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Socio economic inequalities in adult health behaviour are consistently observed. Despite a well-documented pattern, social determinants of variations in health behaviour have not been sufficiently clarified. This article therefore presents sociological pathways to explain the existing inequalities in health behaviour. At a micro level, control beliefs have been part of several behavioural theories. We suggest that these beliefs might bridge the gap between sociology and psychology by emphasising their roots in fundamental socio-economic environments. At a meso level, social networks and support have not been explicitly considered as behavioural determinants. This contribution states that these social factors influence health behaviour while being unequally distributed across society. At a macro level, characteristics of the neighbourhood environment influence health behaviour of its residents above and beyond their individual background. Providing further opportunity for policy makers, it is shown that peer and school context equalise inequalities in risky behaviour in adolescence. As a conclusion, factors such as control expectations, social networks, neighbourhood characteristics, and school context should be included as strategies to improve health behaviour in socially disadvantaged people.

Objective: Poor social relations are supposed to contribute to adverse health behaviour. We examined this association and the role of low socio-economic position., Methods: We regressed health behaviour on composite variables of the two exposures of social relations and socio-economic position (SEP). Social relations included networks and support; health behaviour was analysed in terms of smoking, poor nutrition and physical inactivity; socio-economic position comprised of income and education. Cross sectional data from a population based epidemiological study in German (4,814 men and women aged 45-75) was analysed., Results: Among the indicators for social relations, social isolation was consistently associated with adverse health behaviour; social support showed modest effect. A combination of poor social relations and low SEP displayed stronger (additive) associations with adverse health behaviour than each factor alone. However, superadditivity was excluded., Conclusion: Given the important role of health adverse behaviour in chronic disease development, results underline the relevance of social environment and socio-economic structure in Public Health interventions.

The role of the gynaecologist in the treatment of female-to-male transsexual patients is largely confined to hysterectomy and vaginectomy. We showed that laparoscopic hysterectomy is feasible and safe in this group. When surgery is not performed completely, follow-up of the remaining organs is necessary. The major part of this thesis deals with the necessity and acceptability of gynaecological follow-up in male-to-female (MTF) transsexual patients. These patients function well on a physical, emotional, psychological and social level. Sexual function was less satisfactory, especially concerning arousal, lubrication and pain. Typical gynaecological exams proved to be feasible and well accepted. Transvaginal palpation of the prostate is of poor clinical value, in contrast to transvaginal ultrasound. Mammography was judged almost painless and 98% of transsexual women intend to return for screening. Since there is uncertainty about breast cancer risk in transsexual women, we conclude that breast screening in this population should not differ from that in biological women. Microflora and cytology of the penile skin-lined neovagina of transsexual women were described for the first time. Vaginal lactobacilli were largely lacking. A mixed microflora of aerobe and anaerobe species, usually found on skin, in bowel or in bacterial vaginosis microflora, was encountered. No high-grade cervical lesions were found, however, one patient displayed a low-grade lesion (positive for HR-HPV with koilocytes). Finally, low bone mass was highly prevalent in our study group. This finding appeared to be largely determined, in comparison to healthy males, by smaller bone size and a strikingly lower muscle mass.

Background: Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking., Methods: We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied., Results: We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0-3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5-0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5-2.0)., Conclusions: Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.

Background: The role of reproductive surgery is declining due to the widespread availability of assisted reproductive technology, but an evidence-based fundament for this decline is lacking. We therefore performed a systematic review of the literature., Methods: We searched MEDLINE, EMBASE and the Cochrane Library for randomised trials evaluating laparoscopic or hysteroscopic interventions in subfertile women, studying pregnancy or live birth rates. We present an overview of the results and quality of the detected studies., Results: The methodological quality of the 63 detected studies was mediocre. The laparoscopic treatment of minimal/ mild endometriosis might increase the pregnancy rate but the two major studies report conflicting results. Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5). Laparoscopic ovarian drilling results at least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) but decreases the multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58). Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7). Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1). Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9). The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant (RR 1.2, 95% CI 0.75-1.9). Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9)., Conclusions: Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.

