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Background Recent studies highlight the equigenic potential of greenspaces by showing narrower socioeconomic health inequalities in greener areas. However, results to date have been inconsistent and derived from high-income countries. We examined whether urban greenness modifies the associations between area-level education, as a proxy for socioeconomic status, and life expectancy and cause-specific mortality in Latin American cities. Methods We included 28 large cities, >137 million inhabitants, in nine Latin American countries, comprising 671 sub-city units, for 2012–2016. Socioeconomic status was assessed through a composite index of sub-city level education, and greenness was calculated using the normalized difference vegetation index. We fitted multilevel models with sub-city units nested in cities, with life expectancy or log(mortality) as the outcome. Findings We observed a social gradient, with higher levels of education associated with higher life expectancy and lower cause-specific mortality. There was weak evidence supporting the equigenesis hypothesis as greenness differentially modified the association between education and mortality outcomes. We observed an equigenic effect, with doubling magnitudes in the violence-related mortality reduction by education in areas with low greenness compared to medium-high greenness areas among men (16% [95% CI 12%–20%] vs 8% [95% CI 4%–11%] per 1 SD increase in area-level education). However, in contradiction to the equigenesis hypothesis, the magnitude in cardiovascular diseases (CVD) mortality reduction by education was stronger in areas with medium-high greenness compared to areas with low greenness (6% [95% CI 4%–7%] vs 1% [95% CI -1%–3%] and 5% [95% CI 3%–7%] vs 1% [95% CI -1%–3%] per 1 SD increase in area-level education, in women and men, respectively). Similarly, each 1-SD increase in greenness widened the educational inequality in life expectancy by 0.15 years and 0.20 years, in women and men, respectively. The equigenic effect was not observed in violence-related mortality among women and in mortality due to communicable diseases, maternal, neonatal and nutritional conditions (CMNN). Interpretation Our results confirm socioeconomic health inequalities in Latin American cities and show that the equigenic properties of greenspace vary by health outcome. Although mixed, our findings suggest that future greening policies should account for local social and economic conditions to ensure that greenspaces provide health benefits for all, and do not further exacerbate existing health inequalities in the region. Funding Wellcome Trust (Grant, 205177/Z/16/Z)., Highlights • This study is the first to examine the equigenesis hypothesis of greenspace in Latin America. • Higher education was associated with higher life-expectancy and lower cause-specific mortality. • Education disparities in violence-related mortality were narrower in greener areas. • Greener areas had wider education disparities in life-expectancy and CVD mortality.

