Primary care nursing of coronary patients and reduction of re-infarction risk: a nested case-control study.

OBJECTIVES: To estimate the risk reduction for re-infarction achieved in primary health care centres. STUDY DESIGN: This was a case-control study nested in a cohort of coronary patients. POPULATION: Nine hundred and eighty-five coronary patients, aged less than 76 years who had survived for more than 6 months after their first acute myocardial infarction (AMI), were recruited from two public hospitals in Navarre, Spain. Cases (repeated myocardial infarction, n = 137) and controls (patients with one AMI who had not had a second infarction, [n = 137) who had not been treated with invasive procedures were extracted from this cohort and matched by gender, age, hospital and the secondary prevention time frame. OUTCOMES MEASURED: Re-infarction. RESULTS: In total, 31.4% of cases and 51.8% of controls attended the primary care nurse clinic regularly. This difference accounted for a significant reduction of the risk of re-infarction, even after adjustment for regular visits to the family physician, life styles (smoking, walking habit and dietary changes) and drug treatments (odds ratio: 0.48; 95% confidence interval: 0.26-0.89). A regular schedule of visits to the family physician showed no association with further coronary risk reduction. CONCLUSIONS: Regular attendance of coronary patients at a primary care nurse clinic is associated with a lower risk for re-infarction. Psychological rehabilitation could be the main reason for this benefit, since protection persists after adjustments for other known risk factors.

[Attitudes and practices regarding physical activity: situation in Spain with respect to the rest of Europe]. / Actitudes y prácticas en actividad física: situación en España respecto al conjunto europeo.

AIM: To identify attitudes and practices in the Spanish population regarding physical activity, and to compare the situation in Spain with that of other member stages of the European Union (EU). DESIGN: Descriptive, cross-sectional study. SETTING: European Union (representative samples of all 15 member stages). Participants. From each member stage we obtained a representative sample of approximately 1000 subjects older than 15 years. A total of 15 239 individuals were asked to complete a questionnaire on attitudes regarding physical activity, body weight and health. Main measures. We classified participants into 6 possible stades of change toward physical activity, and subsequently regrouped them into static (precontemplation and relapse) and dynamic stages (contemplation, decision, action and maintenance). Multivariate analysis with unconditional logistic regression was used to determine which sociodemographic variables were related with static stages. RESULTS: Static stages of change were more prevalent in Spain than in the rest of the EU. Spanish participants of both sexes who had received primary education, were married, were smokers or were obese were more likely to be in a static stage with regard to physical activity. CONCLUSIONS: The proportion of Spaniards with a poor attitude toward changing their level of physical activity was higher than in the rest of the EU, and Spanish citizens were less perseverant in achieving positive changes.

Gender, age, socio-demographic and lifestyle factors associated with major dietary patterns in the Spanish Project SUN (Seguimiento Universidad de Navarra).

OBJECTIVE: To ascertain the major dietary patterns in the cohort 'SUN' and to assess the association of several sociodemographic (including age and gender) and lifestyle variables with the adherence to these dietary patterns. DESIGN: This study is a cross-sectional analysis of 3847 subjects (1587 men and 2260 women) belonging to a prospective cohort study based on self-reported questionnaires. A factor analysis based on 30 predefined food groups was conducted to ascertain the major dietary patterns in the cohort. Multiple regression models were fitted to assess the relationship between several sociodemographic and lifestyle variables and the adherence to these dietary patterns (measured using two scores with observed values ranging from -3.2 to +4.6 for the Western pattern and -3.1 to +5.5 for the Mediterranean pattern). RESULTS: Two major dietary patterns were found. The first pattern was labelled as a 'Western' dietary pattern and the other as a 'Spanish-Mediterranean' dietary pattern. Younger subjects were more likely to follow a 'Western' dietary pattern; the coefficient representing the change for every 10 y increase in age was b=-0.24 (P<0.001) for men and b=-0.12 (P<0.001) for women. More physically active subjects were less likely to follow a 'Western' dietary pattern and more likely to follow a 'Spanish-Mediterranean' dietary pattern. CONCLUSIONS: An association between a higher level of physical activity during leisure time and adherence to a 'Spanish-Mediterranean' diet was apparent. However, the profile of being a young, sedentary and single male was identified as the most likely to exhibit a departure from the traditional 'Spanish-Mediterranean' diet and follow a 'Western' dietary pattern.

[Differences in the quality of Spanish clinical trials published in international periodicals and of the ones presented in general medicine periodicals with wide readership]. / Diferencias en la calidad de los ensayos clínicos españoles publicados en revistas internacionales y los aparecidos en revistas generales de medicina de gran difusión.