Background: The ideal goals in penile reconstruction are well described, but the multitude of flaps used for phalloplasty only demonstrates that none of these techniques is considered ideal. Still, the radial forearm flap is the most frequently used flap and universally considered as the standard technique., Methods: In this article, the authors describe the largest series to date of 287 radial forearm phalloplasties performed by the same surgical team. Many different outcome parameters have been described separately in previously published articles, but the main purpose of this review is to critically evaluate to what degree this supposed standard technique has been able to meet the ideal goals in penile reconstruction., Results: Outcome parameters such as number of procedures, complications, aesthetic outcome, tactile and erogenous sensation, voiding, donor-site morbidity, scrotoplasty, and sexual intercourse are assessed., Conclusions: In the absence of prospective randomized studies, it is not possible to prove whether the radial forearm flap truly is the standard technique in penile reconstruction. However, this large study demonstrates that the radial forearm phalloplasty is a very reliable technique for the creation, mostly in two stages, of a normal-appearing penis and scrotum, always allowing the patient to void while standing and in most cases also to experience sexual satisfaction. The relative disadvantages of this technique are the rather high number of initial fistulas, the residual scar on the forearm, and the potential long-term urologic complications. Despite the lack of actual data to support this statement, the authors feel strongly that a multidisciplinary approach with close cooperation between the reconstructive/plastic surgeon and the urologist is an absolute requisite for obtaining the best possible results.

Bone health is a parameter of interest in the daily follow-up of male-to-female (M --> F) transsexual persons both before and after sex reassignment surgery (SRS) due to an intensely changing hormonal milieu. We have studied body composition, areal, geometric, and volumetric bone parameters, using DXA and peripheral quantitative computed tomography at different sites in 50 M --> F transsexual persons, at least 3 yr after the start of the hormonal treatment and 1 yr after SRS. In this cross-sectional study, hormone levels and markers of bone metabolism were assessed using immunoassays. Prevalence of low bone mass as defined by a Z-score < or = -2.0 according to DXA criteria was 26% at lumbar spine and 2% at the total hip. We found no major differences in hormonal parameters between participants with a Z-score < or = or > -2.0. Markers of bone turnover were comparable between subjects with or without low bone mass, indicating a stable bone turnover at the time of investigation. No significant differences in bone size or density were observed between patients on transdermal vs. oral estrogens. Low bone mass is not uncommon in M --> F transsexual persons. Smaller bone size, and a strikingly lower muscle mass compared with men appear to underlie these findings.

Objectives: To assess feasibility and diagnostic performance of prostate examination through transvaginal palpation and transvaginal ultrasound in transsexual women (TSW)., Methods: Fifty TSW who were at least 6 months' posttransition were recruited in a University Hospital. Speculum examination and digital vaginal examination were performed by a gynecologist. Transvaginal ultrasound of the prostate was performed by a radiologist. The information gathered included: ease of insertion of the speculum, vaginal length, palpability of the prostate, vaginal mobility and presence of scar tissue, ease of introduction of the ultrasound probe, ability to visualize prostate and seminal vesicles, echogenicity of the peripheral zone and the central gland, presence of calcifications and delineation of prostatic capsule, attitude toward gynecologic examinations, and anticipated and experienced painfulness of the different examinations., Results: Speculum examination was possible in all but 1 patient and was easy in 78% of the patients. Median vaginal length was 7 cm. A regular digital vaginal examination was possible in 44% of the patients, the vagina was rather mobile and with limited scar tissue on average. In 48% of the patients, the prostate was palpable. In 94% of the patients, the prostate was visible on transvaginal ultrasound. Mean prostate volume was 14 mL, calcifications were present in 33%, and none had cysts. Capsule of the prostate was well delineated in 74% and seminal vesicles were visualized in 80%. All examinations were very well tolerated and nearly painless., Conclusions: Gynecologic examination and prostate assessment were acceptable to TSW. Transvaginal palpation of the prostate is of poor clinical value, yet transvaginal ultrasound allows for proper evaluation of the prostate status.

