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Background: Estimates of the burden of cardio-metabolic risk factors in Latin America and the Caribbean (LAC) rely on relative risks (RRs) from non-LAC countries. Whether these RRs apply to LAC remains unknown. Methods: We pooled LAC cohorts. We estimated RRs per unit of exposure to body mass index (BMI), systolic blood pressure (SBP), fasting plasma glucose (FPG), total cholesterol (TC) and non-HDL cholesterol on fatal (31 cohorts, n=168,287) and non-fatal (13 cohorts, n=27,554) cardiovascular diseases, adjusting for regression dilution bias. We used these RRs and national data on mean risk factor levels to estimate the number of cardiovascular deaths attributable to non-optimal levels of each risk factor. Results: Our RRs for SBP, FPG and TC were like those observed in cohorts conducted in high-income countries; however, for BMI, our RRs were consistently smaller in people below 75 years of age. Across risk factors, we observed smaller RRs among older ages. Non-optimal SBP was responsible for the largest number of attributable cardiovascular deaths ranging from 38 per 100,000 women and 54 men in Peru, to 261 (Dominica, women) and 282 (Guyana, men). For non-HDL cholesterol, the lowest attributable rate was for women in Peru (21) and men in Guatemala (25), and the largest in men (158) and women (142) from Guyana. Interpretation: RRs for BMI from studies conducted in high-income countries may overestimate disease burden metrics in LAC; conversely, RRs for SBP, FPG and TC from LAC cohorts are similar to those estimated from cohorts in high-income countries. Funding: Wellcome Trust (214185/Z/18/Z)

Fil: Critto, María Elena. MELISA Institute. Division of Epidemiology; Chile Fil: Critto, María Elena. Pontificia Universidad Católica Argentina. Facultad de Ciencias Sociales. Programa de Doctorado en Sociología; Argentina Fil: Enríquez, Yordanis. Universidad Católica Sedes Sapientiae. Facultad de Ciencias de la Salud; Perú Fil: Bravo, Miguel. MELISA Institute. Division of Epidemiology; Chile Fil: Bravo, Miguel. University of Chile. Faculty of Medicine. School of Public Health; Chile Fil: De Janon Quevedo, Lenin. Pontificia Universidad Católica Argentina; Facultad de Ciencia Médicas; Argentina Fil: Weinbergf, Ruth. Universidad de Buenos Aires. Facultad de Ciencias Médicas; Argentina Fil: Etchegaray, Adolfo. Universidad Austral. Facultad de Medicina. Hospital Universitario Austral; Argentina Fil: Koch, Elard S. MELISA Institute. Division of Epidemiology; Chile Abstract: Abstract Background Emerging pandemic viruses may have multiple deleterious effects on maternal health. This study examines the effects of a pandemic influenza virus on cause-specific maternal mortality time series, using Argentinian vital statistics. Methods We conducted a population-based natural experiment from national vital records of maternal deaths between 1980 and 2017. Joinpoint regression models were used to model time series of the maternal mortality ratio (MMR). The sensitivity of the registry to detect the effects of the pandemic H1N1 2009 influenza virus on cause-specific MMR was analysed using a panel of parallel interrupted time series (ITS). Findings Over this 38-year study, the MMR decreased by 58¢6% (69¢5 to 28¢8 deaths/100,000 live births), transitioning from direct obstetric causes (67¢0 to 21¢1/100,000 live births; 68¢4% decrease) to indirect causes (2¢6 to 7¢7/ 100,000 live births; 196¢2% increase). The regression analysis showed an average reduction of -2¢2%/year (95% CI: -2¢9 to -1¢4) with 2 join points in the total trend (1998 and 2009). Parallel ITS analyses revealed the pandemic H1N1 virus had an increasing effect on mortality from the respiratory system- and sepsis-related complications (level change 4¢7 and 1¢6/100,000 live births respectively), reversing after the outbreak. No effect was found on MMR from hypertensive disorders, haemorrhage, abortive outcomes, other direct obstetric causes, and indirect non-respiratory comorbidities. Interpretation The Argentinian maternal death registry appears sensitive to detect different effects of emerging infectious epidemics on maternal health. In a population-based natural experiment, pandemic H1N1 virus impacted maternal mortality almost exclusively from the respiratory system- and sepsis-related complications. Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.lana.2021.100116 Resumen: Antecedentes: Los virus pandémicos emergentes pueden tener múltiples efectos nocivos sobre la salud materna. Este estudio examina los efectos de un virus de influenza pandémica mediante series de tiempo ininterrumpidas de mortalidad materna por causas específicas, utilizando estadísticas vitales argentinas. Métodos: Realizamos un experimento natural con base poblacional a partir de registros vitales nacionales de muertes maternas entre 1980 y 2017. Se utilizaron modelos de regresión con punto de unión para modelar series de tiempo de la razón de mortalidad materna (RMM). La sensibilidad del registro para detectar los efectos del virus de la influenza pandémica A H1N1 2009 sobre las causas específicas de la RMM se analizó mediante un panel de series de tiempo interrumpidas (STI). Hallazgos: Durante este estudio de 38 años, la RMM disminuyó en un 58·6% (69·5 a 28·8 muertes/100.000 nacidos vivos), pasando de causas obstétricas directas (67·0 a 21·1/100.000 nacidos vivos; 68·4% de disminución) a causas indirectas (2·6 a 7·7/100.000 nacidos vivos; 196·2% de aumento). El análisis de regresión mostró una reducción promedio de -2·2%/año (IC 95%: -2·9 a -1·4) con 2 puntos de inflexión en la tendencia total (1998 y 2009). Los análisis de STI revelaron que el virus pandémico A H1N1 tuvo un efecto creciente sobre la mortalidad por complicaciones del sistema respiratorio y relacionadas con la sepsis (cambio de nivel 4·7 y 1·6/100.000 nacidos vivos, respectivamente), revirtiéndose después del brote. No se encontró ningún efecto sobre la RMM por trastornos hipertensivos, hemorragia, desenlace abortivo, otras causas obstétricas directas y comorbilidades indirectas no respiratorias. Interpretación: El registro de defunciones maternas de Argentina parece sensible para detectar diferentes efectos de las epidemias infecciosas emergentes sobre la salud materna. En el experimento natural poblacional, el virus pandémico A H1N1 afectó la mortalidad materna casi exclusivamente por complicaciones relacionadas con el sistema respiratorio y la sepsis.

