[Trends in motorcycle road deaths in Colombia, 2008-2021Tendências de mortalidade por acidentes de motocicleta na Colômbia, 2008-2021]. / Tendencias en la mortalidad por accidentes de tránsito en motocicleta en Colombia, 2008-2021.

Objective: To identify trends in motorcycle road deaths in Colombia between 2008 and 2021. Methods: An observational and descriptive study of trends in motorcycle road deaths was conducted using official death records from 2008 to 2021. Jointpoint Poisson regression analysis was performed to detect inflection points in mortality rates specific to age, sex, and area of residence. Results: A total of 28 200 motorcycle road deaths were identified during the period; 24 271 men and 3 929 women died. Of the deaths, 74.1% occurred in urban areas and 25.9% in rural areas. In rural areas, there was an increasing trend in fatalities in young adults of both sexes during the period. The same occurred in men over 65 years of age. In urban areas, there was an upward trend in fatalities in the age group from 45-64 for both sexes during the period. Only one inflection point was detected, in 2015, showing a downward trend in adolescent females. Conclusion: The trend in motorcycle road deaths in Colombia continued to rise during the 2008-2021 period, both in rural areas for young adults and in urban areas for middle-aged adults.

Objetivo: Identificar tendências de mortalidade por acidentes de motocicleta na Colômbia entre 2008 e 2021. Métodos: Realizou-se um estudo observacional e descritivo das tendências de mortalidade por acidentes de motocicleta com base em registros oficiais de óbitos entre 2008 e 2021. Conduziu-se uma análise baseada na regressão de Poisson (Joinpoint) para detectar pontos de inflexão em taxas de mortalidade específicas por idade, sexo e área de residência. Resultados: Foram identificadas 28 200 mortes por acidentes de motocicleta durante todo o período, correspondendo a 24 271 homens e 3 929 mulheres. As mortes ocorreram tanto na área urbana (74,1%) quanto rural (25,9%). Na área rural, observou-se uma tendência crescente na mortalidade de adultos jovens de ambos os sexos ao longo de todo o período. O mesmo ocorreu em relação a homens com mais de 65 anos. Na área urbana, identificou-se uma tendência de aumento da mortalidade na faixa etária de 45 a 64 anos, em ambos os sexos, durante todo o período. Apenas um ponto de inflexão foi detectado em 2015, mostrando uma redução na tendência em adolescentes do sexo feminino. Conclusão: A tendência de mortalidade por acidentes de motocicleta na Colômbia continuou a aumentar durante todo o período (2008 a 2021), tanto na área rural, para jovens adultos, quanto na área urbana, para pessoas de meia-idade.

A longitudinal study of free leptin index in pre-eclamptic pregnancies.

The ratio between circulating levels of leptin and soluble leptin receptor (sOB-R), the free leptin index (FLI), is used as a marker of leptin resistance. Therefore, the aim of our study was to investigate the FLI in mild pre-eclamptic pregnancies in a nested case-control study within a prospective observational study. Circulating levels of leptin and sOB-R levels rise significantly during pregnancy in healthy (p < 0.05) (n = 46) and pre-eclamptic pregnancies (p < 0.05) (n = 20). Serum levels of leptin were significantly higher in pre-eclamptic compared to healthy pregnancies at second and third trimesters of pregnancy (p < 0.05). Additionally, serum levels of sOB-R were significantly lower in pre-eclamptic pregnancies during the second and third trimesters of pregnancy compared to healthy pregnancies (p < 0.05). Moreover, we found that FLI did not vary significantly during pregnancy in healthy women (p > 0.05), while it increases in pre-eclamptic pregnancies (p < 0.05). Indeed, FLI was significantly higher at second and third trimesters of pregnancy in pre-eclamptic compared to healthy pregnancies (p < 0.05). In addition, FLI was significantly higher in the luteal phase compared with the follicular phase of the menstrual cycle in eumenorrheic women (p < 0.05). Receiver operating characteristic (ROC) curve analysis revealed the ability of leptin (AUC = 0.72) and FLI (AUC = 0.67) as a reliable predictor for mild pre-eclampsia during the second trimester of pregnancy. In conclusion, our findings show that FLI were significantly increased in mild pre-eclamptic pregnancies and allowed us to hypothesize that this rise might alter leptin bioavailability and bioactivity which might lead to the sympathetic hyperactivity and the hypertensive disorders during pregnancy.

