Patterns of SES Health Disparities Among Older Adults in Three Upper Middle- and Two High-Income Countries.

OBJECTIVES: To examine the socioeconomic status (SES) health gradient for obesity, diabetes, and hypertension within a diverse group of health outcomes and behaviors among older adults (60+) in upper middle-income countries benchmarked with high-income countries. METHOD: We used data from three upper middle-income settings (Colombia-SABE-Bogotá, Mexico-SAGE, and South Africa-SAGE) and two high-income countries (England-ELSA and US-HRS) to estimate logistic regression models using age, gender, and education to predict health and health behaviors. RESULTS: The sharpest gradients appear in middle-income settings but follow expected patterns found in high-income countries for poor self-reported health, functionality, cognitive impairment, and depression. However, weaker gradients appear for obesity, hypertension, diabetes, and other chronic conditions in Colombia and Mexico and the gradient reverses in South Africa. Strong disparities exist in risky health behaviors and in early nutritional status in the middle-income settings. DISCUSSION: Rapid demographic and nutritional transitions, urbanization, poor early life conditions, social mobility, negative health behavior, and unique country circumstances provide a useful framework for understanding the SES health gradient in middle-income settings. In contrast with high-income countries, the increasing prevalence of obesity, an important risk factor for chronic conditions and other aspects of health, may ultimately change the SES gradient for diseases in the future.

Early Life Displacement Due to Armed Conflict and Violence, Early Nutrition, and Older Adult Hypertension, Diabetes, and Obesity in the Middle-Income Country of Colombia.

Objective: We examine the importance of early life displacement and nutrition on hypertension (HTN) and diabetes in older Colombian adults (60+ years) exposed to rapid demographic, epidemiological, and nutritional transitions, and armed conflict. We compare early life nutritional status and adult health in other middle- and high-income countries. Method: In Colombia (Survey of Health, Wellbeing and Aging [SABE]-Bogotá), we estimate the effects of early life conditions (displacement due to armed conflict and violence, hunger, low height, and not born in the capital city) and obesity on adult health; we compare the effects of low height on adult health in Mexico, South Africa (Study on Global Ageing and Adult Health [SAGE]), the United States, and England (Health and Retirement Study [HRS], English Longitudinal Study of Ageing [ELSA]). Results: Early life displacement, early poor nutrition, and adult obesity increase the risk of HTN and diabetes in Colombia. Being short is most detrimental for HTN in Colombian males. Discussion: Colombian data provide new evidence into how early life conditions and adult obesity contribute to older adult health.

Predictors of early mortality in very elderly patients with bacteremia: a prospective multicenter cohort.

OBJECTIVES: The proportion of very elderly people in the population is increasing, and infectious diseases in this patient group may present with specific characteristics. The objective of this study was to investigate the outcome predictors of bacteremia among the very elderly. METHODS: This was a multicenter prospective cohort study of bloodstream infections (BSI) in patients ≥ 80 years old in 15 hospitals in Spain. The outcome variables were 14-day and 30-day mortality. Multivariate analysis was performed. RESULTS: One hundred and twenty episodes were included. Mortality was 22% (n = 26) on day 14 and 28% (n = 34) on day 30. In the univariate analysis, the variables associated with mortality were neutropenia, recent surgery, Pitt score ≥ 2, intensive care unit (ICU) admission, severe sepsis or shock, and abdominal, unknown, and respiratory tract sources. In the multivariate analysis, variables associated with mortality on day 14 were high-risk source (abdominal, unknown, and respiratory tract sources; odds ratio (OR) 7.9, 95% confidence interval (CI) 1.8-33.9), Pitt score ≥ 2 (OR 5.6, 95% CI 1.3-23.3), inadequate empirical treatment (OR 11.24, 95% CI 1.6-80.2), and severe sepsis or shock at presentation (OR 5.3, 95% CI 1.4-20.7); the interaction between empiric treatment and high-risk source was significant. On day 30, mortality was independently related to a high-risk source (OR 2.92, 95% CI 1.1-7.5) and presentation with severe sepsis or shock (OR 3.81, 95% CI 1.2-12.4). CONCLUSIONS: Presentation with severe sepsis or shock and a high-risk source of BSI were independent predictors of 14-day and 30-day mortality. Inadequate empirical treatment was also a predictor of early mortality in patients with a high-risk source.