This report provides a review, replication, and re-analysis of an study by Darney et al (Contraception. 2017;95(1):105-111) on the association between maternal mortality ratio (MMR, number of maternal deaths per 100,000 live births) and abortion legislation in Mexico City compared with 31 other states. In their study, Darney et al disputed evidence from our study (Koch et al, BMJ Open 2015;5(2):e006013), which found a null association between abortion laws and MMR, and reported their own conclusion of a negative association between abortion availability and MMR. After replicating their dataset and statistical analysis, we found that the beta coefficient (effect size) for abortion legislation was apparently misinterpreted by Darney et al to support the conclusion that legislation allowing abortion on request in Mexico City was associated with a 22.49-unit decrease in MMR. In fact, their analysis showed the opposite result: after multivariable adjustments, Mexico City was associated with a 22.49-unit increase in MMR compared with the 31 states with restricted access to abortion. Moreover, Darney et al did not report the initial time-adjusted effect size, where the 95% CI supports the hypothesis of null association (beta = 4.17; 95%CI -7.19 to 15.54; p=0.470). In our re-analysis of their data, estimates were highly unstable in multiple regression models, and the initial effect size (4.17) for the association between abortion legislation and the MMR was inflated up to 5-fold (22.49) as a result of a ‘tipping effect’ on coefficients and multicollinearity among covariates. In conclusion, our reanalysis of Darney et al’s study provides evidence of serious methodological flaws, faulty statistical analysis and misinterpretation of regression coefficients, ultimately resulting in an invalid conclusion.

Why was the cohort set up? Latin America and the Caribbean (LAC) are characterized by much diversity in terms of socio-economic status, ecology, environment, access to health care,1,2 as well as the frequency of risk factors for and prevalence or incidence of non-communicable diseases;3–7 importantly, these differences are observed both between and within countries in LAC.8,9 LAC countries share a large burden of non-communicable (e.g. diabetes and hypertension) and cardiovascular (e.g. ischaemic heart disease) diseases, with these conditions standing as the leading causes of morbidity, disability and mortality in most of LAC.10–12 These epidemiological estimates—e.g. morbidity—cannot inform about risk factors or risk prediction, which are relevant to identify prevention avenues. Cohort studies, on the other hand, could provide this evidence. Pooled analysis, using data from multiple cohort studies, have additional strengths such as increased statistical power and decreased statistical uncertainty.13 LAC cohort studies have been under-represented,14 or not included at all,15–17 in international efforts aimed at pooling data from multiple cohort studies. We therefore set out to pool data from LAC cohorts to address research questions that individual cohort studies would not be able to answer. Drawing from previous successful regional enterprises (e.g. Asia Pacific Cohort Studies Collaboration),18,19 we established the Cohorts Consortium of Latin America and the Caribbean (CC-LAC). The main aim of the CC-LAC is to start a collaborative cohort data pooling in LAC to examine the association between cardio-metabolic risk factors (e.g. blood pressure, glucose and lipids) and non-fatal and fatal cardiovascular outcomes (e.g. stroke or myocardial infarction). In so doing, we aim to provide regional risk estimates to inform disease burden metrics, as well as other ambitious projects including a cardiovascular risk score to strengthen cardiovascular prevention in LAC. Initial funding has been provided by a fellowship from the Wellcome Trust Centre for Global Health Research at Imperial College London (Strategic Award, Wellcome Trust–Imperial College Centre for Global Health Research, 100693/Z/12/Z). Additional funding is being provided by an International Training Fellowship from the Wellcome Trust (214185/Z/18/Z). At the time of writing, the daily operations and pooled database are hosted at Imperial College London, though a mid-term goal is to transfer this expertise and operations to LAC. The collaboration relies fundamentally on a strong regional network of health researchers and practitioners