Failure to Rescue and Mortality Differences After Appendectomy in a Low-Middle-Income Country and the United States.

BACKGROUND: Major disparities in complications and mortality after appendectomy between countries with different income levels have not been well characterized, as comparative studies at patient level between countries are scant. This study aimed to investigate variations in postoperative complications, mortality, and failure to rescue after appendectomy between a high-income country and a low-to-middle-income country. METHODS: Hospital discharges on adult patients who underwent appendectomy were extracted from administrative databases from Colombia and 2 states of the United States (Florida and New York). Outcomes included major postoperative complications, in-hospital mortality, and failure to rescue. Univariate analyses were conducted to compare outcomes between the 2 countries. Multivariable logistic regression analyses were conducted to examine the independent effect of country on outcomes after adjustment for patient age, sex, comorbidity index, severity of appendicitis, and appendectomy route (laparoscopic/open). RESULTS: A total of 62,338 cases from Colombia and 57,987 from the United States were included in the analysis. Patients in Colombia were significantly younger and healthier but had a higher incidence of peritonitis. Use of laparoscopy was significantly lower in Colombia (5.9% vs 89.4%; P < .0001). After adjustment for covariates, multivariable logistic regression analyses revealed that compared to the United States, Colombia had lower complication rates (2.8% vs 6.6%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.39-0.44; P < .0001) but higher mortality (0.44% vs 0.08%; OR, 8.92; 95% CI, 5.69-13.98; P < .0001) and failure to rescue (13.6% vs 1.0%; OR, 17.01; 95% CI, 10.66-27.16; P < .0001). CONCLUSIONS: Despite lower rates of postoperative complications, in-hospital mortality after appendectomy was higher in Colombia than in the United States. This difference may be explained by higher rates of failure to rescue in the low-to-middle-income country (ie, decreased ability of Colombian hospitals to rescue patients from complications).

Tackling potentially inappropriate prescriptions in older adults: development of deprescribing criteria by consensus from experts in Colombia, Argentina, and Spain.

BACKGROUND: Potentially inappropriate medication use is prevalent among older adults in primary care, leading to increased morbidity, adverse drug reactions, hospitalizations, and mortality. This study aimed to develop and validate a tool for identifying PIMs in older adults within the primary care setting. The tool is composed of a list of criteria and was created based on consensus among experts from three Spanish-speaking countries, including two from Latin America. METHODS: A literature review was conducted to identify existing tools, and prescription patterns were evaluated in a cohort of 36,111 older adults. An electronic Delphi method, consisting of two rounds, was used to reach a formal expert consensus. The panel included 18 experts from Spain, Colombia, and Argentina. The content validity index, validity of each content item, and Kappa Fleiss statistical measure were used to establish reliability. RESULTS: Round one did not yield a consensus, but a definitive consensus was reached in round two. The resulting tool consisted of a list of 5 general recommendations per disease, along with 33 criteria related to potential problems, recommendations, and alternative therapeutic options. The overall content validity of the tool was 0.87, with a Kappa value of 0.69 (95% CI 0.64-0.73; Substantial). CONCLUSIONS: The developed criteria provide a novel list that allows for a comprehensive approach to pharmacotherapy in older adults, intending to reduce inappropriate medication use, ineffective treatments, prophylactic therapies, and treatments with an unfavorable risk-benefit ratio for the given condition. Further studies are necessary to evaluate the impact of these criteria on health outcomes.

Health Insurance Scheme: Main Contributor to Inequalities in COVID-19 Mortality in Colombia.

Objectives. To quantify socioeconomic inequalities in COVID-19 mortality in Colombia and to assess the extent to which type of health insurance, comorbidity burden, area of residence, and ethnicity account for such inequalities. Methods. We analyzed data from a retrospective cohort of COVID-19 cases. We estimated the relative and slope indices of inequality (RII and SII) using survival models for all participants and stratified them by age and gender. We calculated the percentage reduction in RII and SII after adjustment for potentially relevant factors. Results. We identified significant inequalities for the whole cohort and by subgroups (age and gender). Inequalities were higher among younger adults and gradually decreased with age, going from RII of 5.65 (95% confidence interval [CI] = 3.25, 9.82) in participants younger than 25 years to RII of 1.49 (95% CI = 1.41, 1.58) in those aged 65 years and older. Type of health insurance was the most important factor, accounting for 20% and 59% of the relative and absolute inequalities, respectively. Conclusions. Significant socioeconomic inequalities exist in COVID-19 mortality in Colombia. Health insurance appears to be the main contributor to those inequalities, posing challenges for the design of public health strategies. (Am J Public Health. 2022;112(S6):S586-S590. https://doi.org/10.2105/AJPH.2021.306637).

