Mapping socio-geographical disparities in the occurrence of teenage maternity in Colombia using multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

BACKGROUND: The prevalence of teenage pregnancy in Colombia is higher than the worldwide average. The identification of socio-geographical disparities might help to prioritize public health interventions. AIM: To describe variation in the probability of teenage maternity across geopolitical departments and socio-geographical intersectional strata in Colombia. METHODS: A cross-sectional study based on live birth certificates in Colombia. Teenage maternity was defined as a woman giving birth aged 19 or younger. Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was applied using multilevel Poisson and logistic regression. Two different approaches were used: (1) intersectional: using strata defined by the combination of health insurance, region, area of residency, and ethnicity as the second level (2) geographical: using geopolitical departments as the second level. Null, partial, and full models were obtained. General contextual effect (GCE) based on the variance partition coefficient (VPC) was considered as the measure of disparity. Proportional change in variance (PCV) was used to identify the contribution of each variable to the between-strata variation and to identify whether this variation, if any, was due to additive or interaction effects. Residuals were used to identify strata with potential higher-order interactions. RESULTS: The prevalence of teenage mothers in Colombia was 18.30% (95% CI 18.20-18.40). The highest prevalence was observed in Vichada, 25.65% (95% CI: 23.71-27.78), and in the stratum containing mothers with Subsidized/Unaffiliated healthcare insurance, Mestizo, Rural area in the Caribbean region, 29.08% (95% CI 28.55-29.61). The VPC from the null model was 1.70% and 9.16% using the geographical and socio-geographical intersectional approaches, respectively. The higher PCV for the intersectional model was attributed to health insurance. Positive and negative interactions of effects were observed. CONCLUSION: Disparities were observed between intersectional socio-geographical strata but not between geo-political departments. Our results indicate that if resources for prevention are limited, using an intersectional socio-geographical approach would be more effective than focusing on geopolitical departments especially when focusing resources on those groups which show the highest prevalence. MAIHDA could potentially be applied to many other health outcomes where resource decisions must be made.

Artificial intelligence for cervical cancer screening: Scoping review, 2009-2022.

BACKGROUND: The intersection of artificial intelligence (AI) with cancer research is increasing, and many of the advances have focused on the analysis of cancer images. OBJECTIVES: To describe and synthesize the literature on the diagnostic accuracy of AI in early imaging diagnosis of cervical cancer following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). SEARCH STRATEGY: Arksey and O'Malley methodology was used and PubMed, Scopus, and Google Scholar databases were searched using a combination of English and Spanish keywords. SELECTION CRITERIA: Identified titles and abstracts were screened to select original reports and cross-checked for overlap of cases. DATA COLLECTION AND ANALYSIS: A descriptive summary was organized by the AI algorithm used, total of images analyzed, data source, clinical comparison criteria, and diagnosis performance. MAIN RESULTS: We identified 32 studies published between 2009 and 2022. The primary sources of images were digital colposcopy, cervicography, and mobile devices. The machine learning/deep learning (DL) algorithms applied in the articles included support vector machine (SVM), random forest classifier, k-nearest neighbors, multilayer perceptron, C4.5, Naïve Bayes, AdaBoost, XGboots, conditional random fields, Bayes classifier, convolutional neural network (CNN; and variations), ResNet (several versions), YOLO+EfficientNetB0, and visual geometry group (VGG; several versions). SVM and DL methods (CNN, ResNet, VGG) showed the best diagnostic performances, with an accuracy of over 97%. CONCLUSION: We concluded that the use of AI for cervical cancer screening has increased over the years, and some results (mainly from DL) are very promising. However, further research is necessary to validate these findings.

Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis.

OBJECTIVE: Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy. METHODS: Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension. RESULTS: Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome. CONCLUSION: Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.

Cardiometabolic sex differences in adults born small for gestational age.

