Partial contributions and temporal trends of leading causes of death during the last four decades in Spain.

OBJECTIVES: The study was conducted to assess time trend shifts of leading causes of death and their partial contributions over the years 1975-2016 in Spain. STUDY DESIGN: A longitudinal ecological epidemiologic design was conducted to analyse linear trend period shifts using joinpoint regression as the annual percentage of change (APC) in the period 1975-2016. The partial contributions were illustrated as the rate ratio of a singular-cause to their major-cause shift periods. RESULTS: HIV/AIDS shaped the increasing trend period of infectious diseases in 1989-1995 (APC = 25.3, P < 0.05) and the decreasing trend in 1995-1999 and 1999-2016. Lung cancer fell gradually from 1994 in men (-0.4, P < 0.05); however, in women, the condition continued increasing from 1990 (P < 0.05). Dementia types influenced mental and neurological disease drifts. The recent trend for circulatory periods (1980-2016) was mainly modulated by cardiac ischaemia, with increased partial contributions (25%, 32% and 30%). Traffic accidents defined the descending tendency of external causes. CONCLUSIONS: Spain showed a Western pattern in descended rates, including non-decreasing trends in mental and neurological diseases, pancreatic cancer, drug abuse and suicide. Trend shifts and partial contributions illustrated targets for further mortality reduction.

Do social inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring of diabetes? A systematic review.

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.

Vacuna contra el virus del papiloma humano: reflexiones acerca del proceso de difusión, la evidencia científica y las incertidumbres / No disponible

No disponible

Cancer surveillance based on imaging techniques in carriers of BRCA1/2 gene mutations: a systematic review.

We have systematically reviewed the literature focusing on the performance of surveillance programmes and imaging techniques for the early diagnosis of breast and ovarian cancer in women carrying mutations in BRCA1/2 genes. A search for relevant articles published between 1996 and 2005 (inclusive) was run on Medline, Embase and other databases. Of the 749 articles retrieved, only 13 met the inclusion criteria. Of these, 12 provided information on breast cancer surveillance, 1 on ovarian cancer surveillance and a further study addressed both cancer types. A critical appraisal of the studies was performed using a tool for the quality assessment of diagnostic accuracy studies (QUADAS). The synthesis of results is qualitative. All studies on imaging techniques for the diagnosis of breast cancer indicated that screening MRI had the highest sensitivity (between 77% and 100%). Breast cancer surveillance programmes, including MRI, achieved the highest diagnostic performance (between 83% and 95%) for all women. However, it must be taken into account that biases that may affect the validity of the outcomes were seen in the evaluated studies. Also, MRI is an expensive test with a low positive predictive value and, to date, MRI screening has not been proven to reduce mortality rates in women carrying BRCA1/2 gene mutations. As a result of the scant information and low quality of the papers reviewed, no definitive conclusion could be drawn on the performance of ovarian cancer surveillance in women carrying BRCA1/2 mutations.

[Applications of proteomic techniques in clinical practice: present situation and perspectives]. / Aplicaciones de las técnicas proteómicas en medicina asistencial: situación actual y perspectivas.

Study of the human proteome has given rise to the appearance of abundant and increasing scientific literature. This has resulted in the proposal to use proteomic techniques in the management of some diseases and the suggestion of its future use in clinical laboratories. In order to identify which proteomic techniques are being used or may be used in the near future in the clinical practice, a survey was made to experts in proteomics and the bibliometric study was done. Concordance between this study and a survey was observed. However, in general, standardized uses of proteomic techniques in the current clinical practice were not found. In regards to possible applications in the short-middle term, the experts have different opinions, from those who mention specific techniques (coinciding with the most repeated aspects of the bibliometric study) to those who think that its use in a near future is unlikely.

