treatment.

SETTING

An outpatient clinic at a Swedish university hospital.

METHODS

A total of 102 postmenopausal women were recruited to two studies performed in parallel. In Study I, the women were randomized between transdermal placebo or estrogen treatment and, in Study II, between oral estrogens, acupuncture or applied relaxation for 12 weeks. Climacteric symptoms were measured with daily logbooks on hot flushes. Women completed the assessment questionnaire for the Kupperman index at baseline and after 12 weeks.

RESULTS

The number of flushes/24 h decreased significantly after 4 and 12 weeks in all groups except the placebo group. Both at 4 and 12 weeks, acupuncture decreased the number of flushes more (p<0.05; p<0.01, respectively) than placebo. At 12 weeks, applied relaxation decreased the number of flushes more (p<0.05) than placebo. The Kupperman index score decreased in all groups except the placebo group. The decrease in score was significantly greater in all treatment groups than in the placebo group (p<0.01).

CONCLUSION

Acupuncture and applied relaxation both reduced the number of hot flushes significantly better than placebo and should be further evaluated as alternatives to hormone therapy in women with menopausal vasomotor complaints.

Alternation of band gap and localization of excitons in InGaNAs nanostructures with low nitrogen content

Continuous wave photoluminescence (cw PL) spectroscopy has been used to study the optical properties of a set of InGaNAs epilayers and single quantum wells with nitrogen concentration less than a few per cent at different temperatures and different excitation powers. We found that nitrogen has a critical role on the emission light of InGaNAs nanostructures and the recombination mechanism. The incorporation of a few per cent of nitrogen leads to shrinkage of the InGaNAs band gap. The physical origin of such band gap reduction has been investigated both experimentally and theoretically by using a band anticrossing model. We have found that localization of excitons that have been caused by incorporation of a few per cent of nitrogen in these structures is the main explanation of such anomalous behavior observed in the low-temperature photoluminescence spectra of these nanostructures. The localization energies of carriers have been evaluated by studying the variation of the quantum well (QW) emission versus temperature, and it was found that the localization energy increases with increasing nitrogen composition. Our data also show that, with increasing excitation intensity, the PL peak position moves to higher energies (blue shift) due to the filling of localized states and capture centers for excitons by photo-generated carriers.

Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial

OBJECTIVE

To evaluate the effects of electro-acupuncture (EA) and hormone therapy (HT) on vasomotor symptoms in women with a history of breast cancer.

METHODS

Forty-five women were randomized to EA (n = 27) for 12 weeks or HT (n = 18) for 24 months. The number of and distress caused by hot flushes were registered daily before, during and up to 24 months after start of treatment.

RESULTS

In 19 women who completed 12 weeks of EA, the median number of hot flushes/24 h decreased from 9.6 (interquartile range (IQR) 6.6-9.9) at baseline to 4.3 (IQR 1.0-7.1) at 12 weeks of treatment (p < 0.001). At 12 months after start of treatment, 14 women with only the initial 12 weeks of EA had a median number of flushes/24 h of 4.9 (IQR 1.8-7.3), and at 24 months seven women with no other treatment than EA had 2.1 (IQR 1.6-2.8) flushes/24 h. Another five women had a decreased number of flushes after having additional EA. The 18 women with HT had a baseline median number of flushes/24 h of 6.6 (IQR 4.0-8.9), and 0.0 (IQR 0.0-1.6; p = 0.001) at 12 weeks.

CONCLUSION

Electro-acupuncture is a possible treatment of vasomotor symptoms for women with breast cancer and should be further studied for this group of women.

Risk communication in consultations about hormone therapy in the menopause: concordance in risk assessment and framing due to the context

BACKGROUND

It is important for the physician and the patient to have a mutual understanding of the possible consequences of different treatment alternatives in order to achieve a partnership in decision-making.

OBJECTIVE

The aim of this study was to explore to which degree first-time consultations for discussion of climacteric discomfort achieved shared understanding of the risks and benefits associated with hormone therapy in the menopausal transition.