Aim: This study aimed to assess the cardiometabolic sex similarities and differences in adults born small for gestational age. Methods: This study was an ambispective cohort study from a birth registry in Barcelona, Spain, including 523 adult participants (20-40 years-old) subdivided as born small for gestational age (SGA, if birth weight <10th centile) or adequate fetal growth for gestational age (AGA). Cardiometabolic health was assessed by echocardiography, electrocardiogram, blood pressure measurement, vascular ultrasound, anthropometric measurements, and serum glycemia and lipid profile. Stratified analyses by sex were performed by estimation of adjusted absolute difference (AAD) using inverse probability weighting. Results: Compared with AGA, the stratified analyses by sex showed a more pronounced reduction in ejection fraction [AAD: female -1.73 (95% CI -3.2 to -0.28) vs. male -1.33 (-3.19 to 0.52)] and increment in heart rate [female 3.04 (0.29-5.8) vs. male 2.25 (-0.82 to 5.31)] in SGA females compared with SGA males. In contrast, a more pronounced reduction in PR interval [female -1.36 (-6.15 to 3.42) vs. male -6.61 (-11.67 to -1.54)] and an increase in systolic blood pressure [female 0.06 (-2.7 to 2.81) vs. male 2.71 (-0.48 to 5.9)] and central-to-peripheral fat ratio [female 0.05 (-0.03 to 0.12) vs. male 0.40 (0.17-0.62)] were mainly observed in SGA male compared with SGA female. Conclusions: Sex differences were observed in the effect of SGA on cardiometabolic endpoints with female being more prone to cardiac dysfunction and male to electrocardiographic, vascular, and metabolic changes. Future research including sex-stratification data is warranted.

Reevaluating the protective effect of smoking on preeclampsia risk through the lens of bias.

Preeclampsia is a hypertensive disorder that is usually diagnosed after 20 weeks' gestation. Despite the deleterious effect of smoking on cardiovascular disease, it has been frequently reported that smoking has a protective effect on preeclampsia risk and biological explanations have been proposed. However, in this manuscript, we present multiple sources of bias that could explain this association. First, key concepts in epidemiology are reviewed: confounder, collider, and mediator. Then, we describe how eligibility criteria, losses of women potentially at risk, misclassification, or performing incorrect adjustments can create bias. We provide examples to show that strategies to control for confounders may fail when they are applied to variables that are not confounders. Finally, we outline potential approaches to manage this controversial effect. We conclude that there is probably no single epidemiological explanation for this counterintuitive association.

Women's critical experiences with the pap smear for the development of cervical cancer screening devices.

Global cervical cancer incidence and mortality have remained a major public health problem. Depending on the quality and coverage of preventive programs, and the capacity of health care systems, different screening tests are used, with the Pap smear being the most widely implemented. Several difficulties have been reported in accessing timely detection, causing late cervical cancer diagnosis. Trying to close these gaps, new screening devices have been developed in recent years; however, there is a lack of knowledge about whether or not women perspective has been included in the design process and technological development of these devices. This scoping review aimed to describe and synthesize scientific literature on women's critical experiences with Pap smears to prospectively contribute to the design, development, and scale-up of cervical cancer screening devices. The electronic databases Web of Science, Scopus, PubMed, PsycINFO and SciELO were searched for relevant studies published between 2012 and 2021; finally, 18 qualitative studies were included. Experiences were classified into four categories: fear and embarrassment, speculum pain and discomfort, outcome distress and health service barriers. Critical experiences before, during, and after the test were analyzed in turn. In particular, during the test, women reported pain associated with the use of the speculum. The acceptability of new screening devices will largely depend on comfort during the test and timely delivery of results. This review provides a useful qualitative synthesis, not only to advance the design of novel devices but also for future implementation research in cervical screening services.

Association of central obesity with unique cardiac remodelling in young adults born small for gestational age.