Reappraisal of the outcome of healthcare-associated and community-acquired bacteramia: a prospective cohort study.

BACKGROUND: Healthcare-associated (HCA) bloodstream infections (BSI) have been associated with worse outcomes, in terms of higher frequencies of antibiotic-resistant microorganisms and inappropriate therapy than strict community-acquired (CA) BSI. Recent changes in the epidemiology of community (CO)-BSI and treatment protocols may have modified this association. The objective of this study was to analyse the etiology, therapy and outcomes for CA and HCA BSI in our area. METHODS: A prospective multicentre cohort including all CO-BSI episodes in adult patients was performed over a 3-month period in 2006-2007. Outcome variables were mortality and inappropriate empirical therapy. Adjusted analyses were performed by logistic regression. RESULTS: 341 episodes of CO-BSI were included in the study. Acquisition was HCA in 56% (192 episodes) of them. Inappropriate empirical therapy was administered in 16.7% (57 episodes). All-cause mortality was 16.4% (56 patients) at day 14 and 20% (71 patients) at day 30. After controlling for age, Charlson index, source, etiology, presentation with severe sepsis or shock and inappropriate empirical treatment, acquisition type was not associated with an increase in 14-day or 30-day mortality. Only an stratified analysis of 14th-day mortality for Gram negatives BSI showed a statically significant difference (7% in CA vs 17% in HCA, p = 0,05). Factors independently related to inadequate empirical treatment in the community were: catheter source, cancer, and previous antimicrobial use; no association with HCA acquisition was found. CONCLUSION: HCA acquisition in our cohort was not a predictor for either inappropriate empirical treatment or increased mortality. These results might reflect recent changes in therapeutic protocols and epidemiological changes in community pathogens. Further studies should focus on recognising CA BSI due to resistant organisms facilitating an early and adequate treatment in patients with CA resistant BSI.

In vitro susceptibilities of bloodstream isolates of Candida spp: results from a multicenter active surveillance program in Andalusia

Objetivos: Determinar la sensibilidad antifúngica de las cepas de Candida spp. aisladas en sangre en Andalucía, obtenidas en un estudio prospectivo multicéntrico realizado entre octubre de 2005 y septiembre de 2006. Métodos: Se aislaron 197 cepas de Candida spp. Las CMIs de anfotericina B, fluconazol, itraconazol y voriconazol se realizaron usando el panel de Sensititre YeastOne. Las CMIs de posaconazol y caspofungina se determinaron por Etest. Resultados: C. albicans (..) (AU)

Objectives The aim of this study was to determine the antifungal drug susceptibilities of Candida bloodstream isolates in Andalusia, obtained through a multicenter active laboratory-based surveillance between October 2005 and September 2006.MethodsOne hundred and ninety-seven Candida isolates were collected. The MICs of amphotericin B, fluconazole, itraconazole and voriconazole were established using the Sensititre Yeast One panel. The MICs of posaconazole and caspofungin were determined by Etest. Results C. albicans was the most frequently isolated species (49.2%), followed (..) (AU)

In vitro susceptibilities of bloodstream isolates of Candida spp.: results from a multicenter active surveillance program in Andalusia.