METHODS

Analysis of structure and content of transcribed consultations (n = 20), and follow-up interviews of the women (n = 19 pairs of consultations and interviews), from first-time visits for discussion of climacteric discomfort and/or HT with five physicians at three different outpatient clinics of gynecology in Sweden.

RESULTS

Four distinctively different interpretations of risk, depending on whether or not benefits were discussed in the same context, emerged from the analysis. On average, five advantages (range 0-11) and two (0-3) disadvantages were mentioned during the consultations. In the interviews, the women expressed on average four advantages (0-7) and one disadvantage (0-3). There were major variations between advantages and disadvantages expressed in the consultation and the following interview.

CONCLUSION

Even though the consultations scored high in patient involvement, the information in most consultations was not structured in a way that made it possible to achieve a shared or an informed decision-taking.

Psychological wellbeing after laparoscopic and abdominal hysterectomy-a randomised controlled multicentre study

OBJECTIVE

To compare laparoscopic hysterectomy and abdominal total hysterectomy regarding influence on postoperative psychological wellbeing and surgical measures.

DESIGN

A prospective, open, randomised multicentre trial.

SETTING

Five hospitals in the South East of Sweden.

POPULATION

Hundred and twenty-five women scheduled for hysterectomy for benign conditions were enrolled in the study, and 119 women completed the study. Fifty-six women were randomised to abdominal hysterectomy and 63 to laparoscopic hysterectomy.

METHODS

Psychometric tests measuring general wellbeing, depression and anxiety preoperatively and 5 weeks and 6 months postoperatively.

MAIN OUTCOME MEASURES

Effects of operating method on the psychological wellbeing postoperatively. Analysis of data regarding operating time, peroperative and postoperative complications, blood loss, hospital stay and recovery time.

RESULTS

No significant differences in the scores were observed between the two groups in any of the four psychometric tests. Both the surgical methods were associated with a significantly higher degree of psychological wellbeing 5 weeks postoperatively compared with preoperatively. The operating time was significantly longer for the laparoscopic hysterectomy group, but the duration of the stay in hospital and sick-leave were significantly shorter for laparoscopic hysterectomy group compared with the abdominal hysterectomy group.

CONCLUSIONS

General psychological wellbeing is equal after laparoscopic and abdominal hysterectomy within 6 months after the operation. The advantages of the laparoscopic hysterectomy are the shorter stay in hospital and shorter sick-leave, but these issues must be balanced by a longer duration of the operation.

Vasomotor symptoms decrease in women with breast cancer randomized to treatment with applied relaxation or electro-acupuncture: a preliminary study

OBJECTIVE

To evaluate the effect of applied relaxation and electro-acupuncture on vasomotor symptoms in women treated for breast cancer.

METHODS

Thirty-eight postmenopausal women with breast cancer and vasomotor symptoms were randomized to treatment with electro-acupuncture (n = 19) or applied relaxation (n = 19) during 12 weeks. The number of hot flushes was registered daily in a logbook before and during treatment and after 3 and 6 months of follow-up.

RESULTS

Thirty-one women completed 12 weeks of treatment and 6 months of follow-up. After 12 weeks of applied relaxation, the number of flushes/24 h had decreased from 9.2 (95% confidence interval (CI) 6.6-11.9) at baseline to 4.5 (95% CI 3.2-5.8) and to 3.9 (95% CI 1.8-6.0) at 6 months follow-up (n = 14). The flushes/24 h were reduced from 8.4 (95% CI 6.6-10.2) to 4.1 (95% CI 3.0-5.2) after 12 weeks of treatment with electro-acupuncture and to 3.5 (95% CI 1.7-5.3) after 6 months follow-up (n = 17). In both groups, the mean Kupperman Index score was significantly reduced after treatment and remained unchanged 6 months after end of treatment.

CONCLUSION

We suggest that applied relaxation and electro-acupuncture should be further evaluated as possible treatments for vasomotor symptoms in postmenopausal women with breast cancer.

Effects of electro-acupuncture on psychological distress in postmenopausal women

OBJECTIVES

To evaluate effects of electro-acupuncture (EA) on general psychological distress and relate to experience of climacteric symptoms in 30 postmenopausal women.