AIMS: Being born small for gestational age (SGA, 10% of all births) is associated with increased risk of cardiovascular mortality in adulthood together with lower exercise tolerance, but mechanistic pathways are unclear. Central obesity is known to worsen cardiovascular outcomes, but it is uncertain how it affects the heart in adults born SGA. We aimed to assess whether central obesity makes young adults born SGA more susceptible to cardiac remodelling and dysfunction. METHODS AND RESULTS: A perinatal cohort from a tertiary university hospital in Spain of young adults (30-40 years) randomly selected, 80 born SGA (birth weight below 10th centile) and 75 with normal birth weight (controls) was recruited. We studied the associations between SGA and central obesity (measured via the hip-to-waist ratio and used as a continuous variable) and cardiac regional structure and function, assessed by cardiac magnetic resonance using statistical shape analysis. Both SGA and waist-to-hip were highly associated to cardiac shape (F = 3.94, P < 0.001; F = 5.18, P < 0.001 respectively) with a statistically significant interaction (F = 2.29, P = 0.02). While controls tend to increase left ventricular end-diastolic volumes, mass and stroke volume with increasing waist-to-hip ratio, young adults born SGA showed a unique response with inability to increase cardiac dimensions or mass resulting in reduced stroke volume and exercise capacity. CONCLUSION: SGA young adults show a unique cardiac adaptation to central obesity. These results support considering SGA as a risk factor that may benefit from preventive strategies to reduce cardiometabolic risk.

Multilevel modelling for measuring interaction of effects between multiple categorical variables: An illustrative application using risk factors for preeclampsia.

BACKGROUND: Measuring multiple and higher-order interaction effects between multiple categorical variables proves challenging. OBJECTIVES: To illustrate a multilevel modelling approach to studying complex interactions. METHODS: We apply a two-level random-intercept linear regression to a binary outcome for individuals (level-1) nested within strata (level-2) defined by all observed combinations of multiple categorical exposure variables. As a pedagogic application, we analyse 36 strata defined by five risk factors of preeclampsia (parity, previous preeclampsia, chronic hypertension, multiple pregnancies, body mass index category) among 652,603 women in the Swedish Medical Birth Registry between 2002 and 2010. RESULTS: The absolute risk of preeclampsia was 4% but was predicted to vary from 1% to 44% across strata. The stratum discriminatory accuracy was 30% according to the variance partition coefficient (VPC) and 0.73 according to the area under the receiver operating characteristic curve (AUC). While the risk heterogeneity across strata was primarily due to the main effects of the categories defining the strata, 5% of the variation was attributable to their two- and higher-way interaction effects. One stratum presented a positive interaction, and two strata presented negative interaction. CONCLUSIONS: Multilevel modelling is an innovative tool for identifying and analysing higher-order interaction effects. Further work is needed to explore how this approach can best be applied to making causal inferences.

Sources of heterogeneity when studying the cardiovascular effects of fetal growth restriction: an overview of the issues.

Intrauterine growth restriction (IUGR) has been repeatedly identified as a risk factor for cardiovascular disease (CVD). A possible explanation for this association is the effect of IUGR on cardiovascular structure and function. However, the specific changes observed are not consistent among studies. In this paper, we analyze several sources of heterogeneity within and between studies related to exposure, outcome and co-variables. A broad IUGR definition might include different phenotypes, expressing heterogeneity as an outcome. Outcome heterogeneity may also be the result of the postnatal effect modification that can be explored within studies. In order to do so, it is important to move beyond mean differences between groups, for example using unsupervised, stratified or interaction analysis. Different definitions of IUGR and the inclusion of different postnatal variables as confounders are potential sources of heterogeneity between studies. Researchers should be aware that postnatal variables may play different roles throughout a person's life and are not limited to behave as confounders. Therefore, their inclusion in the statistical model needs to be carefully considered. We discuss when sources of heterogeneity need to be controlled, and when they need to be identified and shown as a result.