Background: The microflora of the penile skin-lined neovagina in male-to-female transsexuals is a recently created microbial niche which thus far has been characterized only to a very limited extent. Yet the knowledge of this microflora can be considered as essential to the follow-up of transsexual women. The primary objective of this study was to map the neo-vaginal microflora in a group of 50 transsexual women for whom a neovagina was constructed by means of the inverted penile skin flap technique. Secondary objectives were to describe possible correlations of this microflora with multiple patients' characteristics, such as sexual orientation, the incidence of vaginal irritation and malodorous vaginal discharge., Results: Based on Gram stain the majority of smears revealed a mixed microflora that had some similarity with bacterial vaginosis (BV) microflora and that contained various amounts of cocci, polymorphous Gram-negative and Gram-positive rods, often with fusiform and comma-shaped rods, and sometimes even with spirochetes. Candida cells were not seen in any of the smears. On average 8.6 species were cultured per woman. The species most often found were: Staphylococcus epidermidis, Streptococcus anginosus group spp., Enterococcus faecalis, Corynebacterium sp., Mobiluncus curtisii and Bacteroides ureolyticus. Lactobacilli were found in only one of 30 women. There was no correlation between dilatation habits, having coitus, rinsing habits and malodorous vaginal discharge on the one hand and the presence of a particular species on the other. There was however a highly significant correlation between the presence of E. faecalis on the one hand and sexual orientation and coitus on the other (p = 0.003 and p = 0.027 respectively). Respectively 82%, 58% and 30% of the samples showed an amplicon after amplification with M. curtisii, Atopobium vaginae and Gardnerella vaginalis primer sets., Conclusion: Our study is the first to describe the microflora of the penile skin-lined neovagina of transsexual women. It reveals a mixed microflora of aerobe and anaerobe species usually found either on the skin, in the intestinal microflora or in a BV microflora.

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking., Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS., Methods: Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited., Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored., Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals., Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

The current work addresses the unification of Electronic Health Records related to cervical cancer into a single medical knowledge source, in the context of the EU-funded ASSIST research project. The project aims to facilitate the research for cervical precancer and cancer through a system that virtually unifies multiple patient record repositories, physically located in different medical centers/hospitals, thus, increasing flexibility by allowing the formation of study groups "on demand" and by recycling patient records in new studies. To this end, ASSIST uses semantic technologies to translate all medical entities (such as patient examination results, history, habits, genetic profile) and represent them in a common form, encoded in the ASSIST Cervical Cancer Ontology. The current paper presents the knowledge elicitation approach followed, towards the definition and representation of the disease's medical concepts and rules that constitute the basis for the ASSIST Cervical Cancer Ontology. The proposed approach constitutes a paradigm for semantic integration of heterogeneous clinical data that may be applicable to other biomedical application domains.

Inhabitants of deprived neighbourhoods are at higher risk of coronary heart disease. In this study we investigate the hypothesis that social inequalities at neighbourhood level become already manifest in subclinical coronary atherosclerosis, as defined by electron-beam computed tomography derived measures. Coronary artery calcification was assessed as a marker of atherosclerosis in a population based sample of 4301 men and women (45-75 years) without a history of coronary heart disease. Participants lived in three adjacent cities in Germany and were examined between 2000 and 2003 as part of the Heinz Nixdorf Recall Study. Individual level data was combined with neighbourhood level information about unemployment, welfare and living space per inhabitant. This dataset was analysed with descriptive and multilevel regression methods. An association between neighbourhood deprivation and subclinical coronary calcification was observed. After adjustment for age and individual socioeconomic status male inhabitants of high unemployment neighbourhoods had an odds ratio of 1.45 (1.11, 1.96) of exhibiting a high calcification score (>75th percentile) compared to men living in low unemployment areas. The respective odds for women was 1.29 (0.97, 1.70). Additional explorative analyses suggest that clustering of unhealthy lifestyles in deprived neighbourhoods contributes to the observed association. In conclusion, findings suggest that certain neighbourhood characteristics promote the emergence of coronary atherosclerosis. This might point to a pathway from neighbourhood deprivation to manifest coronary heart disease.