DESIGN

A randomised single-blind controlled design was used to evaluate effects of EA and extremely superficial needle insertion, with the latter serving as a near-placebo control.

SETTINGS

The Linköping University Hospital in Sweden.

INTERVENTIONS

Fourteen treatments during 12 weeks with follow-ups at 3 and 6 months.

OUTCOME MEASURES

General psychological well-being, mood and experience of climacteric symptoms.

RESULTS

Mood Scale improved only in EA group and not until 12 weeks compared to baseline, from 110 to 129 (P = 0.01), and to 120 at 3-month follow-up (P = 0.04). Mood was significantly better than control at 8 (P = 0.05) and 12 weeks (P = 0.01). Visual analogue scale estimation of climacteric symptoms was decreased at 4 weeks in both groups, and lasted throughout the study period, in EA group from 5 to 2 (P = 0.04) and in control group from 5 to 3 (P = 0.02) at 6-month follow-up. Well-being was ameliorated from 4 weeks in EA and from 8 weeks in control group until end of study (P = 0.01, P = 0.03). No significant differences on climacteric symptoms or well-being existed between the groups.

CONCLUSIONS

This study does not show that EA is better than superficial needle insertion for the amelioration of general psychological distress and experience of climacteric symptoms in women with vasomotor symptoms after menopause. However, the more pronounced effect on mood suggests that EA might have additional effects compared with superficial needle insertion.

Pros and cons of vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum: examples and experiences from Linköping, Sweden

Problem-based learning (PBL), combined with early patient contact, multiprofessional education and emphasis on development of communications skills, has become the basis for the medical curriculum at the Faculty of Health Sciences in Linköping (FHS), Sweden, which was started in 1986. Important elements in the curriculum are vertical integration, i.e. integration between the clinical and basic science parts of the curriculum and horizontal integration between different subject areas. This article discusses the importance of vertical integration in an undergraduate medical curriculum, according to experiences from the Faculty of Health Sciences in Linköping, and also give examples on how it has been implemented during the latest 15 years. Results and views put forward in published articles concerning vertical integration within undergraduate medical education are discussed in relation to the experiences in Linköping. Vertical integration between basic sciences and clinical medicine in a PBL setting has been found to stimulate profound rather than superficial learning, and thereby stimulates better understanding of important biomedical principles. Integration probably leads to better retention of knowledge and the ability to apply basic science principles in the appropriate clinical context. Integration throughout the whole curriculum entails a lot of time and work in respect of planning, organization and execution. The teachers have to be deeply involved and enthusiastic and have to cooperate over departmental borders, which may produce positive spin-off effects in teaching and research but also conflicts that have to be resolved. The authors believe vertical integration supports PBL and stimulates deep and lifelong learning.

Attitudes among students and teachers on vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum

Important elements in the curriculum at the Faculty of Health Sciences in Linköping are vertical integration, i.e. integration between the clinical and basic science sections of the curriculum, and horizontal integration between different subject areas. Integration throughout the whole curriculum is time-consuming for both teachers and students and hard work is required for planning, organization and execution. The aim was to assess the importance of vertical and horizontal integration in an undergraduate medical curriculum, according to opinions among students and teachers. In a questionnaire 102 faculty teachers and 106 students were asked about the importance of 14 different components of the undergraduate medical curriculum including vertical and horizontal integration. They were asked to assign between one and six points to each component (6 points = extremely important for the quality of the curriculum; 1 point = unimportant). Students as well as teachers appreciated highly both forms of integration. Students scored horizontal integration slightly but significantly higher than the teachers (median 6 vs 5 points; p=0.009, Mann-Whitney U-test), whereas teachers scored vertical integration higher than students (6 vs 5; p=0.019, Mann-Whitney U-test). Both students and teachers considered horizontal and vertical integration to be highly important components of the undergraduate medical programme. We believe both kinds of integration support problem-based learning and stimulate deep and lifelong learning and suggest that integration should always be considered deeply when a new curriculum is planned for undergraduate medical education.

Momentary increase in plasma calcitonin gene-related peptide is involved in hot flashes in men treated with castration for carcinoma of the prostate

PURPOSE

In women the vasodilatory neuropeptides calcitonin gene-related peptide and neuropeptide Y seem to be involved in menopausal hot flashes. We assessed whether plasma calcitonin gene-related peptide and neuropeptide Y change during hot flashes in men after castration.