Improving maternal health and decreasing morbidity and mortality due to induced abortion are key endeavors in developing countries. One of the most controversial subjects surrounding interventions to improve maternal health is the effect of abortion laws. Chile offers a natural laboratory to perform an investigation on the determinants influencing maternal health in a large parallel time-series of maternal deaths, analyzing health and socioeconomic indicators, and legislative policies including abortion banning in 1989. Interestingly, abortion restriction in Chile was not associated with an increase in overall maternal mortality or with abortion deaths and total number of abortions. Contrary to the notion proposing a negative impact of restrictive abortion laws on maternal health, the abortion mortality ratio did not increase after the abortion ban in Chile. Rather, it decreased over 96 percent, from 10.8 to 0.39 per 100,000 live births. Thus, the Chilean natural experiment provides for the first time, strong evidence supporting the hypothesis that legalization of abortion is unnecessary to improve maternal health in Latin America.

Contexto: Chile presenta una tendencia secular hacia una sostenida mejoria en los principales indicadores materno-infantiles. Su situacion constituye una experiencia positiva a nivel de la region de Latino-America y el Caribe. Sin embargo, esta tendencia se ha estancado en los ultimos diez anos lo que produce una situacion inestable y preocupante desde el punto de vista de la salud publica materna. Esto motiva una reunion de expertos a nivel nacional e internacional para proponer estrategias para el alto nivel politico orientadas a alcanzar los Objetivos 4 y 5 del Milenio. Conclusion: Este documento de consenso sobre mortalidad materna, sugiere un enfrentamiento en dos ejes: primero, enfrentar la nueva realidad epidemiologica desde la etapa pre-concepcional, esto incluye considerar la alta prevalencia de obesidad, hipertension arterial, diabetes, hiperlipidemias e hipotiroidismo en la poblacion, y por otro lado reforzar la seguridad de la asistencia del embarazo, parto y puerperio en los lugares mas alejados y mas vulnerables del pais. Es necesario focalizar las intervenciones en los grupos de mayor riesgo vital (edades extremas de la vida fertil y portadoras de enfermedades medico-quirurgicas severas, que se reflejan en el aumento proporcional de las causas indirectas de muerte materna), reforzar las actividades de auditorias de mortalidad/near miss, asi como controlar el aumento alarmante de la tasa de partos por cesareas.

Resumen:Antecedentes: Una relacion inversa entre estatura y riesgo de mortalidad ha sido establecida en estudios prospectivos de paises desarrollados. Sin embargo, di-cha asociacion practicamente permanece inexplorada en sociedades latinoamericanas en rapida transicion economica y epidemiologica. Diseno: De un universo de 11.600 adultos vi-viendo en el centro urbano de Mostazal, Chile, se realizo un estudio de cohorte prospectivo de una muestra aleatoria ponderada de 795 sujetos segui-dos durante 8 anos. Metodo: Desde 1997 a 1999 se evaluo la estatura (percentiles 50 y 75 por sexo), hipertension, diabetes, dislipidemia, obesidad, tabaquismo, consumo de alco-hol y antecedentes hereditarios de enfermedad cardio-vascular. El riesgo relativo de mortalidad por cualquier causa fue estimado a traves de modelos de regresion de Cox ajustando por edad, sexo, factores de riesgo, educacion e ingreso. Resultados: Se observo una relacion inversa entre la estatura adulta y los factores de riesgo cardiovascu-lar. En el modelo completamente ajustado el riesgo de mortalidad por cualquier causa asociado a la estatura fue 0,75 (IC 95% 0,66 – 0,85; p tendencia

The inverse relationship between early life and adult socioeconomic measures and mortality risk has been well established in developed countries, but remains practically unexplored in Latin American societies. The setting was Chile; the study included 11,600 adults living in the urban center of San Francisco de Mostazal. This was a prospective cohort study of a weighted random sample of 795 subjects followed up during 8 years.Education (elementary, high school and college), height (percentiles 50 and 75), and income (population quartiles) were assessed at baseline. Relative risks of all-cause mortality were computed in Cox regression models adjusting for age, gender, body mass index, smoking status, and joint effects of the socioeconomic measures.A graded inverse relationship with all-cause mortality was observed for education (risk: 1.0, 0.67, and 0.30, p for trend0.01) and height (risk: 1.0, 0.75, and 0.56, p for trend0.01), but not for income (p for trend = 0.94).These findings suggest a 'pauper rich' paradox in transitioning Latin American economies. Income level does not seem sufficient to improve survival in cohorts exposed to adverse early life influences reflected by education and height.