Context: Male-to-female (M-->F) transsexual persons undergo extreme changes in gonadal hormone concentrations, both by pharmacological and surgical interventions. Given the importance of sex steroids for developing and maintaining bone mass, bone health is a matter of concern in daily management of these patients., Objective: To provide data on bone metabolism, geometry and volumetric bone mineral density in M-->F transsexual persons., Design/setting/participants: Twenty-three M-->F transsexual persons, recruited from our gender dysphoria clinic and at least 3 yrs after sex reassignment surgery, together with 46 healthy age- and height-matched control men were included in this cross-sectional study., Main Outcome Measures: Body composition, areal and volumetric bone parameters determined using DXA and peripheral quantitative computed tomography. Hormone levels and markers of bone metabolism assessed using immunoassays. Peak torque of biceps and quadriceps muscles and grip strength assessed using an isokinetic and hand dynamometer, respectively., Results: M-->F transsexual persons presented lower total and regional muscle mass and lower muscle strength as compared to controls (all P<0.001). In addition, they had higher total and regional fat mass (P<0.010) and a lower level of sports-related activity index (P<0.010). Bone mineral content and areal density (aBMD) of the lumbar spine, total hip and distal radius, as well as trabecular vBMD of the distal radius was lower as compared to controls (P<0.010). At cortical sites, no differences in cortical vBMD were observed, whereas M-->F transsexual persons were characterized by smaller cortical bone size at both the radius and tibia (P<0.010). Lower levels of biochemical markers of bone formation and resorption (P<0.010) suggested decreased bone turnover., Conclusion: M-->F transsexual persons have less lean mass and muscle strength, and higher fat mass. In addition, they present lower trabecular vBMD and aBMD at the lumbar spine, total hip and distal radius, and smaller cortical bone size as compared to matched controls. Both the lower level of sports-related physical activity as well testosterone deprivation could contribute to these findings. These results indicate that bone health should be a parameter of interest in the long-term follow-up care for M-->F transsexual persons.

Background: Social networks and social support are supposed to contribute to the development of unequal health within populations. However, little is known about their socio-economic distribution. In this study, we explore this distribution., Methods: This study analyses the association of two indicators of socio-economic position, education and income, with different measures of social networks and support. Cross-sectional data have been derived from the baseline examination of an epidemiological cohort study of 4.814 middle aged urban inhabitants in Germany (Heinz Nixdorf Recall Study). Bivariate and multivariate logistic regression analysis were carried out to estimate the risk of having poor social networks and support across socio-economic groups., Results: Socially disadvantaged persons more often report poor social networks and social support. In multivariate analyses, based on education, odds ratios range from 1.0 (highest education) to 4.9 (lowest education) in a graded way. Findings based on income show similar effects, ranging from 1.0 to 2.5. There is one exception: no association of SEP with close ties living nearby and regularly seen was observed., Conclusion: Poor social networks and low social support are more frequent among socio-economically disadvantaged people. To some extent, this finding varies according to the indicator chosen to measure these social constructs.

Background: Previous studies have shown that deprived neighbourhoods have higher cardiovascular mortality and morbidity rates. Inequalities in the distribution of behaviour related risk factors are one possible explanation for this trend. In our study, we examined the association between cardiovascular risk factors and neighbourhood characteristics. To assess the consistency of associations the design is cross-national with data from nine industrial towns from the Czech Republic and Germany., Methods: We combined datasets from two population based studies, one in Germany ('Heinz Nixdorf Recall (HNR) Study'), and one in the Czech Republic ('Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) Study'). Participation rates were 56% in the HNR and 55% in the HAPIEE study. The subsample for this particular analysis consists of 11,554 men and women from nine German and Czech towns. Census based information on social characteristics of 326 neighbourhoods were collected from local administrative authorities. We used unemployment rate and overcrowding as area-level markers of socioeconomic status (SES). The cardiovascular risk factors obesity, hypertension, smoking and physical inactivity were used as response variables. Regression models were complemented by individual-level social status (education) and relevant covariates., Results: Smoking, obesity and low physical activity were more common in deprived neighbourhoods in Germany, even when personal characteristics including individual education were controlled for. For hypertension associations were weak. In the Czech Republic associations were observed for smoking and physical inactivity, but not for obesity and hypertension when individual-level covariates were adjusted for. The strongest association was found for smoking in both countries: in the fully adjusted model the odds ratio for 'high unemployment rate' was 1.30 [95% CI 1.02-1.66] in the Czech Republic and 1.60 [95% CI 1.29-1.98] in Germany., Conclusion: In this comparative study, the effects of neighbourhood deprivation varied by country and risk factor; the strongest and most consistent effects were found for smoking. Results indicate that area level SES is associated with health related lifestyles, which might be a possible pathway linking social status and cardiovascular disease. Individual-level education had a considerable influence on the association between neighbourhood characteristics and risk factors.