[Health insurance scheme: main contributor to inequalities in COVID-19 mortality in ColombiaTipo de cobertura de assistência à saúde: o principal fator contribuinte para as desigualdades em mortalidade por COVID-19 na Colômbia]. / Plan de seguro de salud: factor que más contribuye a las desigualdades en la mortalidad por COVID-19 en Colombia.

Objectives: To quantify socioeconomic inequalities in COVID-19 mortality in Colombia and to assess the extent to which type of health insurance, comorbidity burden, area of residence, and ethnicity account for such inequalities. Methods: We analyzed data from a retrospective cohort of COVID-19 cases. We estimated the relative and slope indices of inequality (RII and SII) using survival models for all participants and stratified them by age and gender. We calculated the percentage reduction in RII and SII after adjustment for potentially relevant factors. Results: We identified significant inequalities for the whole cohort and by subgroups (age and gender). Inequalities were higher among younger adults and gradually decreased with age, going from RII of 5.65 (95% confidence interval [CI] = 3.25, 9.82) in participants younger than 25 years to RII of 1.49 (95% CI = 1.41, 1.58) in those aged 65 years and older. Type of health insurance was the most important factor, accounting for 20% and 59% of the relative and absolute inequalities, respectively. Conclusions: Significant socioeconomic inequalities exist in COVID-19 mortality in Colombia. Health insurance appears to be the main contributor to those inequalities, posing challenges for the design of public health strategies.

Objetivos: Quantificar as desigualdades socioeconômicas na mortalidade por COVID-19 na Colômbia e avaliar até que ponto o tipo de cobertura de assistência à saúde, a carga de comorbidades, o local de residência e a etnia contribuíram para tais desigualdades. Métodos: Analisamos dados de uma coorte retrospectiva de casos de COVID-19. Calculamos os índices relativo e angular de desigualdade (RII e SII, respectivamente) utilizando modelos de sobrevivência em todos os participantes, estratificando-os por idade e gênero. Calculamos o percentual de redução no RII e no SII após ajuste para fatores possivelmente relevantes. Resultados: Identificamos desigualdades significativas na coorte como um todo e por subgrupos (idade e gênero). As desigualdades foram maiores para adultos mais jovens e decaíram gradualmente com a idade, indo de um RII de 5,65 (intervalo de confiança [IC] de 95% = 3,25; 9,82] nos participantes com idade inferior a 25 anos a um RII de 1,49 [IC 95% = 1,41; 1,58] nas pessoas com 65 anos ou mais. O tipo de cobertura de assistência à saúde foi o fator mais importante, representando 20% e 59% das desigualdades relativa e absoluta, respectivamente. Conclusões: Desigualdades socioeconômicas significativas afetaram a mortalidade por COVID-19 na Colômbia. O tipo de cobertura de saúde parece ser o principal fator contribuinte para essas desigualdades, impondo desafios à elaboração de estratégias de saúde pública.

Mental health consequences of armed conflicts in adults: an overview.

Armed conflicts (AC) in the world are still active and lead to the growth of violence, with a possible impact on mental health (MH).

Global control of COVID-19: good vaccines may not suffice.

The COVID-19 pandemic has unveiled health and socioeconomic inequities around the globe. Effective epidemic control requires the achievement of herd immunity, where susceptible individuals are conferred indirect protection by being surrounded by immunized individuals. The proportion of people that need to be vaccinated to obtain herd immunity is determined through the herd immunity threshold. However, the number of susceptible individuals and the opportunities for contact between infectious and susceptible individuals influence the progress of an epidemic. Thus, in addition to vaccination, control of a pandemic may be difficult or impossible to achieve without other public health measures, including wearing face masks and social distancing. This article discusses the factors that may contribute to herd immunity and control of COVID-19 through the availability of effective vaccines and describes how vaccine effectiveness in the community may be lower than that expected. It also discusses how pandemic control in some countries and populations may face vaccine accessibility barriers if market forces strongly regulate the new technologies available, according to the inverse care law.