MATERIALS AND METHODS

We evaluated 10 men 61 to 81 years old who underwent castration due to cancer of the prostate and had frequent hot flashes for changes in plasma calcitonin gene-related peptide and neuropeptide Y during 1 day at the outpatient clinic. At least 5 blood samples were obtained between flashes and 4 were obtained during each flash. The samples were analyzed for calcitonin gene-related peptide and neuropeptide Y using radioimmunoassay technique. Hot flashes were objectively recorded by measuring peripheral skin temperature and skin conductance.

RESULTS

Plasma calcitonin gene-related peptide increased 46% (95% confidence interval 21 to 71) during flashes in the 6 men in whom it was measurable. This change was statistically significant (p = 0.028). The concentration of neuropeptide Y was below the detection limit. Skin conductance and temperature increased significantly during flashes.

CONCLUSIONS

Calcitonin gene-related peptide is involved in the mechanisms of hot flashes in men who underwent castration due to prostate carcinoma. Thus, there may be a similar mechanism of hot flashes in women and in men deprived of sex steroids.

Progesterone and norethisterone have different effects on tachykinin-like immunoreactivity in rat cortex and striatum

OBJECTIVE

The purpose of this study was to investigate the effects of progesterone and the most commonly prescribed synthetic progestogen, norethisterone, on regional immune-like reactivity of neuropeptide Y (NPY), substance P (SP), neurokinin A (NKA) and neurotensin (NT) in brains of female ovariectomized estradiol-substituted rats.

RESULTS

Norethisterone+estradiol-treated rats had 44% lower SP levels compared with estradiol-only-treated in frontal cortex and 20% lower NKA levels in comparison with progesterone+estradiol-treated in frontal cortex. Progesterone+estradiol-treated rats had 66% lower SP levels in striatum in comparison with both estradiol-only-treated and norethisterone+estradiol-treated. No significant results were found for NPY and NT.

CONCLUSION

Progesterone and the synthetic progestogen, norethisterone, have different effects on SP- and NKA-like immunoreactivity in rat cortex and striatum. The effects of NET on SP- and NKA-like immunoreactivity in frontal cortex may contribute to the mood effects ascribed to this progestogen in clinical usage.

Prospective evaluation of hot flashes during treatment with parenteral estrogen or complete androgen ablation for metastatic carcinoma of the prostate

PURPOSE

We evaluated the incidence and frequency of, and distress due to hot flashes after castration therapy with polyestradiol phosphate and complete androgen ablation.

MATERIALS AND METHODS

A total of 915 men with metastatic prostate carcinoma enrolled in the Scandinavian Prostatic Cancer Group-5 trial study were randomized to intramuscular injections of 240 mg. Polyestradiol phosphate every 2 weeks for 8 weeks followed by monthly subcutaneous injections or complete androgen ablation, that is bilateral orchiectomy or 3.75 mg. of the gonadotropin-releasing hormone analog triptorelin monthly combined with 250 mg. of the antiandrogen flutamide 3 times daily. The incidence and frequency of, and distress due to hot flashes were recorded at regular intervals using a questionnaire.

RESULTS

Of the 915 men 901 were evaluated at a median followup of 18.5 months. The incidence of hot flashes was 30.1% and 74.3% in the polyestradiol phosphate and complete androgen ablation groups, respectively (p <0.001). In the polyestradiol phosphate group the frequency of and distress due to hot flashes were significantly lower than in the androgen ablation group. There was complete relief from hot flashes in 50% of the men on polyestradiol phosphate during followup compared with none on androgen ablation. The incidence of hot flashes did not differ in men with and without tumor progression.

CONCLUSIONS

Endocrine treatment with polyestradiol phosphate induced fewer and less distressing hot flashes than complete androgen ablation. Flashes also disappeared to a greater extent during polyestradiol phosphate than during androgen ablation. The data in this study enable us to provide thorough individual information to patients on the risk and grade of expected distress and duration of hot flashes during polyestradiol phosphate or complete androgen ablation treatment.