In everyday clinical practice, it is not always clear if and when exactly in the fertility work-up a diagnostic laparoscopy should be offered. The aim of this review is to analyse the available evidence with respect to alternative diagnostic methods for detecting tuboperitoneal infertility and with respect to the position of diagnostic laparoscopy in women with infertility. A literature search of the National Library of Medicine and the National Institutes of Health (PubMed) was performed using the key words 'diagnostic laparoscopy and infertility'. The study methodology was carefully considered in an effort to present conclusions preferably based on randomized controlled trials (RCTs). The routine use of diagnostic laparoscopy for the evaluation of all cases of female infertility is currently under debate. According to data published in retrospective non-controlled studies, diagnostic laparoscopy after several failed cycles of ovulation induction enables the detection of a significant proportion of pelvic pathology amenable to treatment. A Cochrane review has shown that laparoscopic ovarian diathermy in clomiphene-resistant polycystic ovarian syndrome is at least as effective as gonadotrophin treatment, and results in a lower multiple pregnancy rate. The role of laparoscopy before the start of treatment with intrauterine insemination is controversial, according to one RCT. In women with bilateral ultrasonically visible hydrosalpinges, two RCTs have demonstrated increased implantation and pregnancy rates in IVF cycles after salpingectomy. Although RCTs which have studied the benefit of laparoscopic surgery in moderate or severe endometriosis are still lacking, its value has generally been accepted. In conclusion, some specific clinical settings, solid evidence is available to recommend the use of diagnostic laparoscopy in current fertility practice. There is however a need for more RCTs to answer remaining questions regarding its value in the diagnosis and treatment of some patients with infertility.

Objective: The purpose of this study was to identify women at risk of spontaneous preterm birth through a 4-category Gram-stained vaginal smear method, not restricted to bacterial vaginosis., Study Design: This was a prospective cohort study correlating Gram-stained vaginal smears in early pregnancy with spontaneous preterm birth. Smears were categorized as 'normal,' 'bacterial vaginosis-like,' 'grade I-like' (atypical gram-positive rods) or 'purulent grade I' (lactobacilli-dominated smears showing heavy leukorrhea of unknown cause)., Results: Normal microflora were associated with a 4-fold decreased risk (95%CI 0.1-0.6, P < .001) of spontaneous preterm birth and an abnormal Gram stain with an overall adjusted odds ratio of 5.2 (95%CI 1.8-14.5, P < .001). The sensitivity of vaginal smear diagnosis for preterm birth increased from 25% with conventional scoring up to 70% with these modified criteria., Conclusion: Accounting for atypical gram-positive bacteria and neutrophils on Gram-stained vaginal smears may identify a larger proportion of women at risk of preterm birth compared to diagnosis of bacterial vaginosis alone.

Against the background of health inequalities, the German Federal Centre for Health Education (BZgA) has coordinated the European project 'Closing the Gap: Strategies for Action to Tackle Health Inequalities in Europe'. Describing the state of the art of reducing health inequalities in each participating country has been one output of the EU project. The aim of this contribution is to present information for Germany with regard to research, political background, initiatives, quality and evaluation of interventions and public awareness. Despite the lack of a national strategy to tackle health inequalities, it can be concluded that there is a range of important activities which are supported by the federal government and which comprise different actors and sectors. Knowledge transfer across Europe can be helpful within the conception of a concerted action.

Background: Socioeconomic inequalities in health are a persistent feature throughout Europe. Researchers and policy makers are increasingly using a lifecourse perspective to explain these inequalities and direct policy. However, there are few, if any, cross national lifecourse comparisons in this area., Methods: Associations between socioeconomic position (SEP) in childhood and in adulthood and poor self rated health among men and women at midlife were tested in four European studies from England (n = 3615), France (n = 11 595), Germany (n = 4183), and the Netherlands (n = 3801)., Results: For women, mutually adjusted analyses showed significant associations between poor self rated health and low SEP in both childhood and adulthood in England and the Netherlands, only low childhood SEP in Germany and neither childhood nor adulthood SEP in France. For men, mutually adjusted analyses showed significant associations between poor self rated health and low SEP in both childhood and adulthood in France and the Netherlands, only with adult SEP in England and only with childhood SEP in Germany., Conclusion: In most countries adult SEP showed stronger associations with self rated health than childhood SEP. There are both gender and national differences in the associations between childhood and adulthood SEP. Policies designed to reduce inequalities in health need to incorporate a lifecourse perspective that is sensitive to different national and gender issues. Ultimately, more cross national studies are required to better understand these processes.