La pandemia de COVID-19 ha puesto al descubierto inequidades socioeconómicas y de salud en todo el mundo. Un control epidémico eficaz requiere el logro de la inmunidad colectiva, mediante la cual se confiere a las personas vulnerables una protección indirecta al estar rodeadas de personas inmunizadas. El umbral de inmunidad colectiva determina la proporción de personas que deben vacunarse para llegar a la inmunidad colectiva. Sin embargo, el número de personas vulnerables y las oportunidades de contacto entre las personas infecciosas y las personas vulnerables influyen en el progreso de una epidemia. Por lo tanto, además de la vacunación, el control de una pandemia puede ser difícil o imposible de lograr sin otras medidas de salud pública, como las mascarillas y el distanciamiento social. Este artículo trata sobre los factores que pueden contribuir al logro de la inmunidad colectiva y el control de la COVID-19 mediante la disponibilidad de vacunas efectivas y describe cómo la efectividad de las vacunas en la comunidad puede ser inferior a la prevista. También aborda cómo el control pandémico en algunos países y grupos poblacionales puede enfrentarse a obstáculos que dificultan la accesibilidad de las vacunas si las fuerzas del mercado son el principal factor que regula las nuevas tecnologías disponibles, como se indica en la ley de atención inversa.

A pandemia de COVID-19 revelou iniquidades socioeconômicas e de saúde no mundo todo. Um controle epidêmico eficaz requer a obtenção da imunidade coletiva, em que indivíduos suscetíveis recebem proteção indireta por estarem rodeados de indivíduos imunizados. A proporção de pessoas que precisam ser vacinadas para se alcançar a imunidade coletiva é definida pelo limiar da imunidade coletiva. Porém, o número de indivíduos suscetíveis e as oportunidades de contato entre indivíduos infecciosos e suscetíveis influenciam o progresso de uma epidemia. Portanto, além da vacinação, o controle de uma pandemia pode ser difícil ou impossível de ser alcançado sem outras medidas de saúde pública, incluindo o uso de máscaras e o distanciamento social. Este artigo discute os fatores que podem contribuir para a imunidade coletiva e para o controle da COVID-19 por meio da disponibilidade de vacinas eficazes, e descreve como a eficácia das vacinas na comunidade pode ser menor do que o esperado. Também discute como o controle da pandemia em alguns países e populações pode enfrentar barreiras de acessibilidade às vacinas se as forças de mercado regularem fortemente as novas tecnologias disponíveis, conforme a lei dos cuidados inversos.

Comparison of shear wave elastography (supersonic) with liver biopsy in a cohort of patients from a medium-income country: an observational study.

INTRODUCTION: shear-wave elastography is a non-invasive diagnostic test that calculates the degree of liver fibrosis by measuring liver elasticity. This technique was recently introduced in Colombia. Thus, cutoff points delineating the change between fibrosis stages (using the Metavir scale) have not been previously defined in our patient population. PATIENTS AND METHODS: a retrospective study was performed of patients who had undergone two-dimensional shear-wave elastography (2D-SWE) and liver biopsy (LB) between June 2010 and June 2018 at a private outpatient hepatology center in Bogota, Colombia. We used a training dataset (subjects with time between biopsy and 2D-SWE of ≤ 6 months) to establish diagnostic cutoff values and a test dataset (subjects with time between biopsy and 2D-SWE of > 6 months) to validate our results. RESULTS: a total of 453 subjects (training dataset, n = 153; test dataset, n = 300) were included. In the training dataset, the cutoff points were 7.6, 8.4, 9.5 and 10.9 kPa, and the areas under the curve were 0.75, 0.83, 0.89 and 0.94 for mild fibrosis, significant fibrosis, advanced fibrosis and cirrhosis, respectively. In the test dataset, the areas under the curve were 0.77, 0.78, 0.83 and 0.89 for mild fibrosis, significant fibrosis, advanced fibrosis, and cirrhosis, respectively. CONCLUSION: two-dimensional shear-wave elastography was reliable and useful for the non-invasive evaluation of liver fibrosis, particularly in patients with advanced fibrosis and cirrhosis. Cutoff points for fibrosis in a Hispanic population were described.