Aplicaciones de las técnicas proteómicas en medicina asistencial: situación actual y perspectivas / Applications of proteomic techniques in clinical practice: present situation and perspectives

El estudio del proteoma humano ha dado lugar a la aparición de abundante y creciente literatura, llegándose a plantear el uso de técnicas proteómicas en el manejo de algunas enfermedades y sugiriéndose su futura utilización en laboratorios clínicos. A fin de identificar técnicas proteómicas en uso o de previsible uso próximo en medicina asistencial, se realizó una encuesta a expertos en el ámbito de la proteómica y un estudio bibliométrico. Se observó concordancia entre dicho estudio y la encuesta: no se hallaron, en general, usos estandarizados de la proteómica en medicina asistencial. En cuanto a posibles aplicaciones a corto-medio plazo hay diversidad de pareceres entre expertos, desde los que citan técnicas concretas (coincidentes con los aspectos más iterativos del estudio bibliométrico), hasta los que piensan que es poco probable que se usen en un futuro cercano (AU)

Study of the human proteome has given rise to the appearance of abundant and increasing scientific literature. This has resulted in the proposal to use proteomic techniques in the management of some diseases and the suggestion of its future use in clinical laboratories. In order to identify which proteomic techniques are being used or may be used in the near future in the clinical practice, a survey was made to experts in proteomics and the bibliometric study was done. Concordance between this study and a survey was observed. However, in general, standardized uses of proteomic techniques in the current clinical practice were not found. In regards to possible applications in the short-middle term, the experts have different opinions, from those who mention specific techniques (coinciding with the most repeated aspects of the bibliometric study) to those who think that its use in a near future is unlikely (AU)

Effectiveness of preventive interventions in BRCA1/2 gene mutation carriers: a systematic review.

A systematic review of the literature was conducted to assess the outcomes of preventive interventions (prophylactic surgery, intensive cancer screening, and chemoprevention) in women who carry mutations in BRCA1/2 genes, in terms of reducing breast and gynaecological cancer incidence and/or mortality. A search for relevant articles published between 1996 and 2005 (inclusive) was run on Medline, Embase and other databases. From the 749 journal articles retrieved from this search strategy, 18 studies were eligible for this review (2 systematic reviews, 10 cohort studies and 6 case-control studies). The critical appraisal of the studies was performed by two independent reviewers with a list of ad hoc selected criteria. The synthesis of results was qualitative. Mastectomy and prophylactic gynaecological surgery (oophorectomy or salpingo-oophorectomy) reduced breast and gynaecological cancer incidence in carriers of BRCA mutations, by comparison to surveillance. However, all the studies presented flaws in internal and external validity, none of these preventive interventions is risk-free, and protection against breast and gynaecological cancer, as well as other cancers linked to BRCA mutations, is incomplete. No studies comparing surveillance programmes of varying intensity were found. Exposure to drugs (tamoxifen, and oral contraceptives) in women carrying BRCA mutations was assessed through a limited number of papers. All of these were case-control studies with prevalent cases and presented major methodological flaws.

La incertidumbre sobre la efectividad y seguridad de los fármacos. Relevancia de los estudios de utilización de medicamentos / Uncertainty on drug effectiveness and safety. Relevance of studies on drug use

No disponible

Rehabilitación respiratoria: aproximación a la situación en España / Respiratory rehabilitation: situation in Spain

Objetivo. Estimar la implantación y la coberturade los programas de rehabilitación respiratoria en el sistemasanitario público español, describir las características delos programas existentes y explorar las barreras para la ampliaciónde su implantación.Métodos. Se realizó una entrevista semiestructurada, caraa cara, a seis informadores clave, elegidos por destacar comoinvestigadores en el campo de la rehabilitación respiratoria ocomo representantes de las sociedades científicas, siendoclínicos al mismo tiempo.Resultados. Los informadores clave están de acuerdo enque la rehabilitación respiratoria entendida como fisioterapiarespiratoria está bien difundida por los hospitales de primernivel y que se dirige principalmente a pacientes con enfermedadpulmonar obstructiva crónica (EPOC). Sin embargo,sólo una minoría de centros públicos incluye en el programade rehabilitación el entrenamiento al esfuerzo, que es el componentede beneficio mejor demostrado y la rehabilitaciónrespiratoria sólo llega a una pequeña proporción de los pacientesque la necesitan. La enseñanza de técnicas de relajacióny el apoyo para dejar de fumar no son constantes.Conclusiones. Actualmente, la atención al paciente conEPOC, con una correcta rehabilitación respiratoria, está lejosde quedar garantizada en el sistema sanitario público español

