Jan Brynhildsen

Weight gain restriction for obese pregnant women : A case-control intervention study

Objective  To minimise obese women’s total weight gain during pregnancy to less than 7 kg and to investigate the delivery and neonatal outcome.

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

Follow-up of patients with low back pain during pregnancy

Objective To identify the long-term risk for low back pain among women with previous severe low back pain during pregnancy. Methods In a previous prospective study, 79 pregnant women developed low back pain severe enough to require sick leave. Twelve years later a questionnaire was sent to 62 of these women and 84 controls who did not develop severe low back pain during pregnancy. The questionnaire asked about occupation, low back pain in general and during later pregnancies, and sick leave due to low back pain. There were also questions regarding use of oral contraceptives and its possible relation to low back pain. Results The response rate was 84% in the back pain group and 80% among controls. The two groups were similar according to the percentage of women having had another pregnancy (33 of 52 [63%] versus 39 of 67 [58%]) but ten (19%) of the women with previous low back pain stated they had refrained from another pregnancy because of their fear of low back pain compared with only one control. Almost all women (31 of 33) with previous severe low back pain experienced the same symptoms in a subsequent pregnancy, compared with 17 of 39 (44%) controls. Even when they were not pregnant, women with previous low back pain suffered more often and used more sick leave due to low back pain (44 of 52 versus 43 of 67, χ2 = 5.68, P < .05). The location (sacroiliac joint or lumbar affection) of the previous low back pain did not affect the long-term prognosis. In a logistic regression model, previous low back pain during pregnancy was the only independent risk factor for low back pain during a subsequent pregnancy, whereas an occupation involving physical demand did not affect the results. However, together with previous low back pain during pregnancy, heavy occupation increased the risk for current non-pregnant low back pain. Conclusion Women with severe low back pain during pregnancy have an extremely high risk for experiencing a new episode of severe low back pain during another pregnancy and when not pregnant.

Age at onset of multiple sclerosis is correlated to use of combined oral contraceptives and childbirth before diagnosis

The aim of this study was to evaluate whether age of onset of multiple sclerosis is related to use of combined oral contraceptives and/or timing of childbirth. The results showed that use of combined oral contraceptives and childbirth before the first multiple sclerosis symptom was correlated to a higher mean age at the onset of the disease.

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.

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.

Is hormone replacement therapy a risk factor for low back pain among postmenopausal women

Study Design. Cross‐sectional study with two age cohorts. Objective. To assess whether women receiving hormone replacement therapy after menopause have a higher prevalence of back problems than women who do not receive such treatment. Background. Back pain is a common medical problem throughout life and especially during pregnancy. Hormonal factors have been proposed as a possible contributor. Patients and Methods. A validated postal questionnaire was sent in early 1995 to all 1324 women of 55 years and 56 years of age residing in Linköping, Sweden. This questionnaire included questions about current hormone replacement treatment, previous and current back problems, medical care for back problems, parity, exercise and smoking habits, and occupation. Results. The questionnaire was returned by 84.7% of the women. There was a significant, albeit weak, positive association between current use of hormone replacement treatment and low back pain. Previous back problems during pregnancy was a strong risk factor for current back pain, whereas neither current smoking nor regular physical exercise was a risk factor according to multiple logistic regression analysis. The interaction of smoking and an occupation involving heavy lifting significantly affected back pain. Conclusions. Women receiving hormone replacement treatment had a slightly, but significantly, higher prevalence of current back pain than nonusers (48% vs. 42%, respectively, P < 0.05), which could not be explained by differences in occupation, smoking habits, or current physical activity. Although the association between hormone replacement therapy and back problems is weak and probably of minor clinical importance, it is speculated that hormonal effects on joints and ligaments may be involved.

Hormone replacement therapy and previous use of oral contraceptives among Swedish women

OBJECTIVES To assess the current and previous use of hormone replacement therapy (HRT) and alternative remedies in a postmenopausal population and to relate HRT use to previous use of oral contraceptives. MATERIAL AND METHODS All 1323 women living in Linköping of 55 or 56 years old during 1995 were sent a questionnaire asking for data with relation to health and climacteric symptoms as well as to previous and current use of HRT, oral contraceptives and alternative remedies. RESULTS Current use of HRT was more common among women who previously used oral contraceptives (41.3%) than among women who had never used oral contraceptives (23.1%). HRT users were also more often physically active, had undergone hysterectomy and had lighter occupation than non-users. Of all women 35% were current users of HRT, half of them for at least 2 years, whereas only 5% had tried HRT and abandoned therapy. Alternative remedies were used by 5% of the women as therapy for climacteric complaints, and about four times as many women had tried such therapy but abandoned it. The only characteristic about use of alternative medicines was that they were used less often by women who had been hysterectomized. No women treated for breast cancer used HRT and only few of them used alternative remedies. CONCLUSIONS The prevalence of HRT use, as well as compliance, was high. Previous use of oral contraceptives probably affected the attitude towards using HRT.

Combined hormonal contraceptives: prescribing patterns, compliance, and benefits versus risks

Combined hormonal contraceptives [combined oral contraceptives (COCs)] have been available for over 50 years and the impact of this invention may not be overestimated. Today over 100 million women are current users and in Western Europe and the United States approximately 80% of women of fertile ages can be considered as ever-users. Over the years several drawbacks have been identified and media alarms on risks are frequently presented, resulting in suboptimal compliance and low compliance and continuation rates. Poor compliance and discontinuation is a big problem and is not generally identified by prescribers. During ideal use COCs offer very good protection against unwanted pregnancies, however there is a big problem with compliance and continuation and thus the ‘real-life’ efficacy is much lower. Reasons for poor compliance include side effects and fear of side effects and it is crucial that the prescriber gives the individual woman thorough and balanced information on the benefits and risks. Most well known is the increased risk of venous thromboembolism, but also an elevated risk of arterial thrombosis and several types of cancer has been reported. The risk estimates are low but according to the large number of users a substantial number of extra cases will occur. However, use of COCs also offers several additional health benefits with significant impact on morbidity and quality of life. COC use is associated with a substantial decrease in the risk of ovarian cancer, endometrial cancer and colorectal cancer. Moreover, COCs are a major option of treatment for women suffering from heavy menstrual bleeding and dysmenorrhea as well as hirsutism and acne vulgaris. The net effect of the additional health effects of COC- use may very well be positive, i.e. a slight increase in life expectancy.

Oral contraceptive use among female elite athletes and age-matched controls and its relation to low back pain

Background. Exogenous and endogenous female sex steroids may influence the risk of low back pain. The fact that back pain is a very common symptom during pregnancy supports this theory. Back pain is also more common among female than male athletes. Oral contraceptives have been suggested to increase the risk of low back pain.