Perfect-use and typical-use Pearl Index of a contraceptive mobile app.

OBJECTIVES: The Natural Cycles application is a fertility awareness-based contraceptive method that uses dates of menstruation and basal body temperature to inform couples whether protected intercourse is needed to prevent pregnancies. Our purpose with this study is to investigate the contraceptive efficacy of the mobile application by evaluating the perfect- and typical-use Pearl Index. STUDY DESIGN: In this prospective observational study, 22,785 users of the application logged a total of 18,548 woman-years of data into the application. We used these data to calculate typical- and perfect-use Pearl Indexes, as well as 13-cycle pregnancy rates using life-table analysis. RESULTS: We found a typical-use Pearl Index of 6.9 pregnancies per 100 woman-years [95% confidence interval (CI): 6.5-7.2], corrected to 6.8 (95% CI: 6.4-7.2) when truncating users after 12months. We estimated a 13-cycle typical-use failure rate of 8.3% (95% CI: 7.8-8.9). We found that the perfect-use Pearl Index was 1.0 pregnancy per 100 woman-years (95% CI: 0.5-1.5). Finally, we estimated that the rate of pregnancies from cycles where the application erroneously flagged a fertile day as infertile was 0.5 (95% CI: 0.4-0.7) per 100 woman-years. We estimated a discontinuation rate over 12months of 54%. CONCLUSIONS: This study shows that the efficacy of a contraceptive mobile application is higher than usually reported for traditional fertility awareness-based methods. The application may contribute to reducing the unmet need for contraception. IMPLICATIONS: The measured typical- and perfect-use efficacies of the mobile application Natural Cycles are important parameters for women considering their contraceptive options as well as for the clinicians advising them. The large available data set in this paper allows for future studies on acceptability, for example, by studying the efficacy for different cohorts and geographic regions.

Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy.

BACKGROUND: Several randomized clinical trials have compared laparoscopic cholecystectomy (LC) and small-incision open cholecystectomy (SIOC). Most have had wide exclusion criteria and none was expertise-based. The aim of this expertise-based randomized trial was to compare healthcare costs, quality of life (QoL), pain and clinical outcomes after LC and SIOC. METHODS: Patients scheduled for cholecystectomy were randomized to treatment by one of two teams of surgeons with a preference for either LC or SIOC. Each team performed their specific method (SIOC or LC) as a first-choice operation, but converted to open cholecystectomy and common bile duct exploration when necessary. Intraoperative cholangiography was carried out routinely. The intention was to include all patients undergoing cholecystectomy, including emergency operations and procedures involving surgical training for residents. RESULTS: Some 74·9 per cent of all patients undergoing cholecystectomy were included. Of 355 patients randomized, 333 were analysed. Self-estimated QoL scores in 258 patients, analysed by the area under the curve method, were significantly lower in the SIOC group at 1 month after surgery: median 2326 (95 per cent confidence interval 2187 to 2391) compared with 2411 (2334 to 2502) for the LC group (P = 0·030). The mean(s.d.) duration of operation was shorter for SIOC: 97(41) versus 120(48) min (P < 0·001). There were no significant differences between the groups in conversion rate, pain, complications, length of hospital stay or readmissions. CONCLUSION: SIOC had comparable surgical results but slightly worse short-term QoL compared with LC. REGISTRATION NUMBER: NCT00370344 (http://www.clinicaltrials.gov).

Educational inequalities in tuberculosis mortality in sixteen European populations.

OBJECTIVE: To describe the magnitude of socioeconomic inequalities in tuberculosis (TB) mortality by level of education in male, female, urban and rural populations in several European countries. DESIGN: Data were obtained from the Eurothine Project, covering 16 populations between 1990 and 2003. Age- and sex-standardised mortality rates, the relative index of inequality and the slope index of inequality were used to assess educational inequalities. RESULTS: The number of TB deaths reported was 8530, with a death rate of 3 per 100 000 per year, of which 73% were males. Educational inequalities in TB mortality were present in all European populations. Inequalities in TB mortality were greater than in total mortality. Relative and absolute inequalities were large in Eastern European and Baltic countries but relatively small in Southern European countries and in Norway, Finland and Sweden. Inequalities in mortality were observed among both men and women, and in both rural and urban populations. CONCLUSIONS: Socio-economic inequalities in TB mortality exist in all European countries. Firm political commitment is required to reduce inequalities in the social determinants of TB incidence. Targeted public health measures are called for to improve access to treatment of vulnerable groups and thereby reduce TB mortality.

Educational differences in cancer mortality among women and men: a gender pattern that differs across Europe.