Suppressors of ssy1 and ptr3 null mutations define novel amino acid sensor-independent genes in Saccharomyces cerevisiae

Ssy1p and Ptr3p are components of the yeast plasma membrane SPS amino acid sensor. In response to extracellular amino acids this sensor initiates metabolic signals that ultimately regulate the functional expression of several amino acid-metabolizing enzymes and amino acid permeases (AAPs). As a result of diminished leucine uptake capabilities, ssy1Delta leu2 and ptr3Delta leu2 mutant strains are unable to grow on synthetic complete medium (SC). Genes affecting the functional expression of AAPs were identified by selecting spontaneous suppressing mutations in amino acid sensor-independent (ASI) genes that restore growth on SC. The suppressors define 11 recessive (asi) complementation groups and 5 dominant (ASI) linkage groups. Strains with mutations in genes assigned to these 16 groups fall into two phenotypic classes. Mutations in the class I genes (ASI1, ASI2, ASI3, TUP1, SSN6, ASI13) derepress the transcription of AAP genes. ASI1, ASI2, and ASI3 encode novel membrane proteins, and Asi1p and Asi3p are homologous proteins that have conserved ubiquitin ligase-like RING domains at their extreme C termini. Several of the class II genes (DOA4, UBA1, BRO1, BUL1, RSP5, VPS20, VPS36) encode proteins implicated in controlling aspects of post-Golgi endosomal-vacuolar protein sorting. The results from genetic and phenotypic analysis indicate that SPS sensor-initiated signals function positively to facilitate amino acid uptake and that two independent ubiquitin-mediated processes negatively modulate amino acid uptake.

[Continuing should be a part of the clinical reality. Courage is required to see both the strong and the weak sides of the professional situation]

Continuing professional development (CPD) is a joint responsibility of the individual physician and the employer. CPD should focus on identification and documentation of the learning needs of the individual, based on professional demands. Reflection, feedback and evaluation of the results are central elements of the process. Efficient learning demands active participation; modern information technology is now becoming more widely available.

Guidelines for counselling in infertility: outline version

The Guidelines for Counselling in Infertility describe the purpose, objectives, typical issues and communication skills involved in providing psychosocial care to individuals using fertility services. The Guidelines are presented in six sections. The first section describes how infertility consultations differ from other medical consultations in obstetrics and gynaecology, whereas the second section addresses fundamental issues in counselling, such as what is counselling in infertility, who should counsel and who is likely to need counselling. Section 3 focuses on how to integrate patient-centred care and counselling into routine medical treatment and section 4 highlights some of the special situations which can provoke the need for counselling (e.g. facing the end of treatment, sexual problems). Section 5 deals exclusively with third party reproduction and the psychosocial implications of gamete donation, surrogacy and adoption for heterosexual and gay couples and single women without partners. The final section of the Guidelines is concerned with psychosocial services that can be used to supplement counselling services in fertility clinics: written psychosocial information, telephone counselling, self-help groups and professionally facilitated group work. This paper summarizes the different sections of the Guidelines and describes how to obtain the complete text of the Guidelines for Counselling in Infertility.

Urinary excretion of calcitonin gene-related peptide in males with hot flushes after castration for carcinoma of the prostate

OBJECTIVE

The majority of men who undergo surgical or medical castration due to prostatic carcinoma develop vasomotor symptoms with hot flushes. The mechanisms behind these symptoms are poorly understood. One possible explanation is a release of the vasodilatory peptide calcitonin gene-related peptide (CGRP) from perivascular nerves, which seem to be involved in the mechanisms behind vasomotion and sweating in postmenopausal women. The aim of this report was to investigate whether CGRP is involved in vasomotion in men after castration therapy.

MATERIAL AND METHODS

Twenty-four hour urine excretion of CGRP was analysed in 15 men with prostatic carcinoma, using radioimmunoassay before and 3 months after surgical or medical castration.

RESULTS

Eleven of the 15 men developed hot flushes during the observation period of 3 months. Twenty-four hour urine excretion of CGRP did not change significantly after castration, either in the group as a whole or in those 11 men who developed hot flushes.