Aim: To find out whether there is an association between parity and obesity, evaluated through body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) in Chilean women after controlling for sociodemographic characteristics, health risk and gynaeco-obstetric factors. Design: Cross-sectional study, using baseline data of the San Francisco Project. Setting: San Francisco de Mostazal, located in the central region of Chile, 6512 Chilean-Hispanic women (Spanish heritage with a variable indigenous component). Methods: A weighted random sample of 508 women who had their first pregnancy inside the primary child-bearing ages. Data were collected between 1997 and 1999. Statistical associations between parity and different anthropometric measurements of adiposity in multiple linear (MLnR) and logistic regression models (MLtR) were evaluated. Results: In MLnR a modest parity-related increment in BMI and practically null increment in WC, WHR and WHtR was observed. Covariates that showed a statistically significant association with anthropometric measures of adiposity were age, low education, marital status, employment, smoking, smoking cessation, hypertension, diabetes, dyslipidaemia, parent’s obesity, menarche and fetal macrosomia. Crude odds ratio (OR) showed a strong association between parity and anthropometric markers of obesity. Nevertheless, after adjustments in MLtR models, the association remained only for BMI. All the measures of abdominal obesity related to parous women showed OR smaller than 1 (95% confidence intervals 0.57 to 0.96). Conclusions: Parity modestly influences BMI, but does not seem to be related to WC, WHR and WHtR after controlling by confounders. Parity can increase adiposity but not necessarily following an abdominal pattern.

Mortality by abortion has continuously decreased over the past fifty years in Chile. In fact, maternal death as a result of an induced abortion has become an exceptionally rare phenomenon in epidemiological terms (a risk of 1 in 4 million pregnant women of fertile age or 0.4 per 100,000 life births for abortion of any type, excluding ectopic pregnancy). After abortion became illegal in 1989, deaths related to abortion continued to decrease from 10.8 to 0.39 per 100,000 live births. This scientific fact challenges the common notion that less permissive abortion laws lead to greater mortality associated with abortion.

Background: Inadequate blood pressure control in hypertensive patients remains a persistent health problem in Chile and worldwide. Poor adherence to antihypertensive drug therapy is one of the frequently cited factors. Objectives: To determine the influence of psychosocial factors in the adherence to drug therapy in hypertensive patients followed through a Cardiovascular Health Program (CHP) that provides free access to primary care centers located in the Metropolitan Region of Santiago, Chile. Methods: Cross sectional study. A randomized sample of 513 hypertensive patients (30 to 68 years) was obtained from a universe of 1.484 patients. Adherence to treatment was determined by the Morisky-Green-Levine test. Demographic, socioeconomic and average values of blood pressure were recorded. Validated questionnaires were utilized to assess the patient-physician relationship, awareness of being hypertensive, patient perception of social support, family cohesion, patient self-health assessment and symptoms of emotional stress and depression. Results: The drug therapy adherence was 36.6%, higher in women (38.4% vs 28.9%; p < 0.001). After multivariate analysis, absence of adherence was associated with male gender (OR: 1.76 [95% CI 1.21-2.56]), low education (OR: 1.72 [95% CI 1.18 to 2.53]), inadequate patient-physician relationship (OR: 1.56 [95% CI 1.13 to 2.27]), and high level of emotional stress and depression (OR: 1.93 [95% CI 1.27 to 2.94]). Conclusions: Our study highlights the influence of inadequate patient-physician relation, high level of emotional stress and depression, low education level and income and male gender in the lack of adherence to antihypertensive drug therapy in hypertensive patients followed throughout the CHP.