We used longitudinal mortality data sets for the 1990s to compare socioeconomic inequalities in total cancer mortality between women and men aged 30-74 in 12 different European populations (Madrid, Basque region, Barcelona, Slovenia, Turin, Switzerland, France, Belgium, Denmark, Norway, Sweden, Finland) and to investigate which cancer sites explain the differences found. We measured socioeconomic status using educational level and computed relative indices of inequality (RII). We observed large variations within Europe for educational differences in total cancer mortality among men and women. Three patterns were observed: Denmark, Norway and Sweden (significant RII around 1.3-1.4 among both men and women); France, Switzerland, Belgium and Finland (significant RII around 1.7-1.8 among men and around 1.2 among women); Spanish populations, Slovenia and Turin (significant RII from 1.29 to 1.88 among men; no differences among women except in the Basque region, where RII is significantly lower than 1). Lung, upper aerodigestive tract and breast cancers explained most of the variations between gender and populations in the magnitude of inequalities in total cancer mortality. Given time trends in cancer mortality, the gap in the magnitude of socioeconomic inequalities in cancer mortality between gender and between European populations will probably decrease in the future.

Reduction of abdominal wall blood flow by clamping or carbon dioxide insufflation increases tumor growth in the abdominal wall: an experimental study in rats.

BACKGROUND: We have previously demonstrated that there is a reduction of blood flow in the abdominal wall in rats insufflated with air concomitant with an increase in tumor growth. The present study was designed to examine whether a reduction of blood flow achieved by clamping or insufflation with carbon dioxide (CO(2)) would increase tumor growth in the abdominal wall. METHODS: In the first part of the experiments, laser Doppler blood flow of both rectus muscles was measured in 16 Wistar Fu rats. The left rectus muscle was clamped to reduce blood flow, and 5 x 10(4) adenocarcinoma cells were injected into both rectus muscles. Clamping was maintained for 45 min. In the second part, 22 rats had 5 x 10(4) adenocarcinoma cells injected into the rectus muscle and blood flow was measured. The experimental group (n = 11) was insufflated with CO(2) at 10 mmHg for 45 min; the control group (n = 11) was not insufflated. After 9 days, tumor weight and volume were analyzed. RESULTS: Clamping caused a 69% reduction of blood flow (p < 0.001), whereas no reduction was registered on the nonclamped side. Tumor weight (p = 0.028) and volume (p = 0.030) were increased on the clamped side. The insufflation of CO(2) caused a 71% reduction of blood flow, whereas no reduction was registered in the control group. Tumor weight (p = 0.006) and volume (p = 0.006) were increased in the insufflated group. CONCLUSION: Clamping, as well as CO(2) insufflation, causes a significant reduction of blood flow in the abdominal wall, which seems to increase tumor growth at the same site.

Pneumoperitoneum impairs blood flow and augments tumor growth in the abdominal wall.

BACKGROUND: Despite several clinical and experimental studies, the mechanisms behind the development of port site metastases in laparoscopic surgery have remained largely unknown. The current study was designed to investigate the effect of pneumoperitoneum on blood flow in the abdominal wall and its possible effects on tumor growth at this site. METHODS: A total of 40 Wistar Fu rats had a laser Doppler probe placed on their left rectus muscle and a suspension of 50,000 adenocarcinoma cells was injected into their right rectus muscle. The experimental group (n = 20) was insufflated with air at 10 mmHg for 45 min while abdominal blood flow was registered before and during insufflation and after exsufflation. The control group (n = 20) was not insufflated but the blood flow was recorded in the same manner. After 9 days, all animals were killed and the occurrence of tumor was observed. The tumors were analyzed with respect to weight and volume. RESULTS: The insufflation caused an 82% reduction in blood flow in the experimental group (p < 0.001). No reduction in blood flow was registered in the control group. Tumor nodules developed significantly more often in the insufflated group (20/20) compared to the controls (14/20) (p = 0.016). Tumor weight (p = 0.003) and volume (p < 0.001) were significantly increased in the insufflated group. CONCLUSIONS: Pneumoperitoneum seems to enhance tumor growth. It also causes a significant reduction in blood flow in the abdominal wall, which may contribute to the increased susceptibility of tumor take.

Changing health inequalities in the Nordic countries?

The Nordic countries, referring here to Denmark, Finland, Norway, and Sweden, have often been viewed as a group of countries with many features in common, such as geographical location, history, culture, religion, language, and economic and political structures. It has also been habitual to refer to a "Nordic model" of welfare states comprising a large public sector, active labour market policies, high costs for social welfare as well as high taxes, and a general commitment to social equality. Recent research suggests that much of this "Nordicness" appears to remain despite the fact that the Nordic countries have experienced quite different changes during the 1980s and 1990s. How this relates to changes in health inequalities is in the focus of this supplement.

Changing health inequalities in a changing society? Sweden in the mid-1980s and mid-1990s.