Multilevel analysis of birthplace effect on the proportion of C-Section in Colombia" / Análisis multinivel del efecto del lugar de nacimiento en la proporción de partos por cesárea en Colombia

Abstract Objectives: To determine the general contextual effect of the department in the variation of Cesarean section in Colombia in 2016, and their individual and contextual related factors. Methods: Cross-sectional study based on a birth cohort. We used the birth certificate database from January 1 to December 31, 2016. Three multilevel logistic models were constructed. Pregnant women were set at the first level and department at the second level. We fitted a null multilevel model followed by two multiple models, including individual and individual and department variables, respectively. Results: The overall prevalence of C-section was 45.5% (95% CI: 45.4-45.6), ranged from 5 to 76%. The variance partition coefficient was 15%. Individual factors did not explain the general contextual effect. However, the region to which these departments belong explained 71% of the variance. The Caribbean region was positively associated with C-section compared to the Andean region (OR:3.88, 95% CI: 2.65-5.67). Conclusions: Multilevel analysis of individual heterogeneity and discriminatory accuracy showed that the department plays an important role in the variation of C-sections in Colombia. Our results suggest that the proportional universalism approach should be applied to reduce the proportion of C-Section, focusing on departments with the highest risk and on the Caribbean and Insular region.

Resumen Objetivos: Determinar el efecto contextual de los límites político administrativo de los departamentos, en la posibilidad individual de cesárea en el año 2016 y, las características individuales y contextuales asociadas a la misma. Métodos: Estudio transversal de una cohorte de nacimientos. Se realizó un análisis multinivel utilizando como fuente la base de datos de los certificados de nacimientos de Colombia desde el 1 de enero al 31 de diciembre de 2016. Se elaboraron tres modelos logísticos multinivel, con las gestantes en el primer nivel y el departamento como segundo nivel. El primer modelo incluyó solo el departamento como efecto aleatorio, seguido de otro con variables individuales y el último incluyó también las variables de contexto. Resultados: La proporción de cesáreas fue de 45.5% (IC 95%: 45.4-45.6), con un rango de 5% al 76%. El coeficiente de partición de varianza fue de 15%, indicando la existencia de una considerable desigualdad geográfica en la posibilidad del parto por cesárea. La región a la que pertenecen los departamentos explicó 71 % de la varianza entre departamentos. En particular, la región Caribe se asoció de manera positiva con la posibilidad de cesáreas comparado con la región Andina (OR:3.88, IC 95%: 2.65-5.67). Conclusiones: El análisis multinivel de la heterogeneidad individual mostró que el departamento juega un papel importante en la posibilidad de partos por cesáreas. Nuestros resultados sugieren que intervenciones con enfoque de universalismo proporcional son necesarias para reducir el parto por cesárea con énfasis en los departamentos de mayor riesgo y en la región Caribe e Insular

A case-control study of factors associated with SARS-CoV-2 infection among healthcare workers in Colombia.

BACKGROUND: Healthcare Workers (HCW) are repeatedly exposed to SARS-CoV-2 infection. The aim of this study was to identify factors associated with SARS-CoV-2 infection among HCW in one of the largest cities in Colombia. METHODS: We conducted a case-control study, where cases had a positive reverse transcription-polymerase chain reaction and controls had a negative result. Participants were randomly selected and interviewed by phone. Analyses were performed using logistic regression models. RESULTS: A total of 110 cases and 113 controls were included. Men (AdjOR 4.13 95% CI 1.70-10.05), Nurses (AdjOR 11.24 95% CI 1.05-119.63), not using a high-performance filtering mask (AdjOR 2.27 95% CI 1.02-5.05) and inadequate use of personal protective equipment (AdjOR 4.82 95% CI 1.18-19.65) were identified as risk factors. Conversely, graduate (AdjOR 0.06 95% CI 0.01-0.53) and postgraduate (AdjOR 0.05 95% CI 0.005-0.7) education, feeling scared or nervous (AdjOR 0.45 95% CI 0.22-0.91), not always wearing any gloves, caps and goggles/face shields (AdjOR 0.10 95% CI 0.02-0.41), and the use of high-performance filtering or a combination of fabric plus surgical mask (AdjOR 0.27 95% CI 0.09-0.80) outside the workplace were protective factors. CONCLUSION: This study highlights the protection provided by high-performance filtering masks or double masking among HCW. Modifiable and non-modifiable factors and the difficulty of wearing other protective equipment needs to be considered in designing, implementing and monitoring COVID-19 biosafety protocols for HCW.