BACKGROUND: The assessment of the methodological quality of controlled clinical trials (CCTs) carried out in Spain and published in international journals and the comparison with those published in widely read general journals of medicine (N Engl J Med, Lancet, JAMA, BMJ) may help establishing their limitations and improving quality in future studies. METHODS: Search in Medline of CCTs. Studies were evaluated according to a structured questionnaire (J Clin Epidemiol 1992; 45:225-265). The odds ratio and their 95% confidence intervals were used to compare spanish studies with the remaining studies. The following variables were considered as confounders and controlled for by logistic regression analysis: number of participating centers, sample size, funding source, and the inclusion of epidemiologists in the research team. The journal's impact factor was taken into account. RESULTS: Spanish CTTs had a smaller sample size, were mostly monocentric, reported les frequently the source of funding, and exhibited a lower participation of epidemiologists. The informed consent and the approval by the ethics committee were more frequently omitted. The major methodological differences with the other studies were: lack of pre-study sample size and statistical power estimation, lack of inclusion criteria, poor explanation of patients' flow in the selection process, lack of explanation for unmasked procedures, poor description of methods to assess intervention compliance, under-reporting confidence intervals, and less frequent use of the intention-to-treat principle. The quality score of spanish studies was lower (9.4 +/- 1.7 vs 10.7 +/- 1.5; p < 0.001). These limitations improved with higher journal's impact factor, the quality score was 8.5 in journals with an impact factor < 1.5, and 10.6 in those with an impact factor > 4.5. This last figure is almost identical to the average of CCTs published in general journals of medicine. CONCLUSIONS: Most spanish studies achieved a good quality score. Nevertheless, there are still issues which can be overcome easily. If this goal is achieved, the results will obtain a higher repercussion, as a better quality is observed in those published in journals with the highest impact factor.

Factors associated with the condoning of female genital mutilation among university students.

Female genital mutilation (FGM) is practiced in Egypt, despite its recent ban, generally in rural and uneducated communities, under unsanitary conditions and by non-medical personnel. Immediate and long-term complications are frequent. The aim of this study was to gain insight into what beliefs or knowledge are conducive to supporting FGM. One thousand and seventy university students in Cairo, Egypt were randomly selected. A 32-item questionnaire was used to interview students regarding their knowledge and attitudes toward FGM. Multivariable analyses were performed to find factors associated with being against the abolishment of FGM.The response rate was 95% (n=1020). Twenty-eight percent of the students support FGM. The most significant factors associated with the condoning of FGM were believing FGM has a religious basis (OR=2.53), disagreeing that FGM is a custom with no other basis (OR=2.59), not believing it is harmful (OR=4.11), and ignoring that it is usually followed by complications (OR=5.14). Even in an educated population, a considerable amount of ignorance concerning FGM exists. Widespread education about FGM is important to dispel the myths that surround its practice and to bring the practice to an end.

Comparison of different methodological approaches to identify risk factors of nosocomial infection in intensive care units.

OBJECTIVE: Comparison of statistical methods and measurement scales to identify nosocomial infection risk factors in intensive care units (ICU). DESIGN: Prospective study in 558 patients admitted to the ICU of a referral hospital between February and November 1994. METHODS: Analysis using three logistic regression models, three standard Cox regression models, and two Cox regression models with time-dependent extrinsic factors. Different scales were used to measure exposures to risk factors (dichotomous, ordinal, quantitative, and time-dependent variables). RESULTS: The most appropriate models were those that measured exposure using dichotomous variables. Models using ordinal or quantitative variables estimated biased coefficients and/or failed to comply with the statistical assumptions underlying the analyses. The Cox regression model with quantitative time-dependent variables met all the statistical assumptions, obtained a precise assessment of risk by exposure time, and estimated unbiased coefficients. CONCLUSIONS: The Cox regression analysis with quantitative time-dependent variables is the most valid alternative for assessing the risk of nosocomial infection per day of exposure to an extrinsic risk factor in the ICU.

Participation of epidemiologists and/or biostatisticians and methodological quality of published controlled clinical trials.

STUDY OBJECTIVE: This study assessed several methodological aspects related to the quality of published controlled clinical trials (CCTs) in relation to the participation of an epidemiologist/biostatistician (E/B). DESIGN: Handsearch of CCTs published in four medical leading journals for 1993-1995. METHODS: Quality variables, abstracted from a review, were related to authors' specialties. Five hundred and ninety four CCTs were identified via a hand search. The department/unit membership was used to attribute authors' specialties. Of 594 CCTs identified, in 127 the authors' specialties could not be known, leaving 467 trials for analysis. RESULTS: E/B participation occurred in 178 trials (38.1%). This participation was more frequent in multicentric, bigger, and in those trials describing any funding agency. These factors were controlled for in the analysis. E/B participation was positively associated with pre-study sample size estimation (OR = 1.5, 95% confidence intervals (CI) 1.0, 2.3), with reporting the dates for starting/ending the study (OR = 2.1, 95% CI 1.4, 3.3), with using an objectively assessed outcome (OR = 2.4, 95% CI 1.2, 4.6) and with the intention to treat principle (OR = 2.0, 95% CI 1.3, 3.0). The overall quality score was higher in trials where E/B participated. CONCLUSIONS: The results suggest that E/B improve the quality (at least of reports) of clinical trials. Given that quality of research is frequently used to evaluate potential sources of heterogeneity between trials, these results are relevant for meta-analysis.