Objective: To evaluate ease of insertion, acceptability and endometrial safety of a novel, miniature intrauterine, T-shaped, levonorgestrel (LNG)-releasing intrauterine system (IUS), Femilis Slim LNG-IUS (Contrel Research, Belgium), combined with parenteral estrogen substitution therapy (EST) in postmenopausal women., Design: A prospective, non-comparative, study in postmenopausal women. A 3.0 cm long and 2.0 mm wide coaxial fibrous delivery system, delivering approximately 20 microg/day of levonorgestrel (LNG) was used. The drug compartment is provided with crossarms fixed to the upper part of the drug delivery rod. The calculated duration of release of the system is at least 5 years. The majority of women received percutaneous 17beta estradiol (Oestrogel, Besins Int., Belgium), 1.5 mg daily on a continuous basis, which provides sufficient blood levels of estrogen in most women to suppress climacteric symptoms and protection against bone loss., Primary Outcome Measures: ease of insertion, retention and side effects of the T-LNG Slim IUS., Secondary Outcome Measures: endometrial safety assessed by transvaginal ultrasound examination and by endometrial biopsy in a subset of women., Results: One hundred and seventy insertions were performed in postmenopausal women with median age of age 56.6 (range 43.5-80.3). Insertion was easy in 161 (94.2%) and difficult in 9 (5.3%) women. Pain at insertion was rated as none in 57 women (33.5%), mild in 105 (61.7%), moderate in 7 (4.1%) and severe in 1 (0.5%) woman. The system was well retained in the uterus as no expulsions occurred. At the time of study analysis, the total number of women-months was 1797.5. Ninety-five women had the T-LNG-IUS in place for periods in excess of 1 year. The study was well followed-up with lost-to-follow-up rate (defined as no follow-up during 12 months) of zero at the time of study analysis. The number of women continuing the method was 160 (94.1%) including four women which were released from follow-up for various non-medical related reasons. The histological examinations conducted in 105 women showed predominantly inactive endometrium characterized by a pseudo-decidual reaction of the endometrial stroma with endometrial atrophy. The mean thickness (double-layer) of the endometrium was 3.3 mm (range 2-5 mm) which correlated well with the histology results., Conclusions: The results suggest that the small T-LNG-IUS is easy to insert in most postmenopausal women without anaesthesia and dilatation of the cervix. It is well tolerated, well accepted and effective in suppressing the endometrium during EST. The lack of expulsions of the device in this study is attributed to the optimal design characteristics of the IUS, the absence of uterine bleeding and absent or reduced contractility of the uterus. The study confirms earlier studies conducted with other LNG-releasing systems used for endometrial suppression during EST. The ease of insertion of the small LNG-IUS could be an important incentive to expand the use of the continuous combined regimen with local delivery of the progestogen. It could be a method of choice for endometrial suppression in women using EST with fundamental advantages to systemically applied progestogens which have been the subject of considerable debate as reported in the recent literature.

