Stigma toward schizophrenia: do all psychiatrists behave the same? Latent profile analysis of a national sample of psychiatrists in Brazil

Background: An important issue concerning the worldwide fight against stigma is the evaluation of psychiatrists’ beliefs and attitudes toward schizophrenia and mental illness in general. However, there is as yet no consensus on this matter in the literature, and results vary according to the stigma dimension assessed and to the cultural background of the sample. The aim of this investigation was to search for profiles of stigmatizing beliefs related to schizophrenia in a national sample of psychiatrists in Brazil. Methods: A sample of 1414 psychiatrists were recruited from among those attending the 2009 Brazilian Congress of Psychiatry. A questionnaire was applied in face-to-face interviews. The questionnaire addressed four stigma dimensions, all in reference to individuals with schizophrenia: stereotypes, restrictions, perceived prejudice and social distance. Stigma item scores were included in latent profile analyses; the resulting profiles were entered into multinomial logistic regression models with sociodemographics, in order to identify significant correlates. Results: Three profiles were identified. The “no stigma” subjects (n = 337) characterized individuals with schizophrenia in a positive light, disagreed with restrictions, and displayed a low level of social distance. The “unobtrusive stigma” subjects (n = 471) were significantly younger and displayed the lowest level of social distance, although most of them agreed with involuntary admission and demonstrated a high level of perceived prejudice. The “great stigma” subjects (n = 606) negatively stereotyped individuals with schizophrenia, agreed with restrictions and scored the highest on the perceived prejudice and social distance dimensions. In comparison with the first two profiles, this last profile comprised a significantly larger number of individuals who were in frequent contact with a family member suffering from a psychiatric disorder, as well as comprising more individuals who had no such family member. Conclusions: Our study not only provides additional data related to an under-researched area but also reveals that psychiatrists are a heterogeneous group regarding stigma toward schizophrenia. The presence of different stigma profiles should be evaluated in further studies; this could enable anti-stigma initiatives to be specifically designed to effectively target the stigmatizing group.

The double task of preventing malnutrition and overweight: a quasi-experimental community-based trial

Background: The Maternal-Child Pastoral is a volunteer-based community organization of the Dominican Republic that works with families to improve child survival and development. A program that promotes key practices of maternal and child care through meetings with pregnant women and home visits to promote child growth and development was designed and implemented. This study aims to evaluate the impact of the program on nutritional status indicators of children in the first two years of age. Methods: A quasi-experimental design was used, with groups paired according to a socioeconomic index, comparing eight geographical areas of intervention with eight control areas. The intervention was carried out by lay health volunteers. Mothers in the intervention areas received home visits each month and participated in a group activity held biweekly during pregnancy and monthly after birth. The primary outcomes were length and body mass index for age. Statistical analyses were based on linear and logistic regression models. Results: 196 children in the intervention group and 263 in the control group were evaluated. The intervention did not show statistically significant effects on length, but point estimates found were in the desired direction: mean difference 0.21 (95%CI −0.02; 0.44) for length-for-age Z-score and OR 0.50 (95%CI 0.22; 1.10) for stunting. Significant reductions of BMI-for-age Z-score (−0.31, 95%CI −0.49; -0.12) and of BMI-for-age > 85th percentile (0.43, 95%CI 0.23; 0.77) were observed. The intervention showed positive effects in some indicators of intermediary factors such as growth monitoring, health promotion activities, micronutrient supplementation, exclusive breastfeeding and complementary feeding. Conclusions: Despite finding effect measures pointing to effects in the desired direction related to malnutrition, we could only detect a reduction in the risk of overweight attributable to the intervention. The findings related to obesity prevention may be of interest in the context of the nutritional transition. Given the size of this study, the results are encouraging and we believe a larger study is warranted.