Methodological quality and reporting of ethical requirements in clinical trials.

OBJECTIVES: To assess the relationship between the approval of trials by a research ethics committee (REC) and the fact that informed consent from participants (ICP) was obtained, with the quality of study design and methods. DESIGN: Systematic review using a standardised checklist. MAIN MEASURES: Methodological and ethical issues of all trials published between 1993 and 1995 in the New England Journal of Medicine, the Lancet, the Journal of the American Medical Association and the British Medical Journal were studied. In addition, clinical trials conducted in Spain and published by at least one Spanish author during the same period in any other journal were also included. RESULTS: We studied the published articles of 767 trials and found the following indicators of lower methodological quality to be independent predictors for failure to disclose REC approval or ICP: absence of concealment of allocation, lack of justification for unblinded trials, not using a treatment for the patients in the control group, absent information on statistical methods, not including sample size estimation, not establishing the rules to stop the trial, and omitting the presentation of a baseline comparison of groups. CONCLUSION: Trials of higher methodological and scientific quality were more likely to provide information about their ethical aspects.

[Recent determination of cholesterolemia in a healthy adult population from Pamplona]. / Determinación reciente de la colesterolemia en población adulta sana de Pamplona.

BACKGROUND: The aims of the study were to assess the proportion of the healthy adult population from Pamplona who were aware of their blood cholesterol levels, and to identify factors associated with this awareness. METHODS: A cross-sectional study was implemented with personal interview to 1066 citizens from Pamplona selected by a random routes sampling procedure. The city was stratified in three urban districts according to the socioeconomic status (high, middle, low). The response rate was 91.8%. The crude odds ratios were computed and a multivariable logistic regression model was fitted using awareness of the blood cholesterol level as the dependent variable, and age, sex, socioeconomic status and smoking as independent variables. RESULTS: 71.2% of the sample (95% CI: 68.3-74.0) reported having some cholesterol determination during the last five years. The multivariate analysis disclosed that non-smokers were aware of their cholesterol levels more frequently than smokers (adjusted OR = 1.38; 95% CI 1.0-1.9), determination of cholesterolemia was also less frequent in individuals under 30 years old and in females (adjusted OR in males: 1.5; 95% CI 1.1-2.0). Regarding socioeconomic status, cholesterol measurement was more frequent in middle and high levels with adjusted OR = 3.2; 95% CI 2.2-4.71 and 1.59; 95% CI 1.11-2.27), respectively. CONCLUSIONS: Cholesterol awareness was more frequent in older individuals and among males. It is remarkable that blood cholesterol measurement was less likely in population groups with worse coronary risk profile (lower socioeconomic status, smokers). This study suggests that there is a need for improving the awareness and control of blood cholesterol levels in healthy adults from Pamplona.

Barriers and benefits of a healthy diet in spain: comparison with other European member states.

OBJECTIVE: Our purpose was to identify the main barriers and benefits perceived by the European citizens in regard to following a healthy diet and to assess the differences in expected benefits and difficulties between Spain and the remaining countries of the European Union. DESIGN: A cross-sectional study in which quota-controlled, nationally representative samples of approximately 1000 adults from each country completed a questionnaire. SETTING: The survey was carried out between October 1995 and February 1996 in the 15 member states of the European Union. SUBJECTS: Participants (aged 15 y and older) were selected and interviewed in their homes about their attitudes towards healthy diets. They were asked to select two options from a list of 22 potential barriers to achieve a healthy diet and the benefits derived from a healthy diet. The associations of the perceived benefits of barriers with the sociodemographic variables within Spain and the rest of the European Union were compared with the Pearson chi-squared test and the chi-squared linear trend test. Two multivariate logistic regression models were also fitted to assess the characteristics independently related to the selection of 'Resistance to change' among the main barriers and to the selection of 'Prevent disease/stay healthy' as the main perceived benefits. RESULTS: The barrier most frequently mentioned in Spain was 'Irregular work hours' (29.7%) in contrast with the rest of the European Union where 'Giving up foods that I like' was the barrier most often chosen (26.2%). In the multivariate logistic regression model studying resistance to change, Spaniards were less resistant to change than the rest of the European Union. The benefit more frequently mentioned across Europe was 'Prevent disease/stay healthy'. In the multivariate logistic regression model women, older individuals, and people with a higher educational level were more likely to choose this benefit. CONCLUSIONS: It is apparent that there are many barriers to achieve healthy eating, mostly lack of time. For this reason a higher availability of food in line with the nutrition guidelines could be helpful. The population could have a better knowledge of the benefits derived from a healthy diet.