CONCLUSIONS

Even though we did not observe any significant changes in 24-h urine excretion of the potent vasodilator CGRP after castration it is possible that serum levels of CGRP increase during hot flushes, without having an effect on the 24-h urine excretion of the peptide.

Disturbances in postural balance are common in postmenopausal women with vasomotor symptoms

OBJECTIVES

To establish the prevalence of unsteadiness and rotatory vertigo in peri- and postmenopausal women, and whether balance disturbances are more common in women with vasomotor symptoms and without hormone replacement therapy (HRT).

METHOD

A validated questionnaire was sent to all 1523 women aged 54 or 55 years in Linköping, Sweden.

RESULTS

Daily or weekly unsteadiness was reported by 5%, and daily or weekly rotatory vertigo by 4% of all women. The frequency of vasomotor symptoms correlated with reported unsteadiness (rs = 0.23, p < 0.001). Fourteen per cent of women with daily vasomotor symptoms reported weekly or daily unsteadiness, compared with 3% of those without vasomotor symptoms (odds ratio (OR) 7.58, 95% confidence interval (CI) 3.72-15.45). The frequency of vasomotor symptoms correlated with rotatory vertigo (rs = 0.19, p < 0.001). Ten per cent of women with daily vasomotor symptoms reported weekly or daily rotatory vertigo, compared with 2% of women without vasomotor symptoms (OR 5.21, 95% CI 1.07-25.52). No correlation was seen between vasomotor symptoms and falls. Users of HRT had the same prevalence of balance disturbances as non-users.

CONCLUSIONS

Women with frequent vasomotor symptoms seem to run a greater risk of unsteadiness and rotatory vertigo than do women without symptoms. This association may not be explained by means of a cross-sectional study, but there might exist a causal connection between vasomotor symptoms and balance disturbances.

Effects of estrogens and hormone replacement therapy on breast cancer risk and on efficacy of breast cancer therapies

This review summarises preclinical and clinical data on effects of endogenous and exogenous estrogens on probability of breast cancer diagnosis, and on the course and efficacy of breast cancer therapies. The data indicate that higher endogenous estrogen exposure (e.g. pregnancy, early menarche and late menopause, estrogen levels in future breast cancer patients, obesity) or exogenous estrogens (oral contraceptives; hormone replacement therapies) may be associated with an increased probability of breast cancer diagnosis. However, there is little evidence that estrogens have deleterious effects on the course of breast cancer. Moreover, increased incidence of breast cancer diagnosis after prolonged hormone replacement therapy (HRT) use seems to be associated with clinically less advanced disease. In studies assessing both diagnosis and mortality, HRT is frequently associated with reduced mortality compared to never users. The interaction of progestagens and estrogens on the probability of breast cancer diagnosis is complex and dependent on type of progestagens and regimens employed. Efficacy of current treatment modalities for breast cancer (surgery, irradiation, adjuvant therapy or chemotherapy) is not negatively influenced by estrogens at concentrations considerably higher than those attained with current HRT preparations. Although it cannot be excluded that estrogens increase the probability of breast cancer diagnosis, available data fail to demonstrate that, once breast cancer has been diagnosed, estrogens worsen prognosis, accelerate the course of the disease, reduce survival or interfere with the management of breast cancer. It may therefore be concluded that the prevalent opinion that estrogens and estrogen treatment are deleterious for breast cancer, needs to be revisited. However, results of ongoing prospective, randomised clinical trials with different HRT regimens in healthy women or breast cancer survivors are needed to provide more definite conclusions about risks and benefits of HRT.

[All physicians--not only physicians in charge need leadership training]

Management education programmes for physicians range from university courses to courses offered by private companies. Some hospitals and regions arrange local management education for physicians in specialist training and certified specialists, but mostly for staff in executive positions. Only 245 places are available on the one-week courses for physicians in specialist training during the whole of year 2000 in Sweden; 637 applications were received for the spring courses only. There are 5,000 physicians in specialist training in Sweden. There is a great need for increased investments in the fields of education in administration, economy, leadership and management for physicians.