Introduction: Lesions in the oral cavity, pharynx and larynx due to endotracheal intubation can cause reduction in the local motility and sensitivity, impairing the swallowing process, resulting in oropharyngeal dysphagia. Objective: To verify the predictive factors for the development of oropharyngeal dysphagia and the risk of aspiration in patients with prolonged orotracheal intubation admitted to an intensive care unit. Methods: This is an observational, analytical, cross-sectional and retrospective data collection study of 181 electronic medical records of patients submitted to prolonged orotracheal intubation. Data on age; gender; underlying disease; associated comorbidities; time and reason for orotracheal intubation; Glasgow scale on the day of the Speech Therapist assessment; comprehension; vocal quality; presence and severity of dysphagia; risk of bronchoaspiration; and the suggested oral route were collected. The data were analyzed through logistic regression. The level of significance was set at 5%, with a 95% Confidence Interval. Results: The prevalence of dysphagia in this study was 35.9% and the risk of aspiration was 24.9%. As the age increased, the altered vocal quality and the degree of voice impairment increased the risk of the presence of dysphagia by 5-; 45.4- and 6.7-fold, respectively, and of aspiration by 6-; 36.4- and 4.8-fold. The increase in the time of orotracheal intubation increased the risk of aspiration by 5.5-fold. Conclusion: Patients submitted to prolonged intubation who have risk factors associated with dysphagia and aspiration should be submitted to an early speech-language/audiology assessment and receive appropriate and timely treatment. The recognition of these predictive factors by the entire multidisciplinary team can minimize the possibility of clinical complications inherent to the risk of dysphagia and aspiration in extubated patients. Resumo: Introdução: Lesões na cavidade oral, faringe e laringe, em virtude de intubação endotraqueal, podem causar redução da motricidade e da sensibilidade local e comprometer o processo da deglutição, determinando disfagia orofaríngea. Objetivo: Verificar os fatores preditivos do desenvolvimento de disfagia orofaríngea e risco de aspiração em pacientes pós-intubação orotraqueal prolongada internados em uma unidade de terapia intensiva. Método: Estudo observacional, analítico, de delineamento transversal e retrospectivo de coleta de dados de 181 prontuários eletrônicos, de pacientes submetidos à intubação orotraqueal prolongada. Foram coletadas informações referentes a idade; sexo; doença de base, comorbidades associadas; tempo e motivo da intubação orotraqueal; Escala Glasgow no dia da avaliação fonoaudiológica; compreensão; qualidade vocal; presença de disfagia e a gravidade; risco de broncoaspiração; e via oral sugerida. Os dados foram analisados por meio da regressão logística. Adotou-se o nível de significância de 5% e intervalo de confiança de 95%. Resultados: A prevalência de disfagia neste estudo foi de 35,9% e de risco de aspiração de 24,9%. O aumento da idade, a qualidade vocal alterada e o grau de comprometimento da voz elevam os riscos de presença em disfagia em 5; 45,4 e 6,7 vezes, respectivamente, e de aspiração em 6; 36,4 e 4,8 vezes. Já o aumento do tempo de intubação orotraqueal elevou em 5,5 vezes o risco de aspiração. Conclusão: Pacientes submetidos a intubação prolongada que apresentam os fatores de risco relacionados às disfagia e aspiração devem ser submetidos a avaliação fonoaudiológica precoce e receber conduta adequada em tempo hábil. O reconhecimento desses fatores preditivos por toda a equipe multidisciplinar pode minimizar as possibilidades de complicações clínicas inerentes ao risco de disfagia e aspiração em pacientes extubados. Keywords: Swallowing disorders, Intratracheal intubation, Intensive care units, Dysphonia, Palavras-chave: Transtornos de deglutição, Intubação intratraqueal, Unidades de terapia intensiva, Disfonia

Background: Women’s Empowerment (WE) has been shown to reduce infant mortality rates (IMR) in high-income countries. However, the role of WE in affecting IMR across growing cities of the global South has not been documented. Objectives: To examine whether WE is associated with differences in IMR across Latin American cities Methods: We estimated IMR for the period 2014-2016 using vital registration and demographic methods for 286 cities with population over 100,000 in 8 countries. We calculated socioeconomic (SE) and WE indicators from national census. We combined SE indicators into factors reflecting living conditions, and service provision. WE was measured using two indicators: women’s labor force participation (WLFP) and education attainment among women. We included a scale of country’s enforcements of laws (CEL) related to women’s rights. Using Poisson multilevel regression, we estimated the percentage difference in IMR associated with one standard deviation (1SD) higher WE scores, adjusted for SE characteristics of cities. Results: Overall IMR was 11.2 deaths per 1,000 live births. A 1SD higher score for WLFP was associated with 6.1% (95%CI -11.1; -0.8) lower IMR, after accounting for SE indicators. A higher CEL was associated with a lower IMR. Education attainment among women was inversely associated with IMR only in countries with low GDP per capita. Interpretation: Strategies that promote participation of women in labor market may have a positive impact in reducing IMR in Latin American cities. Women’s educational attainment is still relevant for reducing IMR in cities from countries with lower economic development. Funding Statement: Wellcome Trust Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Not required.