An overview of reviews on strategies to reduce health inequalities.

BACKGROUND: Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions. OBJECTIVE: Identify and synthesize strategies or interventions that facilitate the reduction of health inequalities. METHODS: A systematic search strategy was carried out up until August 2019 in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, LILACS, Scopus, Scielo and Epistemonikos. In addition, a snowball strategy was used. Literature reviews (LRs) of experimental and quasi-experimental studies were included. The identified interventions and outcomes were categorized based on the recommendation by the Cochrane group in "Effective Practice and Organization of Care". The quality of the included LRs was evaluated using the AMSTAR 2 tool. RESULTS: Four thousand ninety-five articles were identified, of which 97 were included in the synthesis of evidence. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes. CONCLUSION: The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.

Prognostic Factors Associated with Clinical and Economic Outcomes of Appendectomies in Children: A Multilevel Analysis in a National Retrospective Cohort Study.

BACKGROUND: Acute appendicitis is the most common acute surgical abdominal pathology in children, and it has a large impact on morbidity and the costs incurred by health care systems. In low- and median-income countries, national information on the clinical and economic outcomes associated with this surgery does not exist. This study aimed to identify and describe the clinical and economic outcomes for children undergoing appendectomy in Colombia's contributory system and to determine the prognostic factors associated with these outcomes. METHODS: A retrospective cohort study was conducted using administrative data from patients under 18 years of age who underwent an appendectomy between July 1, 2013, and September 30, 2015, in Colombia's contributory health system. Thirty-day mortality rates, intensive care unit (ICU) admission rates, length of stay (LOS), readmission rates and median costs were estimated for the entire country by geographic region and insurer. The prognostic factors associated with these outcomes were identified using generalized multilevel mixed models. RESULTS: A total of 21,674 children were included. The 30-day postoperative mortality rate was 0.06% [95% CI 0.02-0.9], the ICU admission rate was 8.00% [95% CI 7.63-8.36], the mean LOS was 2.48 days (SD 5.24), the readmission rate was 1.5% [95% CI 1.33-1.66] and the median cost for Colombia was 394 USD [p25-p75: 256-555]. The prognostic factors that were associated with the 30-day ICU admission rate, LOS and readmission rate were the insurer, geographic region, age, occurrence of an appendectomy with peritoneal drainage, and certain comorbidities, such as cancer and neurological, respiratory and gastrointestinal illnesses. The prognostic factors associated with costs were those previously mentioned as well as the occurrence of a laparoscopic appendectomy. CONCLUSIONS: In Colombia's contributory health system, large differences in clinical outcomes and the costs incurred by the system exist, and these differences are associated with the geographic region, the insurer, and some of the clinical characteristics of the children undergoing appendectomy.

Dental Anomalies in Permanent Teeth Associated With Nonsyndromic Cleft Lip and Palate in a Group of Colombian Children.

OBJECTIVES: To assess the risk of dental anomaly presentation in permanent teeth in a group of Colombian children with nonsyndromic cleft lip and palate (NSCLP) and to determine the frequency of the anomalies according to the cleft type. METHODS: An analytical matched case-control study was conducted with 210 controls and 210 patients with NSCLP. The patients were classified into 3 groups: complete right unilateral cleft lip and palate (RCLP), complete left unilateral cleft lip and palate (LCLP), and complete bilateral cleft lip and palate (BCLP). Univariate and multivariate Poisson regression models were used to analyze paired samples (Bonferroni adjustment, P ≤ .002). RESULTS: A high risk of finding agenesis of the maxillary lateral incisors, supernumerary teeth, microdontia of the maxillary lateral incisors, and rotation of the maxillary central incisors adjacent to the cleft (P < .0001) was observed in the patients with NSCLP. One or more dental anomalies were found in 98% of patients with BCLP, in 96% of those with LCLP, and in 87% of those with RCLP. Most of the anomalies were located on the cleft area. The incidence relative risk (IRR) of anomalies was highest in patients with BCLP (IRR: 10.5; 95% confidence interval [CI]: 6.76-16.3), followed by in those with LCLP (IRR: 8.51; 95% CI: 5.64-12.8). CONCLUSIONS: Most dental anomalies were found in the cleft area; this was expected because the cleft area was the most affected in the patients included in this study.