Collagen metabolism markers as a reflection of bone and soft tissue turnover during the menstrual cycle and oral contraceptive use

Two different groups of women, 23 healthy young adults and 13 women with chronic posterior pelvic pain, were studied before and during use of oral contraceptives (OC). Collagen metabolism markers-here, the amino-terminal propeptide of type I procollagen, the carboxy-terminal telopeptide of type I collagen, and the amino-terminal of procollagen type III-as well as hormones and other endocrine factors indicating the balance between androgen expression/anabolism and catabolism of the subjects (testosterone, sex-hormone binding globulin, and insulin-like growth factor I were measured. Type I procollagen, the carboxy-terminal telopeptide of type I collagen, and the amino-terminal of procollagen type III were all significantly decreased during OC use. These findings implicate OC use-induced changes in collagen type I and III turnover. A shift in the anabolic/catabolic balance was also recorded indicating a less anabolic situation during OC use.

Estrogen effects on postural balance in postmenopausal women without vasomotor symptoms: a randomized masked trial

OBJECTIVE

To assess whether estrogen treatment given to postmenopausal women without vasomotor symptoms improves balance more than placebo.

METHODS

Forty healthy postmenopausal women without vasomotor symptoms were randomized to transdermal 17beta-estradiol (E2) 50 microg/day for 14 weeks or identical transdermal placebo patches. Postural balance was measured with dynamic posturography before and after 4, 12, and 14 weeks of therapy. In this test, the visual, vestibular, and somatosensory systems were provoked with increasing difficulty and body sway was measured with a dual forceplate. A low score showed large sway and a score of 100 showed no sway at all.

RESULTS

Thirty-eight women completed the study. Both groups had normal balance for their ages and near maximum scores in the three easier balance tests at baseline. In the most difficult test, both groups improved their postural balance significantly (from 13 to 32 and from 22 to 39, respectively) after 4 weeks. Thereafter, no change was seen. One problem was low statistical power, but the relative change in balance did not differ between groups. The comparison did not show even a minute advantage of E2 over placebo, so a study with higher power would probably not have shown a more pronounced effect of estrogen than placebo. The change over time did not differ between groups, which indicates a significant learning effect.

CONCLUSION

In women without vasomotor symptoms, estrogen therapy did not seem to increase postural balance significantly more than placebo. However, we could not rule out that estrogens affect postural balance in women with vasomotor symptoms.

Hypersecretion of ovarian androgens may be gonadotrophin dependent many years after menopause

BACKGROUND

In fertile women both adrenals and ovaries contribute to androgen production, whereas after the menopause the ovarian contribution normally decreases.

OBJECTIVE

The objective of this case study was to assess whether ovarian androgen secretion was responsive to decreased gonadotrophin stimulation and whether gonadotrophins were sensitive to negative feedback from sex steroids many years after the menopause.

METHODS

In this uncontrolled case study a 72 years old slightly overweight woman with noninsulin-dependent diabetes mellitus presented with hirsuitism and elevated serum testosterone concentrations. The woman was reluctant to have an oophorectomy, and received an oral estradiol/progestagene preparation. Serum testosterone and gonadotrophin concentrations were measured before and after steroid hormone therapy.

RESULTS

Serum gonadotrophin concentrations decreased and testosterone levels returned to normal during therapy. When the hormone therapy was stopped for 1 month the high testosterone concentrations returned, but were again normalized when the hormone therapy was reinitiated.

CONCLUSION

The ovaries of this woman were apparently still responsive to pituitary stimulation and her hypothalamic pituitary ovarian feed-back system still seemed to be working after 70 years of age.

[Big differences in leadership and management training within health care services. Leadership and issues concerning cooperation should be more emphasized in basic medical education]

A recent survey of medical management programmes at universities across the country showed manifest national differences to exist, both quantitative and qualitative. Using a questionnaire, the Swedish Society of Medical Management examined the programmes for physiotherapists, occupational therapists, social workers, nurses and physicians, with respect to such issues as leadership, self-awareness and communication, health economics, and administration. It was concluded that knowledge acquired differs between fields; that physiotherapy programmes tend to have a very didactic approach; that nurses are taught the importance of participation in developmental processes; that doctors are exposed to somewhat the same approach but to a large extent on a voluntary basis; and that social workers obtain good insight into the administrative skills necessary to their work. In the article it is concluded that students would benefit from orientation in the diverse approaches used in the other fields than their own, and that pooling of resources among different programmes might be a more economic alternative to current practice.