Assessing malaria transmission in a low endemicity area of north-western Peru

Background Where malaria endemicity is low, control programmes need increasingly sensitive tools for monitoring malaria transmission intensity (MTI) and to better define health priorities. A cross-sectional survey was conducted in a low endemicity area of the Peruvian north-western coast to assess the MTI using both molecular and serological tools. Methods Epidemiological, parasitological and serological data were collected from 2,667 individuals in three settlements of Bellavista district, in May 2010. Parasite infection was detected using microscopy and polymerase chain reaction (PCR). Antibodies to Plasmodium vivax merozoite surface protein-119 (PvMSP119) and to Plasmodium falciparum glutamate-rich protein (PfGLURP) were detected by ELISA. Risk factors for exposure to malaria (seropositivity) were assessed by multivariate survey logistic regression models. Age-specific antibody prevalence of both P. falciparum and P. vivax were analysed using a previously published catalytic conversion model based on maximum likelihood for generating seroconversion rates (SCR). Results The overall parasite prevalence by microscopy and PCR were extremely low: 0.3 and 0.9%, respectively for P. vivax, and 0 and 0.04%, respectively for P. falciparum, while seroprevalence was much higher, 13.6% for P. vivax and 9.8% for P. falciparum. Settlement, age and occupation as moto-taxi driver during previous year were significantly associated with P. falciparum exposure, while age and distance to the water drain were associated with P. vivax exposure. Likelihood ratio tests supported age seroprevalence curves with two SCR for both P. vivax and P. falciparum indicating significant changes in the MTI over time. The SCR for PfGLURP was 19-fold lower after 2002 as compared to before (λ1 = 0.022 versus λ2 = 0.431), and the SCR for PvMSP119 was four-fold higher after 2006 as compared to before (λ1 = 0.024 versus λ2 = 0.006). Conclusion Combining molecular and serological tools considerably enhanced the capacity of detecting current and past exposure to malaria infections and related risks factors in this very low endemicity area. This allowed for an improved characterization of the current human reservoir of infections, largely hidden and heterogeneous, as well as providing insights into recent changes in species specific MTIs. This approach will be of key importance for evaluating and monitoring future malaria elimination strategies.

Different approaches for dealing with rare variants in family-based genetic studies: application of a Genetic Analysis Workshop 17 problem

Rare variants are becoming the new candidates in the search for genetic variants that predispose individuals to a phenotype of interest. Their low prevalence in a population requires the development of dedicated detection and analytical methods. A family-based approach could greatly enhance their detection and interpretation because rare variants are nearly family specific. In this report, we test several distinct approaches for analyzing the information provided by rare and common variants and how they can be effectively used to pinpoint putative candidate genes for follow-up studies. The analyses were performed on the mini-exome data set provided by Genetic Analysis Workshop 17. Eight approaches were tested, four using the trait’s heritability estimates and four using QTDT models. These methods had their sensitivity, specificity, and positive and negative predictive values compared in light of the simulation parameters. Our results highlight important limitations of current methods to deal with rare and common variants, all methods presented a reduced specificity and, consequently, prone to false positive associations. Methods analyzing common variants information showed an enhanced sensibility when compared to rare variants methods. Furthermore, our limited knowledge of the use of biological databases for gene annotations, possibly for use as covariates in regression models, imposes a barrier to further research.

Densidade energética da dieta e fatores associados: como está a população de São Paulo?

OBJETIVO: Avaliar a densidade energética da dieta de adultos do município de São Paulo e fatores associados. SUJEITOS E MÉTODOS: Participantes do estudo ISA-Capital, com amostragem probabilística (n = 710 adultos). O consumo alimentar foi avaliado pelo R24h. As correlações foram investigadas pelo coeficiente de correlação de Pearson. As associações com dados demográficos, socioeconômicos e de estilo de vida foram investigadas por modelos de regressão multivariados. RESULTADOS: A densidade energética média foi 1,98 kcal/g (IC95% [1,94; 2,01]) e correlacionou-se positivamente com a ingestão de energia, gordura, carboidrato, colesterol, gordura saturada, sacarose, gordura trans e açúcar adicionado e negativamente com fibras. Apenas idade e hábito de fumar apresentaram associação com a densidade energética. CONCLUSÕES: Os valores elevados da densidade energética da dieta e a relação demonstrada com outros constituintes nutricionais denotam má qualidade da dieta nessa população, o que pode estar contribuindo para crescentes taxas de excesso de peso. Arq Bras Endocrinol Metab. 2012;56(9):638-45

Impact of urban atmospheric environment on hospital admissions in the elderly

OBJECTIVE: To analyze the impact of intra-urban atmospheric conditions on circulatory and respiratory diseases in elder adults. METHODS: Cross-sectional study based on data from 33,212 hospital admissions in adults over 60 years in the city of São Paulo, southeastern Brazil, from 2003 to 2007. The association between atmospheric variables from Congonhas airport and bioclimatic index, Physiological Equivalent Temperature, was analyzed according to the district's socioenvironmental profile. Descriptive statistical analysis and regression models were used. RESULTS: There was an increase in hospital admissions due to circulatory diseases as average and lowest temperatures decreased. The likelihood of being admitted to the hospital increased by 12% with 1ºC decrease in the bioclimatic index and with 1ºC increase in the highest temperatures in the group with lower socioenvironmental conditions. The risk of admission due to respiratory diseases increased with inadequate air quality in districts with higher socioenvironmental conditions. CONCLUSIONS: The associations between morbidity and climate variables and the comfort index varied in different groups and diseases. Lower and higher temperatures increased the risk of hospital admission in the elderly. Districts with lower socioenvironmental conditions showed greater adverse health impacts.