Objective. To consider the implantation andthe cover of the programs of respiratory rehabilitation in theSpanish Health System; to describe the characteristics ofthe existing programs and to explore the barriers for theextension them. Methods. Semistructured interview, to six key informants,chosen by prestige criteria in the field of the respiratory rehabilitationresearch or by the scientific societies, being clinicalat the same time.Results. The informants agree in which the respiratory fisiotherapyas a component of RR programs is extended bythe first level hospitals and that mainly goes to patients withchronic obstructive pulmonary disease (COPD). Nevertheless,the exercise training, the more effective intervention, isinclude in only a minority of public centers (hospitals) withrehabilitation program, and only a small proportion of the patientswho need RR are provided. The relax techniques andthe smoking cessation support are not always included.Conclusions. At the moment, the attention to the patientwith COPD with a correct respiratory rehabilitation is farfrom being guaranteed in the Spanish Health System

[Organizational characteristics of primary care and hospitalization for to the main ambulatory care sensitive conditions]. / Características organizativas de la atención primaria y hospitalización por los principales ambulatory care sensitive conditions.

OBJECTIVES: To describe the variability in hospitalisation rates because of the most common ambulatory care sensitive conditions (ACSC), by town and gender; b) to describe the influence on these rates of the characteristics of primary care (reformed or non-reformed model and kind of centre), the health level of the population, geographical accessibility and other factors of a social and economic nature. DESIGN: Observational, cross-sectional study of hospital discharges and ecological study for the analysis of rates between towns. MAIN MEASUREMENTS: The rates of hospitalisation by gender for each ACSC (1997-1999), standardised for age through the indirect method by calculating the standardised rate ratios (SRR). The multivariate analysis used Poisson regression. RESULTS: In the diagnoses studied, 41% of the towns had the same number of cases observed and expected for hospitalisation of men; and 65%, for women. Chronic obstructive pulmonary disease in men and heart failure in women were the illnesses that most varied. Hospitalisation rates for most illnesses were higher in towns without a health centre or with a non-reformed model, with over 3000 inhabitants and closer to hospital, although distance from the hospital was an influential factor only in bigger towns. CONCLUSIONS: There is variability between towns in hospitalisation rates for the most common ACSC; b) the differences in hospitalisation rates for the ACSC studied are linked to organisational features of primary care, the size of the town and the distance from the hospital.

[Factors associated with hospitalization for ambulatory care sensitive conditions in municipalities]. / Factores asociados a la hospitalización por procesos sensibles a cuidados ambulatorios en los municipios.

OBJECTIVES: To describe variability in admission rates for ambulatory care sensitive conditions (ASSC) in municipalities in the catchment area of a tertiary hospital and to determine the influence of primary care characteristics, socioeconomic factors, health of the population, and geographical accessibility to the hospital on this variability. METHODS: An ecological study was carried out in 34 municipalities in the area served by the Hospital Virgen de las Nieves in Granada (Spain) including all admissions for ASSC from 1997 to 1999. The admission rates for men and women were calculated separately and were age-standardized by the indirect method. The following factors were analyzed as independent variables: characteristics of primary care (type of healthcare model and type of center), socioeconomic factors (unemployment rate, income per capita, number of business establishments, size of municipality), health (mortality rate), and accessibility (time in minutes from the municipality to the hospital). A multiple lineal regression model was estimated. RESULTS: A total of 9.8% of all hospital admissions were due to ASSC. The mean annual admission rate was 10 admissions per 1.000 inhabitants. This rate was higher for men and for persons aged more than 74 years. The standardized admission ratios were not statistically different from 1 in 56% of the municipalities and were higher than 1 in 26% and lower than 1 in 18%. Sixty-two percent of the variability in rates for men was associated with time taken to reach the hospital, size of municipality, the interaction between both variables, and mortality. Eighteen percent of the variability in rates for women was associated with time taken to reach the hospital and the unemployment rate. CONCLUSIONS: Variability in admission rates for ASSC was not associated with primary care characteristics in the geographical area analyzed. Accessibility (measured as time to the hospital) was the only variable associated with higher rates in both men and women. Admission rates for ASSC among women were higher when unemployment rates were higher, and rates among men were higher in larger municipalities and in those with higher mortality.

