Antonio Ponce de Leon

Risk factors for abdominal scar endometriosis after obstetric hysterotomies: a case–control study

Objective. to identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. Methods. The authors conducted a case–control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. Results. In the multivariate analysis, positive assoc...Objective. to identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. Methods. The authors conducted a case–control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. Results. In the multivariate analysis, positive associations were observed between scar endometriosis and hysterotomy type (early versus late: OR = 42.99; CI 8.77–210.81), amount of the menstrual blood flow (heavy versus light/normal: OR = 11.97; CI 2.35–60.82), and alcoholic consumption (yes versus no: OR = 5.31; CI 1.22–23.11). Negative association was observed between scar endometriosis and parity (OR = 0.61; CI 0.31–1.23), however it was not statistically significant (p>0.05). Conclusions. Early hysterotomy in pregnancy is the main risk factor for scar endometriosis. Increased menstrual flow and alcohol consumption are also risk factors, while high parity may be a protecting factor.

Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up

BackgroundThe gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation.MethodsSix psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study.ResultsThe documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months.ConclusionsCompliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.

A repeated measurement study investigating the impact of school outdoor environment upon physical activity across ages and seasons in Swedish second, fifth and eighth graders

BackgroundSchool children are confined to and exposed to outdoor environment that happens to be at their disposal during compulsory school time. The health-promoting potential of outdoor environment, and the use of it, is therefore important. We have studied the impact of school outdoor environment in terms of playground features, space, topography and vegetation upon the patterns of moderate to vigorous physical activity (MVPA) across ages and seasons in Swedish pupils at compulsory school.MethodsFour schools in the Middle and Southern parts of Sweden, with outdoor environments differing in playground features, space, topography and vegetation were analyzed during one school year. A sample of 196 children was drawn from eligible pupils in grades 2, 5 and 8, aged 7–14 years. PA was monitored with time-stamped Actigraph accelerometers GT3X+, measuring different intensity levels during outdoor time. Maps were used to mark places where the children stayed and what they did during outdoor time.ResultsMean MVPA during outdoor stay was 39xa0minutes for the entire school year, time in MVPA correlated positively with outdoor time, as did MVPA with used outdoor play area (pu2009<u20090.001). Outdoor MVPA declined with age, boys accumulated more MVPA than girls at all ages (pu2009<u20090.001). Ball play areas increased MVPA in 5th graders in September and May (pu2009<u20090.001). Overall, ball play areas increased 5th graders’ relative MVPA, and helped maintaining it with increasing age in boys but not in girls, whereas woodland stimulated and contributed to maintaining girls’ MVPA with increasing age. Outdoor temperature significantly impacted (pu2009<u20090.01) MVPA throughout all seasons.ConclusionWe conclude that school outdoor environment design and outdoor play time impact physical activity on a daily basis and may contribute to increasing girls’ physical activity and moderate the sharp decline in physical activity by age. The school outdoor environment may thus be a potential health promoter during school time.

Physical Activity and Incident Depression: A Meta-Analysis of Prospective Cohort Studies

OBJECTIVEnThe authors examined the prospective relationship between physical activity and incident depression and explored potential moderators.nnnMETHODnProspective cohort studies evaluating incident depression were searched from database inception through Oct. 18, 2017, on PubMed, PsycINFO, Embase, and SPORTDiscus. Demographic and clinical data, data on physical activity and depression assessments, and odds ratios, relative risks, and hazard ratios with 95% confidence intervals were extracted. Random-effects meta-analyses were conducted, and the potential sources of heterogeneity were explored. Methodological quality was assessed using the Newcastle-Ottawa Scale.nnnRESULTSnA total of 49 unique prospective studies (N=266,939; median proportion of males across studies, 47%) were followed up for 1,837,794 person-years. Compared with people with low levels of physical activity, those with high levels had lower odds of developing depression (adjusted odds ratio=0.83, 95% CI=0.79, 0.88; I2=0.00). Furthermore, physical activity had a protective effect against the emergence of depression in youths (adjusted odds ratio=0.90, 95% CI=0.83, 0.98), in adults (adjusted odds ratio=0.78, 95% CI=0.70, 0.87), and in elderly persons (adjusted odds ratio=0.79, 95% CI=0.72, 0.86). Protective effects against depression were found across geographical regions, with adjusted odds ratios ranging from 0.65 to 0.84 in Asia, Europe, North America, and Oceania, and against increased incidence of positive screen for depressive symptoms (adjusted odds ratio=0.84, 95% CI=0.79, 0.89) or major depression diagnosis (adjusted odds ratio=0.86, 95% CI=0.75, 0.98). No moderators were identified. Results were consistent for unadjusted odds ratios and for adjusted and unadjusted relative risks/hazard ratios. Overall study quality was moderate to high (Newcastle-Ottawa Scale score, 6.3). Although significant publication bias was found, adjusting for this did not change the magnitude of the associations.nnnCONCLUSIONSnAvailable evidence supports the notion that physical activity can confer protection against the emergence of depression regardless of age and geographical region.