Whereas the end of the 1980s was characterized by an economic boom, the early 1990s saw the worst recession since the 1930s. In Sweden, the crisis that started in the fall of 1991 and culminated in 1995 meant dramatically increased unemployment rates followed by cutbacks in welfare state programs. In addition, other major changes in economic and political conditions have taken place during this period, including tax reforms and EU membership. Although public health as well as health inequalities are likely to be linked with these kinds of macro changes, it is unclear what types of changes in health and health inequalities one would expect. In this paper analyses of Swedish data on health inequalities in the periods 1986-87 and 1994-95 are undertaken on the basis of the Swedish Surveys of Living Conditions. The main finding is that overall health levels as well as differences in health between men and women, different age groups, educational groups, social classes, and employment status groups have remained constant.

[Small changes in health differences in the Nordic countries during the 1980s and 1990s]. / Liten förändring av hälsoskillnader i Norden under 1980- och 1990-talen.

The study examined changes over time in health inequality in Denmark, Finland, Norway and Sweden. Data derive from comparable interview surveys carried out in 1986/87 and 1994/95. Limiting long-standing illness and perceived ill health were analysed regarding age, gender; educational attainment, and employment status. Age adjusted prevalence rates were calculated. Changes in differences in health were found in education and employment status groups. There was little or no change in the prevalence of ill health during the time period studied. Despite social and economic changes differences in health remained broadly stable in the examined countries.

Body height, birth cohort and social background in Finland and Sweden.

BACKGROUND: Poor childhood living conditions are associated with short stature. Before the Second World War Finland had much lower living standards than Sweden, but this gap had largely disappeared by the 1970s. Body height differences were examined by birth cohort, economic difficulties in childhood and adult socioeconomic position in Finland and Sweden. METHODS: Two nationally representative data sets were used (n = 7,300 in Finland and n = 4,551 in Sweden). Three indicators of social background were included, i.e. economic difficulties in childhood, education and occupational class. The methods used were direct age-standardisation, index of dissimilarity and regression analysis. RESULTS: In the cohort born in 1920-1929 body height was taller in Sweden (175.8 cm among men and 163.7 cm among women) than in Finland (173.9 and 161.2 cm respectively). Body height by birth cohort increased faster in Finland, with the result that, in the cohort born in 1960-1969, the gap between the countries had narrowed to 0.8 cm among men and 0.3 cm among women. Body height differences by social background were larger in Finland than in Sweden. Socioeconomic body height differences have remained largely stable over the birth cohorts in both countries. CONCLUSIONS: The results suggest that differential economic development is partly seen in the narrowing of body height differences between Finland and Sweden. However, socioeconomic differences in body height have remained largely similar over the birth cohorts studied and between Finland and Sweden.

Open versus laparoscopic cholecystectomy for gallbladder carcinoma.

Laparoscopic surgery has replaced conventional open cholecystectomy for benign gallbladder disease. A major concern is how to handle gallbladder cancer in the laparoscopic era, since there are numerous case reports of port site metastases from gallbladder cancer after laparoscopic cholecystectomy. There are also many experimental studies favoring the opinion that the laparoscopic technique implies a higher risk of spreading malignant disease. This opinion has gained wide acceptance despite little previous clinical effort to determine the risk of tumor dissemination and the lack of comparisons between open and laparoscopic surgery. This report is a short summary of our own studies and present knowledge with special respect to the clinical aspects of the development and incidence of abdominal wall metastases. Among 270 patients with verified gallbladder carcinoma in whom 210 had open surgery and 60 a laparoscopic cholecystectomy, 12 patients (6.5%) in the open cholecystectomy group and 9 (15%) in the laparoscopic group developed incisional metastases. Although the sparse clinical documentation does not unavoidably mean that laparoscopic cholecystectomy has an increased risk of disseminating tumor cells, we recommend open surgery in cases of known or suspected gallbladder carcinoma.

Persistent variations in average height between countries and between socio-economic groups: an overview of 10 European countries.

PRIMARY OBJECTIVES: This paper aims to provide an overview of variations in average height between 10 European countries, and between socio-economic groups within these countries. DATA AND METHODS: Data on self-reported height of men and women aged 20-74 years were obtained from national health, level of living or multipurpose surveys for 1987-1994. Regression analyses were used to estimate height differences between educational groups and to evaluate whether the differences in average height between countries and between educational groups were smaller among younger than among older birth cohorts. RESULTS: Men and women were on average tallest in Norway, Sweden, Denmark and the Netherlands and shortest in France, Italy and Spain (range for men: 170-179 cm; range for women: 160-167 cm). The differences in average height between northern and southern European countries were not smaller among younger than among older birth cohorts. In most countries average height increased linearly with increasing birth-year (approximately 0.7-0.8 cm/5 years for men and approximately 0.4 cm/5 years for women). In all countries, lower educated men and women on average were shorter than higher educated men (range of differences: 1.6-3.0 cm) and women (range of differences: 1.2-2.2 cm). In most countries, education-related height differences were not smaller among younger than among older birth cohorts. CONCLUSIONS: The persistence of international differences in average height into the youngest birth cohorts indicates a high degree of continuity of differences between countries in childhood living conditions. Similarly, the persistence of education-related height differences indicates continuity of socio-economic differences in childhood living conditions, and also suggests that socio-economic differences in childhood living conditions will continue to contribute to socio-economic differences in health at adult ages.