Acupuncture treatment of vasomotor symptoms in men with prostatic carcinoma: a pilot study

PURPOSE

Most men who undergo castration therapy for prostatic carcinoma will have vasomotor symptoms that usually persist for years. Vasomotor symptoms are elicited from the thermoregulatory center, possibly due to a decrease in hypothalamic opioid activity induced by low sex steroid concentrations. Acupuncture treatment in women, which stimulates hypothalamic opioid activity, alleviates vasomotor symptoms. We report on men treated with acupuncture for relief of vasomotor symptoms after castration therapy.

MATERIALS AND METHODS

We asked 7 men with vasomotor symptoms due to castration therapy to receive acupuncture treatment 30 minutes twice weekly for 2 weeks and once a week for 10 weeks. Effects on flushes were recorded in logbooks.

RESULTS

Of the 7 men 6 completed at least 10 weeks of acupuncture therapy and all had a substantial decrease in the number of hot flushes (average 70% after 10 weeks). At 3 months after the last treatment the number of flushes was 50% lower than before therapy. Therapy was discontinued after 10 weeks because of a femoral neck fracture in 1 man and after 3 weeks due to severe back pain in 1.

CONCLUSIONS

Acupuncture may be a therapeutic alternative in men with hot flushes after castration therapy and merits further evaluation.

Postmenopausal women without previous or current vasomotor symptoms do not flush after abruptly abandoning estrogen replacement therapy

BACKGROUND

Most but not all women suffer from vasomotor symptoms around menopause. The exact mechanisms behind these symptoms are unknown, but the rate of decline in estrogen concentrations has been suggested to affect the risk of hot flushes.

OBJECTIVE

The objective was to assess whether vasomotor symptoms were induced in women without previous such symptoms, when the women were given combined estradiol and progestagen therapy for 3 months, whereafter therapy was abruptly withdrawn.

MATERIALS AND METHOD

After randomization, 40 postmenopausal women without previous or current vasomotor symptoms were treated transdermally with either 50 micrograms/day 17 beta-estradiol or placebo during 14 weeks. During the 13th and 14th weeks, treatment was combined with oral medroxyprogesterone acetate 10 mg/day. Serum estradiol and follicle-stimulating hormone (FSH) concentrations were analysed before and after 12 weeks of therapy. Climacteric symptoms were assessed at the same intervals as well as 8 weeks after the end of therapy.

RESULTS

All women had low pretreatment levels of estradiol and high FSH concentrations. During estradiol therapy estradiol levels increased significantly, whereas FSH only decreased slightly. No woman developed vasomotor symptoms after withdrawal of therapy.

CONCLUSION

Postmenopausal women without previous or current vasomotor symptoms did not develop such symptoms when estrogen replacement therapy was first instituted and then abruptly stopped. Probably other factors than the rate with which estrogen concentrations decrease determine whether or not a woman will develop vasomotor symptoms. Evidently, estrogens can be prescribed to a woman who has no vasomotor symptoms, without much risk of inducing such symptoms if she decides to abandon therapy, even after 3 months of treatment.

Sex differences in neuropeptide distribution in the rat brain

We have investigated possible sex differences in the regional concentrations of neuropeptides in the rat brain. Immunoreactive neurotensin (NT), neurokinin A (NKA), galanin (GAL), calcitonin gene-related peptide (CGRP), substance P (SP) and neuropeptide Y (NPY) were measured by radioimmunoassay in frontal cortex, occipital cortex, hippocampus, striatum, hypothalamus and pituitary in male and female pre- and postpubertal rats. Sex differences were found for NPY (p < 0.001), NT (p < 0.01) and GAL (p < 0.05), in particular in hippocampus, striatum, hypothalamus and pituitary, but not for CGRP, SP and NKA. Results from analysis of neuropeptides in one sex may not be entirely applicable to the other.