OBJECTIVES: The aim of this study was to determine the antifungal drug susceptibilities of Candida bloodstream isolates in Andalusia, obtained through a multicenter active laboratory-based surveillance between October 2005 and September 2006. METHODS: One hundred and ninety-seven Candida isolates were collected. The MICs of amphotericin B, fluconazole, itraconazole and voriconazole were established using the Sensititre YeastOne panel. The MICs of posaconazole and caspofungin were determined by Etest. RESULTS: C. albicans was the most frequently isolated species (49.2%), followed by C. parapsilosis (17.3%), C. tropicalis (15.2%), C. glabrata (13.7%) and C. krusei (3.6%). All strains were inhibited at MICs of or = 64 mg/L) and 7 (3.6%) were considered resistant to itraconazole (MIC > or = 1 mg/L). All the isolates were susceptible to voriconazole and caspofungin. CONCLUSION: In our study C. krusei and C. glabrata were identified in over 18% of cases of candidemia. Most clinical isolates of these species are resistant or susceptible-dose-dependent to fluconazole but susceptible to voriconazole and caspofungin. These agents must be used in the empiric treatment of candidemia rather than fluconazole.

Endocarditis por Arcanobacterium pyogenes: Primer caso en Europa / Endocarditis due to Arcanobacterium pyogenes: The first case in Europe

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Perla: plantilla transparente en cirugía de Mohs / Surgical pearl: transparent template in Mohs surgery

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Factores socioeconómicos y contextuales que determinan la actividad reproductiva de las adolescentes en Colombia / Socioeconomic and contextual determinants of reproductive activity among adolescent women in Colombia

OBJETIVO: Contribuir a un mejor entendimiento de la problemática del embarazo en las adolescentes y de sus factores determinantes, próximos y socioeconómicos, en dos contextos culturalmente diferentes, las ciudades de Cali y Santa Fe de Bogotá, en Colombia. MÉTODO: De carácter longitudinal, el estudio combina métodos de investigación cuantitativa y cualitativa. Se basa en la encuesta retrospectiva, cuantitativa y cualitativa de salud de los adolescentes de 2003. La encuesta cuantitativa tuvo una muestra de 1 100 adolescentes representativas de cada estrato socioeconómico. Para el análisis de los factores determinantes se utilizaron modelos de riesgo proporcional de tiempo discreto. Para el estudio cualitativo se efectuaron 72 entrevistas a profundidad y cuatro grupos focales. Asimismo, se identificaron las categorías que surgían de pautas y recurrencias en los datos, para generar patrones socioculturales por sexo, estrato y ciudad. RESULTADOS: Los patrones de actividad sexual, unión y maternidad difieren considerablemente entre estratos en las dos ciudades. Las adolescentes del estrato bajo inician las relaciones sexuales, se unen a compañeros y son madres con mucha mayor antelación e intensidad que las de estratos más altos. El principal factor determinante del comportamiento reproductivo de las adolescentes es el conjunto de influencias contextuales y socioeconómicas del hogar, principalmente el contexto familiar (ambiente y supervisión) y el clima educativo. CONCLUSIONES: Resulta evidente el escaso impacto que ha tenido la educación sexual que se imparte en las escuelas, desde 1993, en el comportamiento reproductivo de las adolescentes.

Abscesos esplénicos por Salmonella / Splenic abscesses from Salmonella infection

Los abscesos esplénicos son infrecuentes. Describimos el caso de un paciente de 56 años, quien consultó por diarrea, fiebre, vómito y pérdida de peso; al examen físico presentaba ictericia, hepatomegalia y ascitis. Se demostró por medio de imágenes diagnosticas la presencia de abscesos esplénicos, causados por Salmonella species. Considerando el tipo de abscesos se dio manejo medico sin necesidad de ser intervenido, presentando evolución adecuada. No se encontró ningún factor de riesgo diferente al foco gastrointestinal como precursor de la formación de los abscesos esplénicos.

[Socioeconomic and contextual determinants of reproductive activity among adolescent women in Colombia]. / Factores socioeconómicos y contextuales que determinan la actividad reproductiva de las adolescentes en Colombia.