Inadequate blood pressure control in hypertensive patients remains a persistent health problem in Chile and worldwide. Poor adherence to antihypertensive drug therapy is one of the frequently cited factors.To determine the influence of psychosocial factors in the adherence to drug therapy in hypertensive patients followed through a Cardiovascular Health Program (CHP) that provides free access to primary care centers located in the Metropolitan Region of Santiago, Chile.Cross sectional study. A randomized sample of 513 hypertensive patients (30 to 68 years) was obtained from a universe of 1.484 patients. Adherence to treatment was determined by the Morisky-Green-Levine test. Demographic, socioeconomic and average values of blood pressure were recorded. Validated questionnaires were utilized to assess the patient-physician relationship, awareness of being hypertensive, patient perception of social support, family cohesion, patient self-health assessment and symptoms of emotional stress and depression.The drug therapy adherence was 36.6%, higher in women (38.4% vs 28.9%; p0.001). After multivariate analysis, absence of adherence was associated with male gender (OR: 1.76 [95% CI 1.21-2.56]), low education (OR: 1.72 [95% CI 1.18 to 2.53]), inadequate patient-physician relationship (OR: 1.56 [95% CI 1.13 to 2.27]), and high level of emotional stress and depression (OR: 1.93 [95% CI 1.27 to 2.94]).Our study highlights the influence of inadequate patient-physician relation, high level of emotional stress and depression, low education level and income and male gender in the lack of adherence to antihypertensive drug therapy in hypertensive patients followed throughout the CHP.

Recently, the Guttmacher Institute estimated a number of 400,400 clandestine abortions for Colombia. Because of the strong implications that such brief could have in different areas of interest, a full revision of the methodology of estimation was performed. The methodology used by the Guttmacher Institute was as follows: first, the authors estimated the losses from spontaneous and induced abortions from the opinion of 289 subjects who work in an equal number of Colombian health institutions through the opinion survey entitled "Health Facilities Survey". Subsequently, an expansive multiplier (x3, x4, x5, etc.) was applied to the numbers obtained by this survey that also emerges from a subjective opinion of another 102 respondents of the "Health Professional Survey" selected by convenience. There is no objective data based on real vital events, the whole estimate is based on imagining/numbers underlying mere opinions. Even as public opinion survey, the sampling technique introduced serious selection bias in the gathering of information. Valid epidemiological methods using standardized rates, choosing the paradigmatic cases of Chile and Spain as standard populations, it was observed that Guttmacher Institute methodology overestimates more than 9 times the complications due to induced abortion in hospital discharges and more than 18 times the total number of induced abortions. In other Latin American countries where the same methodology was applied including Argentina, Brazil, Chile, Mexico, Peru, Guatemala, and Dominican Republic, the number of induced abortions was also largely overestimated. These results call for caution with this type of reports that alarm public opinion.

Elard Koch,1,2 Paula Aracena,1 Sebastián Gatica,1 Miguel Bravo,1 Alejandra Huerta-Zepeda,3 Byron C Calhoun41Institute of Molecular Epidemiology (MELISA), Center of Embryonic Medicine and Maternal Health, Faculty of Medicine, Universidad Católica de la Santísima Concepción, Concepción, Chile; 2Faculty of Medicine, University of Chile, Santiago, Chile; 3Universidad Popular Autónoma del Estado de Puebla UPAEP, Puebla, México; 4Department of Obstetrics and Gynecology, West Virginia University, Charleston, WV, USAAbstract: In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.Keywords: maternal health, maternal mortality, abortion, estimation methods, developing countries, International Classification of Diseases

As part of the Millennium Development Goals proposed by the United Nations, research on maternal mortality estimates and the determinants that positively influence maternal health outcomes is key for adequate evidence-based public health interventions. In the case of maternal death statistics, accuracy of estimating methods strongly depends on the quality of official records and, when unavailable, on the variables used in the predictive model, e.g. total fertility rate (TFR), percentage of childbirth delivery by skilled attendants, women’s education level, and per capita income, among others. Thus, a thorough evaluation of the reliability of estimated maternal mortality statistics is warranted before drawing any causal inference. In this regard, a recent report by Ahmed et al. provided the largest global estimate of the possible effect of contraceptive use on maternal mortality reduction and concluded that the ‘use of contraception is a substantial and effective primary

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP).Design. A cross-sectional and multicenter study.Setting. 52 primary care centers, metropolitan area of Santiago, Chile.Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients.Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period.Results. 59.7% of patients reached target BP<140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control.Conclusions. The success in improving the BP control to values /90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