Exercise Capacity in Young Adults Born Small for Gestational Age.

Importance: Being born small for gestational age (SGA), approximately 10% of all births, is associated with increased risk of cardiovascular mortality in adulthood, but mechanistic pathways are unclear. Cardiac remodeling and dysfunction occur in fetuses SGA and children born SGA, but it is uncertain whether and how these changes persist into adulthood. Objective: To evaluate baseline cardiac function and structure and exercise capacity in young adults born SGA. Design, Setting, and Participants: This cohort study conducted from January 2015 to January 2018 assessed a perinatal cohort born at a tertiary university hospital in Spain between 1975 and 1995. Participants included 158 randomly selected young adults aged 20 to 40 years born SGA (birth weight below the 10th centile) or with intrauterine growth within standard reference ranges (controls). Participants provided their medical history, filled out questionnaires regarding smoking and physical activity habits, and underwent incremental cardiopulmonary exercise stress testing, cardiac magnetic resonance imaging, and a physical examination, with blood pressure, glucose level, and lipid profile data collected. Exposure: Being born SGA. Main Outcomes and Measures: Cardiac structure and function assessed by cardiac magnetic resonance imaging, including biventricular end-diastolic shape analysis. Exercise capacity assessed by incremental exercise stress testing. Results: This cohort study included 81 adults born SGA (median age at study, 34.4 years [IQR, 30.8-36.7 years]; 43 women [53%]) and 77 control participants (median age at study, 33.7 years [interquartile range (IQR), 31.0-37.1 years]; 33 women [43%]). All participants were of White race/ethnicity and underwent imaging, whereas 127 participants (80% of the cohort; 66 control participants and 61 adults born SGA) completed the exercise test. Cardiac shape analysis showed minor changes at rest in right ventricular geometry (DeLong test z, 2.2098; P = .02) with preserved cardiac function in individuals born SGA. However, compared with controls, adults born SGA had lower exercise capacity, with decreased maximal workload (mean [SD], 180 [62] W vs 214 [60] W; P = .006) and oxygen consumption (median, 26.0 mL/min/kg [IQR, 21.5-33.5 mL/min/kg vs 29.5 mL/min/kg [IQR, 24.0-36.0 mL/min/kg]; P = .02). Exercise capacity was significantly correlated with left ventricular mass (ρ = 0.7934; P < .001). Conclusions and Relevance: This cohort of young adults born SGA had markedly reduced exercise capacity. These results support further research to clarify the causes of impaired exercise capacity and the potential association with increased cardiovascular mortality among adults born SGA.

Postnatal persistence of cardiac remodeling and dysfunction in late fetal growth restriction.

Fetal growth restriction is one of the most common obstetric complications, affecting 7-10% of all pregnancies. Affected fetuses are exposed to an adverse environment in utero during a critical time of development and may face long-term health consequences such as increased cardiovascular risk in adulthood. Growth restricted fetuses develop remodeled hearts with signs of systolic and diastolic dysfunction. Cardiac adaptations are more evident in early severe cases, but also present in late onset fetal growth restriction. Cardiovascular remodeling persists into postnatal life, from the neonatal period to adolescence, encompassing an increased susceptibility to adult disease. In this review, we summarize the current evidence on cardiovascular programming associated to fetal growth restriction, its postnatal consequences and potential strategies to reduce their cardiovascular risk.