Port site metastases after laparoscopic cholecystectomy.

The true incidence of abdominal wall metastases after open or laparoscopic operations is unknown. The large number of reports of patients with port site metastases may represent publication bias, but there is a suspicion that recurrence of the tumour in the abdominal incision is more common after laparoscopic operations. The aetiology of port site metastases is not known but in cases of gallbladder cancer the laparoscopic handling of the tumour, perforation of the gallbladder, and extraction of the malignant specimen may be risk factors for the spread of malignant cells. These risk factors are not equally applicable in laparoscopic colorectal cancer operations in which the incidence of port site metastases seems to be lower. In addition, several other factors are probably involved in the development of such metastases, including the creation of pneumoperitoneum and the use of different gases. Laparoscopic cholecystectomy is contraindicated when gallbladder cancer is known or suspected preoperatively. When signs of malignancy are encountered during a laparoscopic operation it should be converted to an open procedure. If a gallbladder cancer is diagnosed after a completed laparoscopic operation a careful clinical follow up is indicated and if signs of recurrent malignancy develop in the port sites they should be excised, particularly as port site metastases may be the only manifestation of recurrent disease.

Educational differences in smoking: international comparison.

OBJECTIVE: To investigate international variations in smoking associated with educational level. DESIGN: International comparison of national health, or similar, surveys. SUBJECTS: Men and women aged 20 to 44 years and 45 to 74 years. SETTING: 12 European countries, around 1990. MAIN OUTCOME MEASURES: Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level. RESULTS: In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal. CONCLUSIONS: These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries.

Wound recurrence from gallbladder cancer after open cholecystectomy.

BACKGROUND: Reports of port site recurrences from gallbladder cancer after laparoscopic cholecystectomy have raised considerable concern as to whether the laparoscopic technique implies an increased risk of metastatic disease. In a previous study of gallbladder cancer and laparoscopic cholecystectomy, we reported a frequency of 16% port site metastases. The purpose of the present study was to determine the frequency of wound metastases from gallbladder cancer after open cholecystectomy. METHODS: The registers from the Swedish Oncological Centers and the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for open cholecystectomy from 1991 to 1994. The study included all 8 university and 24 county hospitals in Sweden. The files from all patients with gallbladder cancer who had an open cholecystectomy were retrospectively reviewed. RESULTS: The study included 270 patients who had a cholecystectomy, of which 215 were classified as open and 55 as laparoscopic. Of the 215 patients, 11 patients were excluded because of an incorrect or deficient histopathologic or surgical classification. In 186 patients (91%), sufficient data were obtained for follow-up. Twelve patients (6.5%) had wound metastases from their gallbladder cancer. All patients with wound metastases died with a median survival of 10 months (range, 3 to 65 months). CONCLUSIONS: Wound metastases from gallbladder cancer after open cholecystectomy may be more common than previously assumed.

Do risk factors and health behaviours contribute to self-ratings of health?

This study examined the relative importance of five risk factors and health behaviours (namely dietary habits, leisure time exercise, smoking, alcohol consumption and body mass index) on self-ratings of health among the Swedish adult population. The data come from the 1991 Swedish Level of Living Survey, a face-to-face survey interview based on a sample representative of the Swedish population aged between 18 and 75 years (n = 5306). The analyses were carried out using logistic regression analysis. With the exception of the consumption of dietary fat, all the risk factors and health behaviours studied were associated with self-rated health. When they were adjusted for health problems and functional limitations most of the associations weakened or disappeared altogether, but smoking and use of vegetables in the diet were still associated with self-rated health. Self-ratings of young adults (18-34 years) were found to be related to body mass index even when health problems were adjusted for, with both obesity and underweight contributing to less than good self-rated health. The results indicate that risk factors and health behaviours do not, in general, directly contribute to self-ratings of health. Instead, their effect is mediated by more specific health problems and their functional consequences. However, smoking and not consuming vegetables, as well as obesity and underweight among young respondents, were found to have an independent association with self-rated health. This may reflect the effects of health problems not captured by our indicators of ill health, but may also indicate that risk factors and risky behaviours are considered to have an effect on one's perceived health even in the absence of health consequences.