Background: There is consensus in the value of assessing and counseling hypertensive patients in reference to their physical activities (PA). The International Physical Activity Questionnaire (IPAQ) is a commonly used instrument to asses the energy expenditure (EE) through different domains of daily activity. Objectives: The main purpose of this study was to assess the relation of self-reported PA through the IPAQ and the aerobic capacity using oxygen consumption (VO 2 ) measured directly in hypertensive sedentary women. Methods: Cross-sectional study in a simple random sub-sample of 64 hypertensive women between 35 and 55 years old, without physical limitation or coronary event. PA was evaluated using the Spanish version of the IPAQ to assess the energy expenditure (EE) and PA intensity (moderate or vigorous) in different domains (work, transport, domestic, leisure). VO 2 peak was measured directly, breath to breath (Fitmate Pro®), at a submaximal (85% [85 of 100] maximal heart rate) exercise test with 25 watt/3 min load increments in a bicycle ergometer. Results: Mean age was 48.4±5.2 years. Measured peak VO 2 was 16.5±2.6 mL/Kg/min with a predicted VO 2 max of 23±3.7 mL/Kg/min, both corresponding to a sedentary level. The greater proportion of EE was observed in work and domestic domains in contrast to leisure activities that had the lowest. Over 50% (1 of 2) of the PA was done at moderate intensity. Peak VO 2 showed a direct correlation with total EE, work and domestic, and finally, with the cost in PA done at moderate intensity. Table. Relationship between self-reported PA (IPAQ) and direct measurements of VO 2 Domain or PA type IPAQ EE (MET-min/week) * EE(%) † Pearson's Correlation coefficient VO 2 peak (ml/Kg/min) p-value IPAQ total 3,613 (1,976 - 5,589) − 0.539 0.001 Work 358 (0 - 2,230) 25.4 0.577 0.001 Transport 396 (89 - 795) 15.5 −0.103 0.542 Domestic 1,465 (893 - 2,520) 47.1 0.385 0.018 Leisure 153 (0 - 664) 13.1 −0.011 0.950 Moderate 1,672 (978 - 3,275) 57.4 0.560 0.001 Vigorous 0 (0 - 1,216) 12.8 0.249 0.136 * Data expressed as median (percentiles 25 and 75) † Percentage of mean EE of the domain or PA type according to total EE. Conclusion: In sedentary hypertensive women self reported PA using IPAQ is predominantly related to domestic and work activities at moderate intensity. Work, and domestic EE or moderate intensity global PA correlated well with the peak VO 2 directly measured during a sub maximal exercise test. Thus, IPAQ appears as an adequate instrument to assess the EE of hypertensive patients and its impact on their aerobic capacity.

Background: Multiple factors have been implicated in the lack of adherence to drug therapy in hypertensive patients. Objectives: In this study we addressed the impact of psychosocial factors over adherence in a hypertensive cohort followed through a Government sponsored primary care program (PCS) in Santiago, Chile. Method: Cross-sectional study, from a cohort of 738 hypertensive patients followed through the PCS; a sub sample of 89 patients who finished the first stage of recruitment was analyzed, and their results weighted by age and gender. Surveys of family function (APGAR), social support (MOS), health self-perception and physician-patient relationship were carried out. Total family income and education level were evaluated. Therapeutic adherence was determined using the Morisky test. The analyisis was performed by logistic regression estimating age and sex adjusted odds ratio. Results: The mean age of the sample was 54.3±7.6 years, being higher in men (56.2±6.4 years vs. 52.7±8.2 years). Satisfactory blood pressure control (BP Conclusion: In addition to family income and educational level, physician-patient relationship and family function are factors that showed a significant influence on the adherence to anti-hypertensive treatment. The BP control (66.2%) observed in this cohort appeared only partially explained by adherence to therapy (28.1%). A greater observance of dietary and other unmeasured life style changes as a result of the PCS program may have been at play to explain these findings. These aspects will be explored during the follow up. Table 1. Odds -Ratios (OR) of factors influencing adherence to drug Rx in hypertensive patients Adheres to treatment Does not adhere to treatment Raw OR (IC 95%) Adjusted by age and gender OR (IC 95%) Blood pressure (>140/90 mmHg) 29.6% (61 of 208) 36.4% (193 of 530) 1.36 (0.94 - 1.97) 1.48 (1.00 - 2.19) Low education (< 8 years) 30.2% (63 of 208) 47.6% (252 of 530) 2.16 (1.46 . 3.02) 2.28 (1.54 - 3.38) Low family income (Less than 1 minimal salary) 25.4% (53 of 208) 29.6% (157 of 530) 1.22 (0.83 - 1.76) 2.19 (1.42 - 3.37) Health self-perception (Good and very good) 3.3% (7 of 208) 14.3% (76 of 530) 5.43 (1.96 - 15.04) 3.85 (1.36 - 10.93) Scarce social support (MOS < 57 global pts) 44.2% (92 of 208) 36.8% (195 of 530) 0.73 (0.52 - 1.03) 0.84 (0.58 - 1.20) Dysfunctional family (APGAR < 7 pts) 21.6% (45 of 208) 31.0% (164 of 530) 1.65 (1.09 - 2.47) 2.47 (1.59 - 3.81) Inadequate physician-patient relationship 28.4% (59 of 208) 47.3% (251 of 530) 2.26 (0.73 - 6.98) 4.36 (0.81 - 23.39)

BackgroundThe aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).MethodsTime series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957-2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.ResultsDuring the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (-13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (-1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (-69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.ConclusionIncreasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