Growth of the crabgrass species Digitaria ciliaris and Digitaria nuda

The aim of this research paper was to compare the growth of D. ciliaris and D. nuda crabgrass species under non-competitive conditions. To this end, two experiments were conducted, one from March - July 2010 and the other from February - June 2011. The experimental design of both trials was completely randomized making a factorial (2 seasons x 2 species crabgrass x 12 evaluation periods) with four replications. Assessments began at 15 days after sowing (DAS), and repeated weekly until 92 DAS. The variables evaluated were total dry matter (roots+leaves+stems), leaf area, leaf number and tiller. The results were submitted to analysis of variance and the absolute growth rate, relative growth rate and leaf area ratio were calculated using the means, which were adjusted regression models. The crabgrass species were significantly different in leaf area, leaf number, tiller number and dry matter per plant. D. ciliaris for all variables was statistically higher than D. nuda. Regarding the speed at which the growth of the species occurred, the absolute growth rate and relative growth rate of D. ciliaris was also greater than D. nuda. In addition, D. ciliaris also had a lower leaf area ratio indicating greater efficiency in converting light energy into carbohydrates. It can be concluded that D. ciliaris has a higher growth rate in conditions where there is no limitation of nutrients and water availability in relation to D. nuda, mainly due to D. ciliaris have greater leaf area, number of leaves and dry matter accumulation per plant.

Are prescribing doctors sensitive to the price that their patients have to pay in the Spanish National Health System?

[EN] Background This study aims to design an empirical test on the sensitivity of the prescribing doctors to the price afforded for the patient, and to apply it to the population data of primary care dispensations for cardiovascular disease and mental illness in the Spanish National Health System (NHS). Implications for drug policies are discussed. Methods We used population data of 17 therapeutic groups of cardiovascular and mental illness drugs aggregated by health areas to obtain 1424 observations ((8 cardiovascular groups * 70 areas) + (9 psychotropics groups * 96 areas)). All drugs are free for pensioners. For non-pensioner patients 10 of the 17 therapeutic groups have a reduced copayment (RC) status of only 10% of the price with a ceiling of €2.64 per pack, while the remaining 7 groups have a full copayment (FC) rate of 40%. Differences in the average price among dispensations for pensioners and non-pensioners were modelled with multilevel regression models to test the following hypothesis: 1) in FC drugs there is a significant positive difference between the average prices of drugs prescribed to pensioners and non-pensioners; 2) in RC drugs there is no significant price differential between pensioner and non-pensioner patients; 3) the price differential of FC drugs prescribed to pensioners and non-pensioners is greater the higher the price of the drugs. Results The average monthly price of dispensations to pensioners and non-pensioners does not differ for RC drugs, but for FC drugs pensioners get more expensive dispensations than non-pensioners (estimated difference of €9.74 by DDD and month). There is a positive and significant effect of the drug price on the differential price between pensioners and non-pensioners. For FC drugs, each additional euro of the drug price increases the differential by nearly half a euro (0.492). We did not find any significant differences in the intensity of the price effect among FC therapeutic groups. Conclusions Doctors working in the Spanish NHS seem to be sensitive to the price that can be afforded by patients when they fill in prescriptions, although alternative hypothesis could also explain the results found.

Relationship between body image disturbance and incidence of depression: the SUN prospective cohort