Atrioventricular plane displacement versus mitral and tricuspid annular plane systolic excursion: A comparison between cardiac magnetic resonance and M-mode echocardiography.

INTRODUCTION: Both echocardiography and CMR imaging are used to quantify longitudinal function. Inter-method variability for mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion, and variability between directly measured MAPSE and TAPSE and as based on atrioventricular plane displacement (AVPD) analysis by CMR, are, however, not known. This study, therefore, assessed inter-method variability and variability between annular plane systolic excursion and AVPD-based values in a healthy adult population. METHODS: Echocardiography and CMR were performed in 111 adults (35 [32-38] years). Method comparisons were assessed with Deming regression, Bland-Altman analysis and coefficient of variation. Observer reproducibility was assessed by the concordance correlation coefficient. RESULTS: Echocardiography and semi-automatic CMR agreed on MAPSE (17 ± 2 mm vs. 17 ± 2 mm, p = 0.1) and TAPSE (25 ± 3 mm vs. 25 ± 3 mm, p = 0.5), correlated highly between methods (fitted-slope 1.22 [95% CI 1.07-1.38] and 1.12 [95% CI 0.95-1.29]) and showed low bias (0.42 [95% CI - 2.05 to 2.88] and - 0.18 [95% CI - 4.78 to 4.43]). Intra-/inter-observer reproducibility was high for both methods for both MAPSE (echocardiography 0.96/0.86; CMR 0.87/0.85) and TAPSE (echocardiography 0.96/0.95; CMR 0.97/0.96). MAPSE (16 ± 2 mm vs. 17 ± 2 mm; p < 0.001) and TAPSE (24 ± 3 vs. 25 ± 3 mm; p < 0.001) based on AVPD were similar but statistically different compared with semi-automatic CMR. CONCLUSIONS: Echocardiography and semi-automatic CMR have low variability and provide similar values for MAPSE and TAPSE and are thus interchangeable for follow-up studies. Lateral values based on tracked data from AVPD analysis are not clinically significantly different and could be used as a representation of annular displacement.

Multilevel analysis of birthplace effect on the proportion of C-Section in Colombia".

Objectives: To determine the general contextual effect of the department in the variation of Cesarean section in Colombia in 2016, and their individual and contextual related factors. Methods: Cross-sectional study based on a birth cohort. We used the birth certificate database from January 1 to December 31, 2016. Three multilevel logistic models were constructed. Pregnant women were set at the first level and department at the second level. We fitted a null multilevel model followed by two multiple models, including individual and individual and department variables, respectively. Results: The overall prevalence of C-section was 45.5% (95% CI: 45.4-45.6), ranged from 5 to 76%. The variance partition coefficient was 15%. Individual factors did not explain the general contextual effect. However, the region to which these departments belong explained 71% of the variance. The Caribbean region was positively associated with C-section compared to the Andean region (OR:3.88, 95% CI: 2.65-5.67). Conclusions: Multilevel analysis of individual heterogeneity and discriminatory accuracy showed that the department plays an important role in the variation of C-sections in Colombia. Our results suggest that the proportional universalism approach should be applied to reduce the proportion of C-Section, focusing on departments with the highest risk and on the Caribbean and Insular region.