OBJECTIVE: To contribute to a better understanding of the problems of pregnancy among adolescent women, including proximate and socioeconomic determining factors, in two large, culturally different cities in Colombia: Santa Fe de Bogotá and Cali. METHODS: This longitudinal study combined quantitative and qualitative research methods, using information generated by a survey of adolescents conducted in 2003. The survey included 550 adolescents in Bogotá and 550 adolescents in Cali, from all socioeconomic strata. To analyze the determinants, discrete-time proportional hazards models were used. For the qualitative study, 72 in-depth interviews and four focus groups were done. With the information organized by subjects and categories that were defined in relation to the purposes of the study, categories were identified that arose from the patterns and recurrences in the data, in order to see sociocultural trends by sex, stratum, and city. RESULTS: The patterns of sexual activity, union (married or unmarried relationship), and maternity differ considerably among the socioeconomic strata, in both of the cities. The adolescent women in the low stratum begin having sexual relations, form unions, and become mothers earlier in life and with greater frequency than do adolescent women in the medium or high strata. The main determinant of the reproductive behavior of adolescent women is the set of contextual and socioeconomic factors in the home, mainly the family context (environment and supervision) and the educational climate (the average number of years of formal education of the family members over the age of 15). CONCLUSIONS: Sex education has been provided in the schools in Colombia since 1993, but our results clearly indicate that it has had only a limited impact on the reproductive behavior of adolescent women.

Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries.

OBJECTIVE: To explore and describe inequalities in health and use of health care as revealed by self-report in 12 countries of Latin America and the Caribbean. METHODS: A descriptive and exploratory study was performed based on the responses to questions on health and health care utilization that were included in general purpose household surveys. Inequalities are described by quintile of household expenditures (or income) per capita, sex, age group (children, adults, and older adults), and place of residence (urban vs. rural area). For those who sought health care, median polishing was performed by economic status and sex, for the three age groups. RESULTS: Although the study is exploratory and descriptive, its findings show large economic gradients in health care utilization in these countries, with generally small differences between males and females and higher percentages of women seeking health care than men, although there were some exceptions among the lower economic strata in urban areas. CONCLUSIONS: Inequalities in self-reported health problems among the different economic strata were small, and such problems were usually more common among women than men. The presence of small inequalities may be due to cultural and social differences in the perception of health. However, in most countries included in the study, large inequalities were found in the use of health care for the self-reported health problems. It is important to develop regional projects aimed at improving the questions on self reported health in household interview surveys so that the determinants of the inequalities in health can be studied in depth. The authors conclude that due to the different patterns of economic gradients among different age groups and among males and females, the practice of standardization used in constructing concentration curves and in computing concentration indices should be avoided. At the end is a set of recommendations on how to improve these sources of data. Despite their shortcomings, household interview surveys are very useful in understanding the dimensions of health inequalities in these countries.

Perú - Hoja-resumen sobre desigualdades en salud

La Hoja-Resumen presenta una breve descripción de cada variable estudiada, las gráficas y datos utilizados, con un comentario sintético sobre los mismos. Al final, en la Nota técnica y comentarios, se presentan algunas indicaciones de los procedimientos metodológicos utilizados para el estudio, incluyendo posibles interpretaciones sobre los resultados, sin ningún componente inferencial. La Hoja-Resumen de Perú ha sido elaborada utilizando los datos de la Encuesta de Hogares sobre Medición de Niveles de Vida (ENNIV) del 2000, la cual hace parte del programa de encuestas sobre Niveles de Vida (LSMS) del Banco Mundial.

Hoja Resumen. Desigualdades en salud. Ecuador. Febrero 2002

La Hoja-Resumen presenta una breve descripción de cada variable estudiada, las gráficas y datos utilizados, con un comentario sintético sobre los mismos. Al final, en la Nota técnica y comentarios, se presentan indicaciones de los procedimientos metodológicos utilizados para el estudio, incluyendo posibles interpretaciones sobre los resultados, sin ningún componente inferencial. La Hoja-Resumen de Ecuador ha sido producida utilizando los datos de la Encuesta de Condiciones de Vida, Tercera Ronda, de 1998, la cual hace parte del programa de Encuestas MECOVI (Mejoramiento de Encuestas de condiciones de Vida) del Banco Interamericano de Desarrollo, Banco Mundial, CEPAL y la Organización Panamericana de la Salud. El anexo contiene información sobre los tamaños muestrales de dicha encuesta para las variables utilizadas.

Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries / Desigualdades de salud en América Latina y el Caribe: resultados descriptivos y exploratorios basados en la autonotificación de problemas de salud y atención de salud en doce países

Objective. To explore and describe inequalities in health and use of health care as revealed by self-report in 12 countries of Latin America and the Caribbean. Methods. A descriptive and exploratory study was performed based on the responses to questions on health and health care utilization that were included in general purpose household surveys. Inequalities are described by quintile of household expenditures (or income) per capita, sex, age group (children, adults, and older adults), and place of residence (urban vs. rural area). For those who sought health care, median polishing was performed by economic status and sex, for the three age groups. Results. Although the study is exploratory and descriptive, its findings show large economic gradients in health care utilization in these countries, with generally small differences between males and females and higher percentages of women seeking health care than men, although there were some exceptions among the lower economic strata in urban areas. Conclusions. Inequalities in self-reported health problems among the different economic strata were small, and such problems were usually more common among women than men. The presence of small inequalities may be due to cultural and social differences in the perception of health. However, in most countries included in the study, large inequalities were found in the use of health care for the self-reported health problems. It is important to develop regional projects aimed at improving the questions on selfreported health in household interview surveys so that the determinants of the inequalities in health can be studied in depth. The authors conclude that due to the different patterns of economic gradients among different age groups and among males and females, the practice of standardization used in constructing concentration curves and in computing concentration indices should be avoided. At the end is a set of recommendations on how to improve these sources of data. Despite their shortcomings, household interview surveys are very useful in understanding the dimensions of health inequalities in these countries

Objetivo. Explorar y describir las desigualdades detectadas a partir de la autonotificación de problemas de salud y de la búsqueda de atención sanitaria en 12 países de América Latina y el Caribe. Métodos. Se analizan las preguntas sobre los problemas de salud y la búsqueda de atención en encuestas de hogares de tipo general y se describen las desigualdades correspondientes de acuerdo con quintiles de gasto (o ingreso) doméstico per cápita, sexo, grupo de edad (niños, adultos y adultos mayores) y área urbana o rural. En el caso de las personas que buscaron atención de salud, se aplica la técnica de pulimiento de medianas por nivel económico y sexo para los tres grupos de edad. Resultados. Aun cuando el trabajo es exploratorio y descriptivo, los resultados muestran en los países estudiados la existencia de importantes gradientes en la utilización de servicios de salud según nivel económico, y la presencia de diferencias generalmente pequeñas entre hombres y mujeres, con algunas excepciones en los estratos económicos más bajos en áreas urbanas. Conclusiones. Las desigualdades detectadas a partir de la autonotificación de problemas de salud son muy pequeñas entre personas de diferente nivel económico y los problemas suelen ser más frecuentes entre las mujeres que entre los hombres. Esto se debe posiblemente a diferencias culturales y sociales en la percepción de la salud. Las desigualdades en la búsqueda de atención son grandes en la mayoría de los países estudiados. Es muy importante que se desarrollen proyectos regionales encaminados a mejorar las preguntas para la autonotificación de problemas de salud con el fin de poder estudiar a fondo los factores que determinan las desigualdades en el ámbito sanitario. Los autores concluyen que debido a que los gradientes económicos muestran patrones diferentes en los distintos grupos de edad y en hombres y mujeres, los datos no deben estandarizarse a la hora de derivar curvas de concentración y calcular los índices de concentración. Al final hay una lista de recomendaciones sobre cómo mejorar estas fuentes de datos. Pese a sus deficiencias, las encuestas de hogares nos ayudan a entender las complejidades de las desigualdades de salud en estos países.