[EN] Background: Body image disturbance is an increasing problem in Western societies and is associated with a number of mental health outcomes including anorexia, bulimia, body dysmorphia, and depression. The aim of this study was to assess the association between body image disturbance and the incidence of depression. Methods: This study included 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for a median period of 4.2 years (Seguimiento Universidad de Navarra – the SUN study). The key characteristic of the study is the permanently open recruitment that started in 1999. The baseline questionnaire included information about body mass index (BMI) and the nine figure schemes that were used to assess body size perception. These variables were grouped according to recommended classifications and the difference between BMI and body size perception was considered as a proxy of body image disturbance. A subject was classified as an incident case of depression if he/she was initially free of depression and reported a physician-made diagnosis of depression and/or the use of antidepressant medication in at least one of the follow-up questionnaires. The association between body image disturbance and the incidence of depression was estimated by calculating the multivariable adjusted Odds Ratio (OR) and its 95% Confidence Interval (95% CI), using logistic regression models. Results: The cumulative incidence of depression during follow-up in the cohort was 4.8%. Men who underestimated their body size had a high percentage of overweight and obesity (50.1% and 12.6%, respectively), whereas women who overestimated their body size had a high percentage of underweight (87.6%). The underestimation exhibited a negative association with the incidence of depression among women (OR: 0.72, 95% CI: 0.54 – 0.95), but this effect disappeared after adjusting for possible confounding variables. The proportion of participants who correctly perceived their body size was high (53.3%) and gross misperception was seldom found, with most cases selecting only one silhouette below (42.7%) or above (2.6%) their actual BMI. Conclusion: We found no association between body image disturbance and subsequent depression in a cohort of university graduates in Spain.

Constraints on mantle melting from major and trace element systematics in residual abyssal peridotites

ZusammenfassungDie Bildung von mittelozeanischen Rückenbasalten (MORB) ist einer der wichtigsten Stoffflüsse der Erde. Jährlich wird entlang der 75.000 km langen mittelozeanischen Rücken mehr als 20 km3 neue magmatische Kruste gebildet, das sind etwa 90 Prozent der globalen Magmenproduktion. Obwohl ozeanische Rücken und MORB zu den am meisten untersuchten geologischen Themenbereichen gehören, existieren weiterhin einige Streit-fragen. Zu den wichtigsten zählt die Rolle von geodynamischen Rahmenbedingungen, wie etwa Divergenzrate oder die Nähe zu Hotspots oder Transformstörungen, sowie der absolute Aufschmelzgrad, oder die Tiefe, in der die Aufschmelzung unter den Rücken beginnt. Diese Dissertation widmet sich diesen Themen auf der Basis von Haupt- und Spurenelementzusammensetzungen in Mineralen ozeanischer Mantelgesteine.Geochemische Charakteristika von MORB deuten darauf hin, dass der ozeanische Mantel im Stabilitätsfeld von Granatperidotit zu schmelzen beginnt. Neuere Experimente zeigen jedoch, dass die schweren Seltenerdelemente (SEE) kompatibel im Klinopyroxen (Cpx) sind. Aufgrund dieser granatähnlichen Eigenschaft von Cpx wird Granat nicht mehr zur Erklärung der MORB Daten benötigt, wodurch sich der Beginn der Aufschmelzung zu geringeren Drucken verschiebt. Aus diesem Grund ist es wichtig zu überprüfen, ob diese Hypothese mit Daten von abyssalen Peridotiten in Einklang zu bringen ist. Diese am Ozeanboden aufgeschlossenen Mantelfragmente stellen die Residuen des Aufschmelz-prozesses dar, und ihr Mineralchemismus enthält Information über die Bildungs-bedingungen der Magmen. Haupt- und Spurenelementzusammensetzungen von Peridotit-proben des Zentralindischen Rückens (CIR) wurden mit Mikrosonde und Ionensonde bestimmt, und mit veröffentlichten Daten verglichen. Cpx der CIR Peridotite weisen niedrige Verhältnisse von mittleren zu schweren SEE und hohe absolute Konzentrationen der schweren SEE auf. Aufschmelzmodelle eines Spinellperidotits unter Anwendung von üblichen, inkompatiblen Verteilungskoeffizienten (Kd's) können die gemessenen Fraktionierungen von mittleren zu schweren SEE nicht reproduzieren. Die Anwendung der neuen Kd's, die kompatibles Verhalten der schweren SEE im Cpx vorhersagen, ergibt zwar bessere Resultate, kann jedoch nicht die am stärksten fraktionierten Proben erklären. Darüber hinaus werden sehr hohe Aufschmelzgrade benötigt, was nicht mit Hauptelementdaten in Einklang zu bringen ist. Niedrige (~3-5%) Aufschmelzgrade im Stabilitätsfeld von Granatperidotit, gefolgt von weiterer Aufschmelzung von Spinellperidotit kann jedoch die Beobachtungen weitgehend erklären. Aus diesem Grund muss Granat weiterhin als wichtige Phase bei der Genese von MORB betrachtet werden (Kapitel 1).Eine weitere Hürde zum quantitativen Verständnis von Aufschmelzprozessen unter mittelozeanischen Rücken ist die fehlende Korrelation zwischen Haupt- und Spuren-elementen in residuellen abyssalen Peridotiten. Das Cr/(Cr+Al) Verhältnis (Cr#) in Spinell wird im Allgemeinen als guter qualitativer Indikator für den Aufschmelzgrad betrachtet. Die Mineralchemie der CIR Peridotite und publizierte Daten von anderen abyssalen Peridotiten zeigen, dass die schweren SEE sehr gut (r2 ~ 0.9) mit Cr# der koexistierenden Spinelle korreliert. Die Auswertung dieser Korrelation ergibt einen quantitativen Aufschmelz-indikator für Residuen, welcher auf dem Spinellchemismus basiert. Damit kann der Schmelzgrad als Funktion von Cr# in Spinell ausgedrückt werden: F = 0.10×ln(Cr#) + 0.24 (Hellebrand et al., Nature, in review; Kapitel 2). Die Anwendung dieses Indikators auf Mantelproben, für die keine Ionensondendaten verfügbar sind, ermöglicht es, geochemische und geophysikalischen Daten zu verbinden. Aus geodynamischer Perspektive ist der Gakkel Rücken im Arktischen Ozean von großer Bedeutung für das Verständnis von Aufschmelzprozessen, da er weltweit die niedrigste Divergenzrate aufweist und große Transformstörungen fehlen. Publizierte Basaltdaten deuten auf einen extrem niedrigen Aufschmelzgrad hin, was mit globalen Korrelationen im Einklang steht. Stark alterierte Mantelperidotite einer Lokalität entlang des kaum beprobten Gakkel Rückens wurden deshalb auf Primärminerale untersucht. Nur in einer Probe sind oxidierte Spinellpseudomorphosen mit Spuren primärer Spinelle erhalten geblieben. Ihre Cr# ist signifikant höher als die einiger Peridotite von schneller divergierenden Rücken und ihr Schmelzgrad ist damit höher als aufgrund der Basaltzusammensetzungen vermutet. Der unter Anwendung des oben erwähnten Indikators ermittelte Schmelzgrad ermöglicht die Berechnung der Krustenmächtigkeit am Gakkel Rücken. Diese ist wesentlich größer als die aus Schweredaten ermittelte Mächtigkeit, oder die aus der globalen Korrelation zwischen Divergenzrate und mittels Seismik erhaltene Krustendicke. Dieses unerwartete Ergebnis kann möglicherweise auf kompositionelle Heterogenitäten bei niedrigen Schmelzgraden, oder auf eine insgesamt größere Verarmung des Mantels unter dem Gakkel Rücken zurückgeführt werden (Hellebrand et al., Chem.Geol., in review; Kapitel 3).Zusätzliche Informationen zur Modellierung und Analytik sind im Anhang A-C aufgeführt