Objetivos: Determinar el efecto contextual de los límites político administrativo de los departamentos, en la posibilidad individual de cesárea en el año 2016 y, las características individuales y contextuales asociadas a la misma. Métodos: Estudio transversal de una cohorte de nacimientos. Se realizó un análisis multinivel utilizando como fuente la base de datos de los certificados de nacimientos de Colombia desde el 1 de enero al 31 de diciembre de 2016. Se elaboraron tres modelos logísticos multinivel, con las gestantes en el primer nivel y el departamento como segundo nivel. El primer modelo incluyó solo el departamento como efecto aleatorio, seguido de otro con variables individuales y el último incluyó también las variables de contexto. Resultados: La proporción de cesáreas fue de 45.5% (IC 95%: 45.4-45.6), con un rango de 5% al 76%. El coeficiente de partición de varianza fue de 15%, indicando la existencia de una considerable desigualdad geográfica en la posibilidad del parto por cesárea. La región a la que pertenecen los departamentos explicó 71 % de la varianza entre departamentos. En particular, la región Caribe se asoció de manera positiva con la posibilidad de cesáreas comparado con la región Andina (OR:3.88, IC 95%: 2.65-5.67). Conclusiones: El análisis multinivel de la heterogeneidad individual mostró que el departamento juega un papel importante en la posibilidad de partos por cesáreas. Nuestros resultados sugieren que intervenciones con enfoque de universalismo proporcional son necesarias para reducir el parto por cesárea con énfasis en los departamentos de mayor riesgo y en la región Caribe e Insular.

Cross-classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance: the case of hospital differences in patient survival after acute myocardial infarction.

OBJECTIVE: To describe a novel strategy, Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate hospital performance, by analysing differences in 30-day mortality after a first-ever acute myocardial infarction (AMI) in Sweden. DESIGN: Cross-classified study. SETTING: 68 Swedish hospitals. PARTICIPANTS: 43 247 patients admitted between 2007 and 2009, with a first-ever AMI. PRIMARY AND SECONDARY OUTCOME MEASURES: We evaluate hospital performance by analysing differences in 30-day mortality after a first-ever AMI using a cross-classified multilevel analysis. We classified the patients into 10 categories according to a risk score (RS) for 30-day mortality and created 680 strata defined by combining hospital and RS categories. RESULTS: In the cross-classified multilevel analysis the overall RS adjusted hospital 30-day mortality in Sweden was 4.78% and the between-hospital variation was very small (variance partition coefficient (VPC)=0.70%, area under the curve (AUC)=0.54). The benchmark value was therefore achieved by all hospitals. However, as expected, there were large differences between the RS categories (VPC=34.13%, AUC=0.77) CONCLUSIONS: MAIHDA is a useful tool to evaluate hospital performance. The benefit of this novel approach to adjusting for patient RS is that it allowed one to estimate separate VPCs and AUC statistics to simultaneously evaluate the influence of RS categories and hospital differences on mortality. At the time of our analysis, all hospitals in Sweden were performing homogeneously well. That is, the benchmark target for 30-day mortality was fully achieved and there were not relevant hospital differences. Therefore, possible quality interventions should be universal and oriented to maintain the high hospital quality of care.

Nomograms of Fetal Cardiac Dimensions at 18-41 Weeks of Gestation.

OBJECTIVE: There is a need for standardized reference values for cardiac dimensions in prenatal life. The objective of the present study was to construct nomograms for fetal cardiac dimensions using a well-defined echocardiographic methodology in a low-risk population. METHODS: This is a prospective cohort study including 602 low-risk singleton pregnancies undergoing a standardized fetal echocardiography to accurately assess fetal cardiac, ventricular, and atrial dimensions. Parametric regressions were tested to model each measurement against gestational age from 18 to 41 weeks of gestation. RESULTS: Nomograms were constructed for fetal cardiac dimensions (transverse and longitudinal diameters and areas) of the whole heart, atria, and ventricles, as well as myocardial wall thicknesses. All dimensions showed a progressive increase with gestational age. The best model for most parameters was a second-degree linear polynomial. Fetal cardiac, ventricular, and atrial diameters and areas were successfully obtained in 98.6% of the fetuses, while myocardial wall thicknesses could be obtained in 96.5% of the population. The results showed excellent interobserver and intraobserver reproducibility (intraclass correlation coefficient, ICC > 0.811 and ICC > 0.957, respectively). CONCLUSIONS: We provide standardized and comprehensively evaluated reference values for fetal cardiac morphometric parameters across gestation in a low-risk population. These no mograms would enable the early identification of different patterns of fetal cardiac remodeling.