Clinical Outcomes and Healthcare Costs Associated with Laparoscopic Appendectomy in a Middle-Income Country with Universal Health Coverage.

BACKGROUND: Although many studies have compared outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA), some clinical and economic outcomes continue to be controversial, particularly in low-medium-income countries. We aimed at determining clinical and economic outcomes associated with LA versus OA in adult patients in Colombia. METHODS: Retrospective, cohort study based on administrative healthcare records included all patients who underwent LA or OA in Colombia's contributory regime between July 1, 2013, and September 30, 2015. Outcomes were 30-day mortality rates, ICU admissions rates, length of stay (LOS), and hospital costs provided until discharge. Propensity score matching techniques were used to balance the baseline characteristics of patients (age, sex, comorbidities based on the Charlson index, insurer, and geographic location) and to estimate the average treatment effect (ATE) of LA as compared to OA over outcomes. RESULTS: A total of 65,625 subjects were included, 92.9% underwent OA and 7.1% LA. For the entire population, 30-day mortality was 0.74 per 100 appendectomies (95% CI 0.67-0.81), the mean and median LOS were 3.83 days and 1 day, respectively, and the ICU admissions rate during the first 30 days was 7.92% (95% CI 7.71-8.12). The ATE shows an absolute difference in the mortality rate after 30 days of -0.35 per 100 appendectomies (p = 0.023), in favor of LA. No effects on ICU admissions or LOS were identified. LA was found to increase costs by 514.13 USD on average, with total costs of 772.78 USD for OA and 1286.91 USD for LA (p < 0.001). CONCLUSIONS: In Colombia's contributory regime, LA is associated with lower 30-day mortality rate and higher hospital costs as compared to OA. No differences are found in ICU admissions or LOS.

The Surgeon Volume-outcome Relationship: Not Yet Ready for Policy.

OBJECTIVE: Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy. BACKGROUND: The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy. METHODS: The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia. RESULTS: In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016). CONCLUSIONS: Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.

Effects of Increasing Airway Pressures on the Pressure of the Endotracheal Tube Cuff During Pelvic Laparoscopic Surgery.

BACKGROUND: Tracheal tube cuff pressures exceeding the perfusion pressures of the tracheal mucosa have been associated with complications such as sore throat, tracheal mucosa ulcers, tracheal rupture, and subglottic stenosis. Despite appropriate inflation, many factors can increase the tracheal cuff pressure during mechanical ventilation. This prospective observational cohort study was designed to test the hypothesis that during a clinical model of decreasing respiratory compliance, the pressure within the endotracheal tube cuff will rise in direct relationship to increases in the airway pressures. METHODS: Twenty-eight adult obese patients (BMI ≥30 kg/m) scheduled for elective laparoscopic gynecologic procedures were enrolled. All patients received general anesthesia utilizing endotracheal tubes with low-pressure high-volume cuffs. After baseline adjustment of the cuff pressure to 25 cm H2O, the airway pressures and endotracheal cuff pressures were continuously measured using pressure transducers connected to the anesthesia circuit and cuff pilot, respectively. Data on cuff and airway pressures, mechanical ventilation parameters, intraabdominal pressures, and degree of surgical table inclination were collected throughout the anesthetic procedure. General linear regression models with fixed and random effects were fit to assess the effect of increases in airway pressures on cuff pressure, after adjusting for covariates and the clustered structure of the data. RESULTS: The mean (standard deviation) age and body mass index were 42.2 (8.8) years and 37.7 (5.1) kg/m, respectively. After tracheal intubation, the cuffs were overinflated (ie, intracuff pressures >30 cm H2O) in 89% of patients. The cuff pressures significantly changed after concomitant variations in the airway pressures from a mean (standard error) value of 29.6 (1.30) cm H2O before peritoneal insufflations, to 35.6 (0.68) cm H2O after peritoneal insufflation, and to 27.8 (0.79) cm H2O after peritoneal deflation (P < .0001). The multilevel mixed regression models revealed that after controlling for clustering of the data (at the patient and study phase levels) and covariates, increased peak airway pressures were significantly associated with increased pressures within the endotracheal cuff (coefficient [95% confidence interval], 0.25 [0.14-0.36]; P < .0001). Other variables associated with increasing endotracheal cuff pressure included degree of surgical table inclination (0.08 [0.04-0.12]; P = .0003) and I:E ratio of 1:1 (4.47 [2.10-6.83]; P = .0002). CONCLUSIONS: This clinical model of decreased respiratory compliance in mechanically ventilated patients reveals that the pressure within the endotracheal cuff significantly changes in direct relation to changes in the airway pressures. This finding may have clinical relevance in patients requiring prolonged use of high airway pressures.