Informationsgehalt von ERS-1/-2 SAR-Daten zur Erfassung der Arteninventare und des Zustandes landwirtschaftlich genutzter Böden und Vegetation

Auf einer drei Anbauperioden umfassenden Ground Truth Datenbasis wird der Informationsgehalt multitemporaler ERS-1/-2 Synthetic Aperture Radar (SAR) Daten zur Erfassung der Arteninventare und des Zustandes landwirtschaftlich genutzter Böden und Vegetation in Agrarregionen Bayerns evaluiert.Dazu wird ein für Radardaten angepaßtes, multitemporales, auf landwirtschaftlichen Schlägen beruhendes Klassifizierungsverfahren ausgearbeitet, das auf bildstatistischen Parametern der ERS-Zeitreihen beruht. Als überwachte Klassifizierungsverfahren wird vergleichend der Maximum-Likelihood-Klassifikator und ein Neuronales-Backpropagation-Netz eingesetzt. Die auf Radarbildkanälen beruhenden Gesamtgenauigkeiten variieren zwischen 75 und 85%. Darüber hinaus wird gezeigt, daß die interferometrische Kohärenz und die Kombination mit Bildkanälen optischer Sensoren (Landsat-TM, SPOT-PAN und IRS-1C-PAN) zur Verbesserung der Klassifizierung beitragen. Gleichermaßen können die Klassifizierungsergebnisse durch eine vorgeschaltete Grobsegmentierung des Untersuchungsgebietes in naturräumlich homogene Raumeinheiten verbessert werden. Über die Landnutzungsklassifizierung hinaus, werden weitere bio- und bodenphysikalische Parameter aus den SAR-Daten anhand von Regressionsmodellen abgeleitet. Im Mittelpunkt stehen die Paramter oberflächennahen Bodenfeuchte vegetationsfreier/-armer Flächen sowie die Biomasse landwirtschaftlicher Kulturen. Die Ergebnisse zeigen, daß mit ERS-1/-2 SAR-Daten eine Messung der Bodenfeuchte möglich ist, wenn Informationen zur Bodenrauhigkeit vorliegen. Hinsichtlich der biophysikalischen Parameter sind signifikante Zusammenhänge zwischen der Frisch- bzw. Trockenmasse des Vegetationsbestandes verschiedener Getreide und dem Radarsignal nachweisbar. Die Biomasse-Informationen können zur Korrektur von Wachstumsmodellen genutzt werden und dazu beitragen, die Genauigkeit von Ertragsschätzungen zu steigern.