Objective: The objective of the study was to evaluate ease of insertion, contraceptive performance and safety, in parous and nulliparous women, of two new T-shaped levonorgestrel (LNG)-releasing intrauterine systems (LNG-IUS), Femilistrade mark (parous women) and Femilis Slim (nulliparous women), releasing 20 mug of LNG per day. An ancillary objective was to evaluate expulsion and user continuation., Design and Methods: An open, prospective, noncomparative study (interim analysis). Two hundred thirty-five insertions were performed in fertile women seeking contraception. Of these, 143 (60.8%) parous women were fitted with Femilis and 92 (39.2%) nulliparous women were fitted with Femilis Slim. The LNG-IUS was inserted using a simplified push-in technique (without folding the cross-arms in the insertion tube)., Results: This paper is the first report with the Femilis LNG-IUS. The push-in technique of insertion was considered simple and safe. Insertion was reported "easy" in virtually all women (97.9%). Pain at insertion was absent in 24.7% and "mild" in 67.7% of women. With respect to pain, there were no statistical differences between the parous and nulliparous group. At the time of study analysis, the total number of women-months of use was 1769.7. Seventy-six women had the Femilis IUS in place for periods in excess of 1 year. The study was well followed up with lost to follow-up of only two women. No pregnancies were observed. There was one expulsion in the nulliparous and one in the parous group. Ten removals were performed for medical reasons (mainly bleeding and pain). One pelvic infection occurred in a nulliparous woman caused by Chlamydia trachomatis, which was resolved without removing the IUS. There were no other serious adverse events reported. Both Femilis and Femilis Slim were well tolerated, which resulted in a high continuation rate (94.04%)., Conclusion: The Femilis LNG-IUS is an effective contraceptive and is easily inserted. The simple and safe insertion procedure could be an advantage for use by nonspecialist providers such as nurses, midwives, general practitioners, and for those not inserting intrauterine devices regularly. Femilis Slim could be an attractive long-term contraceptive option in young and adolescent women.

Objective: To investigate the effects of sex reassignment surgery (SRS) on lower urinary tract function., Methods: A questionnaire concerning voiding habits and lower urinary tract symptoms after sex reassignment surgery, was given to 24 female-to-male transsexuals (FTM) and 31 male-to-female transsexuals (MTF), who respectively underwent phalloplasty and vaginoplasty. For this study only Dutch speaking patients were selected. Also, uro-flowmetry data from 92 FTM transsexuals were reviewed., Results: In general, no change in voiding patterns was observed. Post-void dribbling was reported by 79% of the FTM transsexuals, and 16% of the MTF group reported some form of incontinence. The uro-flowmetry examination showed a mean, non-significant decrease of 2 ml/s in Q(max) in FTM patients., Conclusion: SRS can cause minor changes in urinary habits. Even if they do not result in patients seeking medical help, transsexuals should be warned about these eventual discomforts pre-operatively.

We have measured the frequency of the 6s(2)S(1/2)(2)-5d D(3/2)(2) electric-quadrupole transition of (171)(Yb) (+) with a relative uncertainty of 1x10(-14) , nu(Yb)=688358 979309312Hz +/-6Hz . We used a femtosecond frequency comb generator to phase-coherently link the optical frequency derived from a single trapped ion to a cesium-fountain-controlled hydrogen maser. This measurement is one of the most accurate measurements of optical frequencies ever reported, and it represents a contribution to the development of optical clocks based on a (171)Yb(+)-ion standard.

Background and Purpose: Elevations of protein S-100 (S-100) in cerebrospinal fluid and serum have been reported after cerebral infarctions. The aim of our study was to evaluate the time course of serum S-100 concentrations after territorial middle cerebral artery (MCA) infarctions in correlation with clinical data and prognosis., Methods: S-100 serum levels were serially determined in 26 patients with an acute infarction in the territory of the MCA at day 0 (within 12 hours after onset of symptoms), day 1 (24 hours after stroke onset), and days 2, 3, 4, 5, 7 or 8, and 10 after stroke and in 26 age- and sex-matched control subjects. S-100 assays were performed using a two-site radioimmunoassay technique. The clinical status was documented using the Scandinavian Stroke Scale. The functional deficit 4 weeks after stroke onset was scored by use of the modified Rankin scale. A cranial computed tomography (CCT) was performed initially and at day 4 or 5., Results: Elevated concentrations of S-100 (> 0.2 microgram/L) were observed in 21 of 26 patients with MCA infarction but in none of the control subjects. S-100 levels peaked at days 2 and 3 after stroke. The S-100 concentrations in serum were significantly higher in patients with severe neurological deficits at admission, with extensive infarctions and a space-occupying effect of ischemic edema as compared with the rest of the population. S-100 values were not significantly correlated with the functional prognosis., Conclusions: Presence of S-100 in serum after ischemic stroke may be due to combined leakage out of necrotic glial cells and passage through an impaired brain-blood barrier, indicating severe ischemic cell injury. Therefore, S-100 in serum can be used as a peripheral marker of ischemic focal brain damage and may be helpful for therapeutic decisions in acute ischemic stroke.