[Food Insecurity Experience Scale (FIES) in Colombia, Guatemala, and México.] / Escala Basada en la Experiencia de Inseguridad Alimentaria (FIES) en Colombia, Guatemala y México.

OBJECTIVE: To compare the psychometric characteristics of the Food Insecurity Experience Scale (FIES) and the grade of similitude or difference among Colombia, Guatemala, and Mexico during three years. MATERIALS AND METHODS: Psychometric comparison using the Rasch model to calculate the relative severity of each item in FIES, INFIT and contrast in the Differential Functioning of Items (c-DIF). RESULTS: The majority of items showed a relative severity corresponding to the theoretical construct and acceptably fit the model (INFIT=0.7-1.3). No c-DIF above 1.0 logit was observed in the comparison men vs women. In the comparison among countries by year 87% of the items showed c-DIF below 0.5 logit. CONCLUSIONS: The FIES presents psychometric characteristics corresponding to the theoretical construct of the tool. Future studies with the inclusion of more countries and more time points are essential to evaluate the relative severity, behavior and distribution of items.

OBJETIVO: Comparar las características psicométricas de la Escala de Experiencia de Inseguridad Alimentaria (FIES, en inglés Food Insecurity Experience Scale) y el grado de similitud o diferencias entre Colombia, Guatemala y México durante tres años. MATERIAL Y MÉTODOS: Estudio de comparación psicométrica a través del modelo Rasch, calculando la severidad relativa, el ajuste próximo (INFIT) y funcionamiento diferencial (c-DIF) para cada ítem de la FIES. RESULTADOS: La mayoría de los ítems mostraron una severidad relativa correspondiente al constructo teórico y un ajuste aceptableal modelo (INFIT=0.7-1.3). No se observaron valores de c-DIF en la comparación hombres vs mujeres por encima de 1.0 logit; y en la comparación entre países por año, 87% de los ítems estuvieron por debajo del valor de 0.5 logit. CONCLUSIONES: La FIES presenta las características psi- cométricas correspondientes al constructo teórico de la herramienta. Futuros estudios, incluyendo más países y más puntos temporales, son esenciales para evaluar la severidad relativa, comportamiento y distribución de los ítems.

[Incorporating health equity into implementation research: review of conceptual modelsIncorporação da igualdade em saúde na pesquisa de implementação: revisão de modelos conceituais]. / Incorporación de equidad en salud en la investigación sobre implementación: revisión de los modelos conceptuales.

OBJECTIVE: Search for conceptual frameworks or models that incorporate aspects of health equity into implementation research and prepare a systematic synthesis of them. METHODS: A systematic search was done of MEDLINE-PubMed, Embase, and LILACS (1965-2016), and Scopus (1998-2016) databases, employing, in addition, a snowball strategy and gray literature search. Article type was assessed, along with elements that were included on implementation research, the science of implementation, and health equity. RESULTS: A total of 701 articles were found, of which 100 were included for review of relevance. Of these, 19 articles related to conceptual frameworks: 12 were general, five were on ethnic or racial disparities, and two related to child health. The most frequent categories were financing, infrastructure, advocacy, quality, internal barriers, and coverage. The least frequent were other sectors, outpatient needs, health status, and equity impact assessment. CONCLUSIONS: In order to reduce health gaps and with them health inequities, it becomes necessary to have a consolidated implementation research framework that includes aspects of health equity. This framework would facilitate improving implementation processes for interventions, services, and health programs.