Effetti idrodinamici prodotti dal costume tecnico sul nuotatore

L’introduzione dei costumi tecnici nel nuoto ha portato miglioramenti senza precedenti sulla prestazione. I miglioramenti nella velocità di nuoto sono stati attribuiti dalla letteratura a riduzioni nelle resistenze idrodinamiche sul nuotatore. Tuttavia, gli effetti specifici dovuti all’utilizzo di questo tipo di costume non sono ancora completamente chiariti. Questa tesi aveva l’obiettivo di indagare gli effetti del costume tecnico sul galleggiamento statico, sulla posizione del corpo e sulla resistenza idrodinamica in avanzamento passivo. Nello studio preliminare sono stati misurati la spinta idrostatica, i volumi polmonari dinamici e la circonferenza toracica di 9 nuotatori che indossavano un costume tradizionale o un costume tecnico in gomma sintetica. Indossare il costume tecnico ha determinato una riduzione significativa del galleggiamento statico, e la compressione toracica causata da questo tipo di costume potrebbe avere una relazione con la significativa riduzione dei volumi polmonari misurati quando il nuotatore indossa questo tipo di costume. Un successiva analisi prevedeva il traino passivo di 14 nuotatori che mantenevano la miglior posizione idrodinamica di scivolamento indossando un costume tradizionale, tecnico in tessuto e tecnico in gomma. La posizione del corpo in avanzamento è stata misurata con un’analisi cinematica. La resistenza passiva indossando i costumi tecnici è risultata significativamente minore per entrambi i costumi tecnici rispetto alla prova con costume tradizionale. L’analisi condotta attraverso modelli di regressione lineari ha mostrato che una parte della riduzione della resistenza passiva era legata a proprietà intrinseche dei costumi tecnici. Tuttavia, anche l’area di impatto frontale determinata dall’inclinazione del tronco del soggetto in scivolamento e l’inclinazione degli arti inferiori hanno mostrato una marcata influenza sulla resistenza idrodinamica passiva. Pertanto, la riduzione di resistenza idrodinamica durante lo scivolamento passivo effettuato con costume tecnico da nuoto è attribuibile, oltre all’effetto del materiale di composizione del costume, ad una variazione della posizione del corpo del nuotatore.

Determinants of cesarean delivery, a population-based study in the Emilia Romagna Region

Cesarean Delivery (CD) rates are rising in many parts of the world. In order to define strategies to reduce them, it is important to explore the role of clinical and organizational factors. This thesis has the objective to describe the contemporary CD practice and study clinical and organizational variables as determinants of CD in all women who gave birth between 2005 and June 2010 in the Emilia Romagna region (Italy). All hospital discharge abstracts of women who delivered between 2005 and mid 2010 in the region were selected and linked with birth certificates. In addition to descriptive statistics, in order to study the role of clinical and organizational variables (teaching or non-teaching hospital, birth volumes, time and day of delivery) multilevel Poisson regression models and a classification tree were used. A substantial inter-hospital variability in CD rate was found, and this was only partially explained by the considered variables. The most important risk factors of CD were: previous CD (RR 4,95; 95%CI: 4,85-5,05), cord prolapse (RR 3,51; 95% CI:2,96-4,16), and malposition/malpresentation (RR 2,72; 95%CI: 2,66-2,77). Delivery between 7 pm and 7 am and during non working days protect against CD in all subgroups including those with a small number of elective CDs while delivery at a teaching hospital and birth volumes were not statistically significant risk factors. The classification tree shows that previous CD and malposition/malpresentation are the most important variables discriminating between high and low risk of CD. These results indicate that other not considered factors might explain CD variability and do not provide clear evidence that small hospitals have a poor performance in terms of CD rate. Some strategies to reduce CD could be found by focusing on the differences in delivery practice between day and night and between working and no-working day deliveries.