Background Highly urbanised and rapidly urbanising countries are facing critical air pollution problems. In Latin American cities, the effect of ambient PM2·5 on child health has not been extensively explored. We examined associations between ambient PM2·5 and under-5 mortality (deaths in those younger than 5 years per 1000 livebirths) infant mortality (deaths in those younger than 1 year per 1000 livebirths), and child mortality (deaths in those aged 1–4 years per 10 000 children) in Latin American cities. Methods In this longitudinal analysis, we estimated under-5 mortality, infant mortality, and child mortality for the period Jan 1, 2010, to dec 12, 2015, for 1152 subcity units clustered in 337 cities in Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, and Mexico. We retrieved mean annual PM2·5 for each subcity unit. Using linear mixed-effects models, we estimated the percentage change in under-5 mortality, infant mortality, and child mortality associated with a 1 μg/m3 increase in annual PM2·5, adjusted for city-level and subcity-level predictors (population growth, gross domestic product, living conditions, water and sanitation provision, population education, and mass transit availability). Findings Over the study period, mean annual PM2·5 was 12·7 μg/m3 (SD 6·3), under-5 mortality was 14·2 deaths per 1000 livebirths, infant mortality was 12·1 deaths per 1000 livebirths, and child mortality was 4·8 deaths per 10 000 children. A 1 μg/m3 annual increase in PM2·5 was associated with 0·4% (95% CI 0·1 to 0·7) increase in under-5 mortality and 0·5% (95% CI 0·2 to 0·9) increase in infant mortality We found no significant association between PM2·5 increases and changes in child mortality (–0·1% [95% CI −0·8 to 0·6]). Interpretation Our findings support the need for environmental protection in the Latin American region for improving both planetary and population health. Transdisciplinary strategies at local levels, including public health practitioners and policy stakeholders involved in urban development, are key for implementing these changes. Funding The Wellcome Trust initiative Our Planet, Our Health.

Introduction The Life in Traffic Program (LTP) was launched in Brazil in 2010, aiming to promote road safety interventions capable of reducing deaths and serious injuries resulting from traffic collisions. The LTP methodology was based on four steps: intersectoral articulation, data qualification and integration, integrated actions of road safety, and monitoring of actions. Objective To determine the degree of implementation of the program in 31 Brazilian municipalities. Method Formal and normative evaluations were adopted, in two phases. In the first one, the content of 28 indicators uniquely developed to evaluate the LTP implementation was verified by a panel of experts composed of 29 program coordinators in the Brazilian municipalities. A Likert scale was used, followed by a comparison of the interquartile range (IQR). In the second phase, the degree of implementation was evaluated based on baseline and follow-up interview applied in 2015 and 2017, defined through a system of scores, with weights differentiated for each indicator, according to the level of importance assigned by the experts, thus constituting the matrix of analysis and judgment. Results Thirty municipalities participated in the 2015 evaluation and 26, in 2017. The indicators of implementation achieved high degree of consensus among the experts, suggesting adequacy of the instrument. Regarding the implementation, the LTP was partially or totally implemented in 84.6% of the 31 Brazilian municipalities. Municipalities in the North region (71.8%) had the highest degree of implementation, followed by South (71.2%), Central West (68.5%), Northeast (62.4%), and Southeast (58.8%). Monitoring of actions implemented was the LTP methodology step with the lowest performance detected among them. Conclusions Despite advances in the program implementation, this process did not occur in an equitable way among the municipalities, indicating the need to prioritize the monitoring of actions.

Objective. This study identified environmental variables associated with obesity in the adult population of a city in Brazil. Methods. It was conducted using the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey from 2008 to 2010. The body mass index (BMI) was calculated from the participants' self-reported weight and height. Obesity was defined as a BMI ≥ 30 kg/m2. The food establishments, georeferenced areas conducive to physical activity, total income of the neighbourhood, homicide rate and population density were used to characterise the environment. In addition, individual variables were considered. A multilevel logistic regression was performed. Results. A total of 5273 individuals were evaluated. The odds of obesity was found to be significantly decreased with increases in the number of establishments that sell healthy food, number of restaurants, number of places for physical activity and total income — in different models. In addition, these associations remained significant after adjustment for age, gender, education and consumption of meat with visible fat. Conclusions. This study contributes to a better understanding of the complex interaction between environmental and individual determinants of obesity and may aid in the development of effective interventions, such as the expansion of obesity control programmes., Highlights • We estimated the association of environmental and individual factors with obesity. • The likelihood of obesity decreased with increases of environmental factors. • There is a complex interaction between environmental determinants of obesity. • Our findings provide justification for the development of effective strategies.