To test the hypothesis that an inverse association exists between socio-economic position and all-cause mortality in a developing country in Latin America.Prospective cohort study carried out in Chile using data from a simple random sample of 920 apparently healthy subjects (weighted population 11,600 aged 30-89 years) followed for 8 years.Education level (0-8 years, 9-12 years andor = 13 years) and income quartiles were established at the outset of the study, along with behavioural and biological risk factors for chronic diseases: smoking, alcohol use, obesity, diabetes, hypertension, lipids and family history of death by cardiovascular disease. Relative risks of all-cause mortality were estimated using age-adjusted Cox regression models.During the follow-up period, 46 deaths were observed. Adjusting for age, gender, and behavioural and biological risk factors, the mortality risk for increasing categories of education after controlling for income was 1.0, 0.76 and 0.33 (P for trend0.01). In contrast, the relative risk for increasing levels of income after controlling for education was 1.0, 0.98, 1.33 and 1.17 (P for trend=0.07).While education level had a protective effect on mortality risk of Chilean adults, income had a slightly unfavourable effect on survival. This finding is described as suggestive of a 'pauper-rich paradox', since the higher income quantiles in this study correspond with the lower income levels in most developed countries. Nevertheless, due to the small number of deaths, additional research is required to assess the validity of these findings.

The socioeconomic position (SEP) and educational level of individuals have an inverse correlation with mortality in developed societies.To assess in a society undergoing a socioeconomic transition, the mortality risk associated to a low SEP (combination of education and income, scale 0-25 points, reference10 points) and low education (education years, reference8 years), adjusting for other known risk factors.In this prospective cohort study, a random sample of 920 subjects, living in San Francisco de Mostazal, Chile, aged more than 20 years (395 males) was examined for the first time in 1997-1999 and re-examined in 2005-2006. All had information about economic household income and level of education. A Cox regression model was used to evaluate the association between mortality and socioeconomic measures.The crude mortality hazard ratio (HR) was 3.34 (95% confidence interval (CI) 2.88-3.87) and 6.05 (95% CI 5.04-7.26) for low SEP and low educational level, respectively. After adjusting for age, gender, hypertension, diabetes, dyslipidemia, abdominal obesity, smoking, alcohol intake and family history of cardiovascular disease, the figures were 1.23 (95% CI 1.04-1.43) and 1.54 (95% CI 1.23-1.85) for low SEP and low educational level, respectively.In a society in socioeconomic transition, low SEP and especially low educational level are risk factors for mortality even after adjusting for known mortality risk factors.

Background: The socioeconomic position (SEP) and educational level of individuals have an inverse correlation with mortality in developed societies. Aim To assess in a society undergoing a socioeconomic transition, the mortality risk associated to a low SEP (combination of education and income, scale 0-25 points, reference > 10 points) and low education (education years, reference > 8 years), adjusting for other known risk factors. Material and methods: In this prospective cohort study, a random sample of 920 subjects, living in San Francisco de Mostazal, Chile, aged more than 20years (395 males) was examined for the first time in 1997-1999 and re-examined in 2005-2006. All had information about economic household income and level of education. A Cox regression model was used to evaluate the association between mortality and socioeconomic measures. Results: The crude mortality hazard ratio (HR) was 3.34 (95% confidence interval (CI) 2.88-3.87) and 6.05 (95% CI 5.04-7.26) for low SEP and low educational level, respectively. After adjusting for age, gender, hypertension, diabetes, dyslipidemia, abdominal obesity, smoking, alcohol intake and family history of cardiovascular disease, the figures were 1.23 (95% CI 1.04-1.43) and 1.54 (95% CI 1.23-1.85) for low SEP and low educational level, respectively. Conclusions: In a society in socioeconomic transition, low SEP and especially low educational level are risk factors for mortality even after adjusting for known mortality risk factors

Este estudio evaluó el efecto del tabaquismo materno durante el embarazo sobre la salud respiratoria de sus lactantes durante el primer año de vida, en 184 binomios madre-hijo. El análisis se realizó mediante chi cuadrado para proporciones y regresión logística multivariada ajustando para covariables. Los hijos de madres que fumaron durante el embarazo tuvieron un riesgo significativamente mayor de sufrir de bronquitis obstructiva (p < 0,01), de enfermedades respiratorias agudas en general (p < 0,01) y de hospitalización por neumonía (p < 0,05), en comparación con los hijos de madres que no fumaron durante el embarazo. Concordantemente con lo descrito en países desarrollados, en esta muestra proveniente de una población de bajos recursos socioeconómicos, el tabaquismo materno durante el embarazo aumentó significativamente la susceptibilidad de los lactantes para sufrir de bronquitis obstructivas, enfermedades respiratorias agudas y de hospitalizaciones por neumonía en su primer año de vida