The impact of water supply and sanitation on area differentials in the decline of diarrhoeal disease mortality among infants in Stockholm 1878—1925:

This study analyses the impact of improved water supply and sanitation on the level and rate of decline of child diarrhoea mortality in Stockholm 1878—1925. Previous studies have failed to demonstrate an effect of improved water supply on the risk of diarrhoea mortality at the individual level. Using data on access to water and sanitation from a household survey in 1895 and mortality rates and sociodemographic information from individual data 1878—1925 to analyse area differentials in diarrhoea mortality, it was found that the proportion having their own latrine in the household was associated with lower mortality risk in 1895—1900, while the proportion having water in the household was associated with lower diarrhoea mortality risk during the mortality decline until 1925. Population effects of improved water and sanitation on diarrhoea mortality may be better measured at area level than at individual level.

Differences in child injury hospitalizations in Sweden : The use of time-trend analysis to compare various community injury-prevention approaches

Aim: Swedens child injury fatality rates are among the lowest in the world. The country has engaged in a number of community injury-prevention programmes. The purpose of this study was to compare child injury hospitalization rates from the Skaraborg District with the rest of Sweden. Our study hypothesis was that municipalities that offered comprehensive child injury-prevention programmes would see significant decreases in their child injury hospitalization rates, compared with other areas. Methods: The study areas comprised three groups, consisting of municipalities in Skaraborg that had adapted the Safe Communities approach to injury prevention programmes, other municipalities in the District, and the rest of Sweden. The aim of the analysis was twofold: (1) to fit time trends for childrens injuries in various areas in an integrated manner; and (2) to compare time trends across locations between community safety-promotion programmes as well as with the control areas. Panel data models and parametric splines were used. Results: There were differences between incidence rates in the study areas and with regard to gender. There was a steep decrease in injury rates in one of the Safe Communities study areas for both genders. Conclusions: The methods applied in this analysis reveal more detailed and sophisticated time trends than the usual simple linear regression approach. The model provided a clearer view of the interactions of gender, area, and time as they impacted on childrens injuries, and allowed for better insight into the impact of safety programmes.

Violence and self-reported health: does individual socioeconomic position matter?

Abstract: Background: Violence is a major public health problem. Both clinical and population based studies shows that violence against men and women has physical and psychological health consequences. However, elsewhere and in Sweden little is known of the effect of individual socioeconomic position (SEP) on the relation between violence and health outcomes. Objective: This study aimed to assess the effect of individual SEP on the relation between violence and three health outcomes (general health, pain and anxiety) among women in Stockholm County. Methods: The study used data from the Stockholm Public Health Survey, a cross-sectional survey carried out in 2006 for the Stockholm County Council by Statistic Sweden. 34 704 respondents answered the survey, the response rate was sixth one percent. Analyses were carried out using descriptive statistics and logistic regression analysis in SPSS v.17.0. Results: Individual SEP increased the odds of reporting poor health outcomes among victimized women in Stockholm County. Regarding self-reported health women in low-SEP who reported victimization in the past twelve months had odds of 2,36 (95% CI 1.48-3.77) for the age group 18-29 years and 3.78 (95% CI 2.53-5.64) for the age group 30-44 years compared with women in high-SEP and non-victim. For pain the odds was 2,41 (95% CI 1,56-3,73) for the age group 18-29 years and 2,98 (95% CI 1,99-4,46) for women aged 30-44 years. Regarding anxiety the age group 18-29 years had odds of 2,53 (95% CI 1,58-4,03) and for the age group 30-44 years had odds of 3,87 (95% CI 2,55-5,87). Conclusion: Results showed that individual SEP (measured by occupation) matters to the relationship between violence and health outcomes such as general self-reported health, pain and anxiety. Women in lower SEP and experienced victimization in the past twelve months had increased odds of reporting poorer self-rated health, pain and anxiety compared to those in higher SEP with no experience of victimization. However, further exploration of the relationship between poverty, individual SEP is needed using other Swedish population samples.