Nomograms of Fetal Right Ventricular Fractional Area Change by 2D Echocardiography.

OBJECTIVES: Fetal right ventricular (RV) function assessment is challenging due to the RV geometry and limitations of in utero assessment. Postnatally, 2D echocardiographic RV fractional area change (FAC) is used to assess RV global systolic function by calculating the percentage of change in RV area from systole to diastole. Reports on FAC are scarce in prenatal life, and nomograms throughout pregnancy are not available. Our aims were (1) to study prenatal RV FAC feasibility and reproducibility and (2) to construct nomograms for RV FAC and end-diastolic (ED) and end-systolic (ES) RV areas from 18 to 41 weeks of gestation. METHODS: Prospective cohort study including 602 low-risk singleton pregnancies undergoing a fetal echocardiography from 18 to 41 weeks of gestation. RV ED and ES areas were measured following standard recommendations for ventricular dimensions and establishing strict landmarks to identify the different phases of the cardiac cycle. RV FAC was calculated as: ([ED area - ES area]/ED area) × 100. RV FAC intra- and inter-observer reproducibility was evaluated in 45 fetuses by calculating the intraclass correlation coefficient (ICC). Parametric regressions were tested to model each parameter against gestational age (GA) and estimated fetal weight (EFW). RESULTS: RV areas and FAC were successfully obtained in ∼99% of fetuses with acceptable reproducibility throughout gestation (RV ED area inter-observer ICC [95% CI] 0.96 [0.93-0.98], RV ES area 0.97 [0.94-0.98], and FAC 0.69 [0.44-0.83]). Nomograms were constructed for RV ED and ES areas and FAC. RV areas showed a quadratic and logarithmic increase with GA and EFW, respectively. In contrast, RV FAC showed a slight quadratic decrease throughout gestation (mean RV FAC ranged from 36% at 18 weeks of gestation [10-90th centiles: 25-47%, respectively] to 29% at 41 weeks [10-90th centiles: 18-40%, respectively]). The best models for RV areas and FAC were a second-degree polynomial. CONCLUSIONS: RV FAC is a feasible and reproducible parameter to assess RV global systolic function in fetal life. We provide reference ranges adjusted by GA and EFW that can be used as normal references for the assessment of RV function in prenatal conditions.

Comparison of 2D versus M-mode echocardiography for assessing fetal myocardial wall thickness.

OBJECTIVE: M-mode and 2D have been proposed for evaluating fetal myocardial thickness. However, studies comparing the performance of both modalities are lacking. We aimed to compare 2D versus M-mode reproducibility for assessing myocardial wall thicknesses. METHODS: A prospective study including 45 healthy fetuses from low-risk pregnancies evaluated between 18 and 41 weeks of gestation. Left and right ventricular free-wall and septal myocardial thicknesses were measured at end-diastole (ED) and end-systole (ES) in transverse 4-chamber view using 2D and M-mode. Intra- and interobserver reproducibility was evaluated by the concordance correlation coefficient (CCC). Both techniques were compared by t-test of the CCC. RESULTS: 2D and M-mode demonstrated excellent and similar intraobserver repeatability, with the best concordance in ES septal thickness (M-mode CCC 0.956 versus 2D-mode CCC 0.914). Interobserver reproducibility demonstrated also a high concordance, optimal in ES left ventricular free wall (M-mode 0.925 versus 2 D 0.855). Comparison of both techniques demonstrated a high concordance in all measurements, except for ED septal thickness with better reproducibility using M-mode (CCC 0.954 versus 0.847, p = .017). CONCLUSIONS: 2D and M-mode can be used in a reproducible manner for measuring fetal myocardial thickness, with a slightly better performance of M-mode for assessing ED septal wall thickness.