Factores asociados a la hospitalización por procesos sensibles a cuidados ambulatorios en los municipios / Hospitalization for ambulatory care sensitive conditions: analysis of related factors in municipalities

Objetivos: Describir la variabilidad en las tasas de hospitalización por procesos sensibles a cuidados ambulatorios (PSCA) entre municipios del área de referencia de un hospital de tercer nivel, y determinar la influencia de las características de la atención primaria, los factores socioeconómicos, el nivel de salud de la población y la accesibilidad geográfica al hospital. Método: Se realizó un estudio ecológico en 34 municipios del área del Hospital Virgen de las Nieves (Granada), abarcando todas las hospitalizaciones por PSCA de 1997 a 1999.Las tasas de hospitalización se calcularon por separado para varones y mujeres y se estandarizaron por el método indirecto según la edad. Se exploraron como variables independientes las siguientes: características de la atención primaria (tipo de modelo y centro), socioeconómicas (desempleo, renta, comercios, tamaño del municipio), de salud (mortalidad) y accesibilidad (crona: minutos desde el municipio al hospital). Se realizó un análisis de regresión lineal múltiple. Resultados: El 9,8 por ciento de los ingresos ocurridos en el hospital fueron por PSCA. La tasa media anual fue de 10 ingresos por 1.000 habitantes, siendo superior en varones y en los mayores de 74 años. En el 56 por ciento de los municipios las razones de hospitalización estandarizadas no fueron estadísticamente diferentes de 1, en un 26 por ciento fueron menores y en un 18 por ciento, mayores. Un 62 por ciento de la variabilidad en las tasas de los varones se explicó por la crona al hospital, el tamaño del municipio, la interacción entre ambas variables y la mortalidad. Las tasas en mujeres se explicaron en un 18 por ciento por la crona y la tasa de desempleo. Conclusiones: La variabilidad de las tasas de hospitalización por PSCA no se asoció a las características de la atención primaria en el ámbito geográfico estudiado. La mayor accesibilidad en tiempo al hospital fue la única variable asociada a mayores tasas en varones y mujeres. Las tasas en mujeres fueron superiores cuanto mayor era el desempleo, y las tasas en varones fueron más altas en los pueblos grandes y con mayor mortalidad.. (AU)

[Preventive activities in primary health care: identifying the agreement among evidence-based guidelines]. / Actividades preventivas en atención primaria: identificación de áreas de concordancia entre guías de práctica clínica basadas en la evidencia.

BACKGROUND: The purpose of this article is to identify the agreement among evidence-based guidelines about recommendations on preventive activities in low risk adults. METHODS: For which we identified, from the 1996 US Task Force on Preventive Services Guide those preventives activities classified like A or B (recommendation in favour of provision) and like D or E (recommendation against provision), excepting those D and E recommendations based on descriptives studies or expert opinions. Both preventive activities aimed at pregnant women and children and those which are not applicable to our context were excluded. Selected preventive services were compared with the range of age, sex and periodicity in which agreement with the recommendations of American College of Physicians and Canadian Task Force on Preventive Services existed. RESULTS: We found the following agreements. Screening activities. In favour: screening for hypercholesterolemia, hypertension, breast cancer, colorectal cancer, uterine cervix cancer, rubella, visual and hearing impairment and problem drinking. Against: cancer of prostate, lung, bladder and thyroid, and asymptomatic bacteriuria. Counseling activities. In favour: smoking, motor-vehicles injuries, alcohol consumption, unintended pregnancy. Immunizations and quimioprophylaxis. In favour: Vaccines for influenza, tetanus-diphtheria, hepatitis B and measles-mumps-rubella. Postexposure prophylaxis to hepatitis A, hepatitis B, meningococcal, rabies and tetanus. CONCLUSIONS: We see then, that a high degree in agreement among the main guidelines exists; about the preventive activities to perform in Primary Health Services, nevertheless we observed low fulfillment of certain preventive activities in Primary Health Services, different barriers for the accomplishment from these activities were described.

[Effect of the presentation of results from clinical trials on the intention to prescribing: relativity of the relative risk]. / Influencia de la presentación de los resultados de los ensayos clínicos en la intención de prescribir: relativizando el riesgo relativo.

OBJECTIVE: To determine if the methods of reporting results of clinical trials affects the physician views on prescribing. DESIGN: Analysis of responses, from a convenience sample of primary care physicians, of one teaching exercise on prescribing intention which showed 5 different methods of reporting results: relative risk reduction (RRR), absolute risk reduction, the percent of event free patients, the number needed to treat (NNT) and RRR and mortality. SETTING: Curses of clinical management in Valencia and Barcelona. RESULTS: The willingness to prescribe was significantly influenced by the way in which data were presented, being major when they were showed as RRR and minor when mortality was added. CONCLUSIONS: The method of reporting trial results has an important influence on the prescribing intention. The reporting of clinical trial results, and their abstracts or citations, should be include the NNT and negative results, for avoiding a subjective bias of treatment effect magnification.