Popperian epidemiology is a biomedical science tool based on the hypothesis-deductive method and the falsifiability of scientific hypotheses. This article explores the applicability of the refutationist logic tools in the analysis of a randomised controlled trial (RCT), the randomised Aldactone evaluation study (RALES). This was carried out by using bi-conditional modus-tollens arguments of the type (i) P-then-Q(n) and (ii) Q(n)-If-X(P), X(P) being a set of potential falsifiers of Q(n) as part of the explicit falsity-content of P. In this model, P is the main hypothesis and Q(n) one or more logical predictions to be tested. The X(P) argument represents inclusion criteria, exclusion criteria and conditional criteria of the RCT so every P-then-X(P) argument should be fulfilled in canonical form to corroborate P-then-Q(n). Thus, falsifiability of a RCT would be determined by the empirical content of the conditional argument Q(n)-If-X(P) and its external validity would be determined by the empirical content of X(P). In this way it would be possible to mathematically assess the external validity of a RCT if the observational predicates of the X(P) argument in a given population are known. According to this popperian model, applicability of the RCT results to clinical practice implies transferring of all its empirical content, in other words, the totality of its truth and falsity contents. Thus, to ignore the explicit falsity-content of a RCT such as RALES may jeopardise its potential benefits in clinical practice as suggested by recent studies.

The San Francisco Project is a prospective study aiming to determine the most important cardiovascular risk factors in the Chilean population.To report the results of the San Francisco Project after a mean follow up of five years.Between 1997 and 1999, 920 subjects (aged 39.5 +/- 16.3 years, 382 males), free of cardiovascular events, were examined to determine their cardiovascular risk factors. The prevalence of risk factors was compared with the Chilean National Health Survey. All non fatal cardiovascular events were registered until 2003. A logistic regression model including gender, obesity, family history, educational level and classical cardiovascular risk factors, was performed to identify independent predictors of cardiovascular events.The prevalence of cardiovascular risk factors in the studied population was similar to that of the Chilean National Health Survey, except for serum lipid levels, that were lower in the latter. The mean follow up was 5.3 +/- 0.3 years (range 4-6 years), and 26 cardiovascular events were registered. The independent predictors of these events were age, with a relative risk (RR) of 4.3 and 95% confidence intervals (CI) of 1.9 to 9.5 (p0.001), high blood pressure with a RR of 5.2 (95% CI 2.3-11.7, p0.001), diabetes mellitus with a RR of 4.5 (95% CI 1.9-10.7, p0.01) and a low socioeconomic level with a RR of 3.5 (95% CI 1.5-7.9, p0.01). The model did not accept serum lipid levels, smoking and alcohol intake as independent predictors.In this cohort of Chilean people, the independent predictors of non fatal cardiovascular events were high blood pressure, diabetes mellitus and a low socioeconomic level.

In 1999 a great multi-site clinical trial known as the randomised Aldactone evaluation study (RALES) showed that the use of spironolactone importantly reduced complications attributable to chronic heart failure without major negative side effects. Recently, RALES has been questioned by a large scale observational study in the Ontario population. In contrast with predictions, the complications and mortality increased dramatically because of hyperkalaemia, reaching dimensions that from a public health perspective are comparable to an epidemic. This review analyses both researches in the light of Karl Popper’s science theory applying the modus tollens syllogism to the reality proposed by the main empirical enunciations that ensue from its epidemiological designs. RALES is deductively refuted because of the non-fulfillment of auxiliary assumptions that would act as reciprocal potential falsifiers in both studies, taking the logical form of a bi-conditional argument of the type: (a) P-then-Q and (b) Q-if-X P , X P being a set of potential falsifiers of Q as part of the explicit falsity content of P . From this popperian model, implications for clinical research are discussed.

Background: The San Francisco Project is a prospective study aiming to determine the most important cardiovascular risk factors in the Chilean population. Aim: To report the results of the San Francisco Project after a mean follow up of five years. Material and methods: Between 1997 and 1999, 920 subjects (aged 39.5 ± 16.3 years, 382 males), free of cardiovascular events, were examined to determine their cardiovascular risk factors. The prevalence of risk factors was compared with the Chilean National Health Survey. All non fatal cardiovascular events were registered until 2003. A logistic regression model including gender, obesity, family history, educational level and classical cardiovascular risk factors, was performed to identify independent predictors of cardiovascular events. Results: The prevalence of cardiovascular risk factors in the studied population was similar to that of the Chilean National Health Survey, except for serum lipid levels, that were lower in the latter. The mean follow up was 5.3 ± 0.3 years (range 4-6 years), and 26 cardiovascular events were registered. The independent predictors of these events were age, with a relative risk (RR) of 4.3 and 95% confidence intervals (CI) of 1.9 to 9.5 (p