OBJETIVO: Fazer uma busca e revisão sistemática dos marcos ou modelos conceituais que abrangem aspectos de igualdade em saúde em pesquisa de implementação. MÉTODOS: Busca sistemática nas bases de dados MEDLINE-PubMed, Embase e LILACS (1965­2016) e Scopus (1998­2016) com o uso de estratégia de amostragem em bola de neve e busca da literatura cinzenta. Foram avaliados o tipo de artigo e os elementos contidos sobre pesquisa de implementação (implementation research, IR), ciência de implementação e igualdade em saúde. RESULTADOS: Foram identificados 701 artigos, dos quais 100 foram incluídos na revisão. Destes, 19 artigos estavam relacionados aos marcos conceituais: 12 gerais, cinco sobre disparidades étnicas ou raciais e dois relacionados com saúde infantil. As categorias mais frequentes dos marcos conceituais foram: financiamento, infraestrutura, defesa da causa, qualidade, barreiras internas e cobertura. As menos frequentes foram: outros setores, necessidades dos pacientes ambulatoriais, estado de saúde e avaliação do impacto na equidade. CONCLUSÕES: Para reduzir as lacunas em saúde e as desigualdades em saúde, faz-se necessário dispor de um modelo consolidado de pesquisa de implementação no qual sejam incluídos os aspectos de igualdade em saúde. Este modelo contribuiria para melhorar os processos de implementação das intervenções, serviços e programas de saúde.

Social determinants, symptoms and mental problems in adults internally displaced by armed conflict. Soacha, Colombia, 2019.

OBJECTIVE: To characterise social determinants of health, mental health problems and potentially problematic symptoms in the adult population displaced by internal armed conflict in Colombia. METHODS: Cross-sectional descriptive study with a random sample of 98 adults forcefully displaced to Soacha, Colombia, due to internal armed conflict. The Self Report Questionnaire to detect potentially problematic mental health problems and symptoms, and a structured questionnaire on social determinants of health were applied. RESULTS: The median age was 38 [interquartile range, 28-46] years, and women predominated (69.39%). The median time since displacement was 36 [16-48] months, and time since settlement in Soacha, 48 [5-48] months. 86.32% survived on less than the minimum wage per month and 93.87% did not have an employment contract. 42.86% and 7.14% reported being owners of their homes before and after displacement, respectively. Upon arriving in Soacha, 79.60% went to primary support networks and 3% to institutions. Before displacement, 16.33% lacked health insurance and 27.55% afterwards. Regarding mental health problems; there were possible depressive or anxious disorders in 57.29%; possible psychosis in 36.73%; and potentially problematic symptoms in 91.66%, being more prevalent and serious in women (p = 0.0025). CONCLUSIONS: A deterioration in living conditions and a higher prevalence of potentially problematic mental health problems and symptoms was reported in displaced adult populations settled in Soacha compared to other regions of the country. Analyses with complementary perspectives are required to evaluate these differences.

Association of Healthcare Fragmentation and the Survival of Patients With Colorectal Cancer in Colombia.

OBJECTIVES: The objective of this study was to identify the association between healthcare fragmentation and survival for patients with colorectal cancer in Colombia. METHODS: A retrospective cohort study was performed using administrative databases, with an electronic algorithm to identify patients with colorectal cancer based on codes. The patients were enrolled between January 1, 2013, and December 31, 2016. The exposure variable was fragmentation, which was measured based on the number of different healthcare institutions that treated a patient during the first year after diagnosis. Matching was performed using propensity scores to control for confounding, and the hazard ratio for exposure to higher fragmentation was calculated for the matched sample. RESULTS: A total of 5036 patients with colorectal cancer were identified, 2525 (49.88%) of whom were women. The mean number of network healthcare institutions for the total sample was 5.71 (SD 1.98). The patients in the quartile with higher fragmentation had the highest mortality rate, 35.67 (95% CI 33.63-38.06) per 100 patients. The comparison of higher and lower quartiles of fragmentation resulted in an incidence rate ratio of 1.23 (95% CI 1.04-1.45; P = .02). Of the 5036 patients, 422 (8.38%) were classified as the exposed cohort (higher fragmentation). The total matched sample consisted of 844 subjects, and an HR of 1.26 (95%CI; 1.05-1.51) was estimated. CONCLUSIONS: Exposure to more highly fragmented healthcare networks decreases overall 4-year survival for patients with colorectal cancer in Colombia.