[Health and social services: needs, preferences and their use by the elderly following hospitalization]. / Servicios sanitarios y sociales: necesidades, preferencias y utilización por los ancianos tras un episodio de hospitalización.

BACKGROUND: Many processes behind the admission to hospital of elderly people can lead to a deterioration in their health at the time of discharge. The aims of the study are to assess the dependency on and need for socio-health care required by elderly people aged over 64 when discharged from a hospital for acute cases, the help that patients prefer and the help that they actually receive one month following their discharge. METHODS: A total of 193 patients aged over 64 and admitted to a hospital in Valencia between February and April 1994 were studied. Information on socio-demographic characteristics, self-care capacity, mental state, main diagnosis and co-morbidity was obtained by means of an interview at the time of admission and the medical record. A multidisciplinary team evaluated the socio-health care required in each case. A second interview, one month after discharge from hospital, gathered data on the actual care received. RESULTS: At the time of admission, 17% of the patients needed partial care and 21% full care. 23% were candidates for receiving home help, 9% to be treated as out-patients and 6% in a chronic illness hospital. Most of the patients asked to live at home. One month after discharge from hospital, only 2% of patients were receiving home help, none were being treated as out-patients or in a chronic illness hospital and 3% had once again admitted to a hospital for acute cases. 8% of the patients who were living at home alone before being admitted to hospital and 5% of those who were living with someone else had gone to live with relatives. CONCLUSIONS: The reality observed reflects the lack of socio-health resources. In many cases, this situation leads families to take on the care of the elderly themselves.

Reduction in hospital admissions for pneumonia in non-institutionalised elderly people as a result of influenza vaccination: a case-control study in Spain.

OBJECTIVE: To estimate the effectiveness of influenza vaccine in preventing hospital admission for pneumonia in non-institutionalised elderly people. DESIGN: This was a case-control study. SETTING: All three public hospitals in the Castellón area of Spain. PARTICIPANTS: Cases were people aged 65 or more not living in an institution who were admitted to hospital for pneumonia between November 15, 1994 and March 31, 1995. Each case was matched with two sex matched control subjects aged 65 years or older admitted to hospital in the same week for acute abdominal surgical conditions or trauma. The sampling of incident cases was consecutive. Eighty three cases and 166 controls were identified and included in the study. MEASUREMENTS: Trained interviewers completed a questionnaire for each subject on the vaccination status, smoking habits, previous diseases, health care use, social contacts, family background, the vaccination status of the family carer, home characteristics, and socioeconomic status. RESULTS: The adjusted odds ratio of the influenza vaccination preventing admission to hospital for pneumonia was 0.21 (95% confidence interval 0.09, 0.55). The variables which best explained the risk of being a case were age, intensity of social contacts, health care use, previous diseases, and the existence of a vaccinated family carer. CONCLUSIONS: Influenza vaccination reduced significantly hospital admissions for pneumonia in non-institutionalised elderly people.

[Satisfaction of parents of children undergoing outpatient surgery]. / Satisfacción de los padres de niños intervenidos con cirugía sin ingreso.

BASIS: The objectives of the study are: 1. Know the grade of satisfaction of the parents of children operated in a program of surgery without admission (CSI). 2. Compare it with another program of surgery with admission (CCI). 3. Know the outputs of reentry and complications of both programs. MATERIAL AND METHOD: 95 children were operated in a program of CSI. They were elected 95 children operated with CCI of similar characteristic. A questionnaire in a type Likert scale was sent for mail to the parents to value diverse looks of the satisfaction: Information, deal, perceived control, security, hostelry and global satisfaction. The questionnaire also picked up social-demographics and cultural data. OUTPUTS: The rate of the answer was from the 83% in the program of CSI and 82% in the CCI. The global satisfaction was over 90% in both programs. They met differences significant in the sensation of insecurity, more frequent in the parents of children operated with CSI (30%) that with CCI (11%). The reentry and complications rate of the evaluated program are similar to other programs of CSI.