Is gender policy related to the gender gap in external cause and circulatory disease mortality? A mixed effects model of 22 OECD countries 1973–2008

BackgroundGender differences in mortality vary widely between countries and over time, but few studies have examined predictors of these variations, apart from smoking. The aim of this study is to investigate the link between gender policy and the gender gap in cause-specific mortality, adjusted for economic factors and health behaviours.Methods22 OECD countries were followed 1973–2008 and the outcomes were gender gaps in external cause and circulatory disease mortality. A previously found country cluster solution was used, which includes indicators on taxes, parental leave, pensions, social insurances and social services in kind. Male breadwinner countries were made reference group and compared to earner-carer, compensatory breadwinner, and universal citizen countries. Specific policies were also analysed. Mixed effect models were used, where years were the level 1-units, and countries were the level 2-units.ResultsBoth the earner-carer cluster (ns after adjustment for GDP) and policies characteristic of that cluster are associated with smaller gender differences in external causes, particularly due to an association with increased female mortality. Cluster differences in the gender gap in circulatory disease mortality are the result of a larger relative decrease of male mortality in the compensatory breadwinner cluster and the earner-carer cluster. Policies characteristic of those clusters were however generally related to increased mortality.ConclusionResults for external cause mortality are in concordance with the hypothesis that women become more exposed to risks of accident and violence when they are economically more active. For circulatory disease mortality, results differ depending on approach – cluster or indicator. Whether cluster differences not explained by specific policies reflect other welfare policies or unrelated societal trends is an open question. Recommendations for further studies are made.

Cannabis, Psychosis, and Mortality: A Cohort Study of 50,373 Swedish Men

OBJECTIVEnThe authors assessed 1) the overall risk of death among cannabis users compared with nonusers and the extent to which psychosis affects excess mortality; 2) mortality among persons with psychotic disorders and the extent to which cannabis use affects excess mortality; and 3) the interaction effect of cannabis use and diagnosis of psychotic disorders on mortality.nnnMETHODnThis was a longitudinal study of 50,373 Swedish male military conscripts (ages 18-19) who were followed in the National Cause of Death Register up to around age 60. Cox proportional hazard modeling was used to assess risk of death in relation to baseline cannabis use and diagnosis of psychotic disorders.nnnRESULTSnSubjects with a baseline history of heavy cannabis use had a significantly higher risk of death (hazard ratio=1.4, 95% CI=1.1, 1.8) than those without such a history. The authors found an excess mortality among subjects with psychotic disorders, but the level did not differ between those with a history of cannabis use (ever users: hazard ratio=3.8, 95% CI=2.8, 5.0; heavy users: hazard ratio=3.8, 95% CI=2.6, 6.2) and those without such a history (hazard ratio=3.7, 95% CI=3.1, 44). No interaction was observed between cannabis use and diagnosis of psychotic disorders with regard to mortality.nnnCONCLUSIONSnThe results suggest that individuals with an early history of heavy use of cannabis are at a higher risk of death than those with a history of no use of cannabis. Although the authors adjusted for several confounders at baseline, the results should be interpreted with caution because of a lack of information on confounders in the period after conscription.

Direct and indirect exposure to violence and psychological distress among civil servants in Rio de Janeiro, Brazil: a prospective cohort study

BackgroundImportant social and economic changes accompanying the recent fast rate of urbanization have been considered a major factor in triggering and sustaining urban violence in Brazil. The purpose of this paper is to investigate the effects of exposure to direct, indirect, and contextual violence on the risk of psychological distress.MethodsProspective longitudinal study carried out among 3,058 civil servants working at university campuses in Rio de Janeiro. Psychological distress was measured using the General Health Questionnaire, and exposure to individual violence was assessed as direct (DV), indirect (IV), and both direct and indirect (DIV). Contextual violence was assessed through the geocoding of residential addresses of study participants and the rates of homicides in 2005 at the corresponding weighting area. Multiple logistic regression was used to evaluate individual and contextual correlates of psychological distress.ResultsExposure to DIV increased more than six times (95% CI 2.7–16.0) the odds of psychological distress occurrence at the six-year follow-up. Regarding persistence of psychological distress, the association with violence exposure was 1.6 (95% CI 1.0–2.4) for DV and 2.7 (95% CI 1.3–5.3) for IV. Contextual violence was not associated with psychological distress, and no interaction effect was found between exposure to individual and contextual violence in the occurrence/persistence of psychological distress.ConclusionsResults of this study highlight the importance of assessing multiple forms of violence in research on the social determinants of mental disorders and support the view that individual exposure to different forms of violence increases the risk of psychological distress.