[Prevalence of eating disorders in a representative sample of female adolescents from Navarra (Spain)]. / Prevalencia de trastornos de la conducta alimentaria en las adolescentes navarras.

BACKGROUND: In spite of the social concern about eating disorders (ED), information of its prevalence in Spain is limited. Further studies in communities are needed to estimate the frequency of this problem in representative samples of the population. SUBJECTS AND METHODS: To estimate the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), and partial syndromes of the "non specified eating disorders" (NOSED) type, a representative sample of the female population of Navarre was selected using a random multistage sampling scheme. A sample of 2862 participants aged 12 to 21 was studied. The screening procedure was performed using the Eating Attitudes Test (EAT) (values over 30 as the cutoff point) and each diagnosis was confirmed using a semi-structured interview performed by a psychiatry according to DSM-IV criteria. RESULTS: The overall prevalence of ED in this female population was 4.1% (95% CI: 3.45-4.95). The disorder specific prevalences being NOSED 3.1% (95% CI: 2.5-3.8), BN 0.8 (95% CI: 0.5-1.2) and AN 0.3 (95% CI: 0.1-0.6). CONCLUSIONS: Our results show a slight lower prevalence than what other Spanish authors have reported, although we found higher prevalences of incomplete syndromes and suggest that a high social burden does exist and primary prevention strategies are needed.

[The perception of body image as a qualitative approach to nutritional status]. / Percepción de la imagen corporal como aproximación cualitativa al estado de nutrición.

OBJECTIVE: To compare body image perception with body mass index (BMI) calculated from the weight and size declared by subjects, and to evaluate its usefulness in classifying the nutritional status. MATERIAL AND METHODS: A representative sample of the Spanish population was selected consisting of 517 males and 483 females older than 15 years of age. Variables were sex, age, educational level, BMI and perceived body image. Differences between groups were estimated with the chi 2 test. Specificity and sensitivity of the agreement between body mass and image were assessed. RESULTS: The nutritional status for both indicators revealed higher overweight prevalence in males and obesity in females, which increase with age and decrease with greater educational level. Perceived body image differed between sexes, and among ages and educational levels (p < 0.01). Sensitivity and specificity as well as positive and negative predictive values were higher than 0.90 in subjects belonging to extreme cases. Precision was higher for sensitivity than for specificity. In all groups, categorization was better in females than in males and so was Spearman's correlation (p < 0.001). The Kendall W coefficient ranked high for both groups. CONCLUSIONS: Body image allowed the identification of individuals with normal, excessive or lean nutrition. This indicator can therefore be useful in epidemiological surveys, considering some limitations for individualized diagnoses.

[The perceptions of the adult Spanish population of the factors determinative of health]. / Percepciones de la población adulta española sobre factores determinantes de la salud.

OBJECTIVE: To assess which are the most important perceived influential factors on health among the Spanish adult population. This may provide sufficient information to promote primary health care campaigns directed specifically to those that acknowledge that lifestyles are important in spite of not living healthy lifestyles themselves. DESIGN: Observational cross-sectional study. SETTING: Spain (Canary Islands not included). PARTICIPANTS: A representative sample of 1000 Spanish participants over 15 years old selected by a multistage procedure. INTERVENTION: Survey to evaluate the population choosing one of nine known health-related factors (smoking, food, alcohol intake, stress, physical activity, environment, body weight, support from family, genetics) as being one of the two most important factors influencing health through a validated questionnaire. MEASUREMENTS AND RESULTS: The chi-square test for linear trend was used to assess the influence of factors coded on an ordinal scale. The Pearson chi-square test was applied for categorical factors. Smoking was considered the most influential health-related factor by most participants (47.8%). Males, those from lower socioeconomic and educational levels; people living in the south of Spain, and rural regions; those married and individuals who had 3 or more children below 15 years, perceived smoking more often as one of the most important determinants of health. CONCLUSIONS: These data suggest that a large percentage of the Spanish adult population recognizes that life-styles are important determinants of health.

[Influence of nosocomial infection on mortality in an intensive care unit]. / Influencia de la infección nosocomial sobre la mortalidad en una Unidad de Cuidados Intensivos.

OBJECTIVE: To evaluate the association between nosocomial infections (NI) and the mortality of Intensive Care Unit (ICU) patients, adjusting for the effect on mortality of other predictive variables. METHODS: Prospective study on 944 concurrent patients admitted for at least 24 hours in the ICU of a tertiary level hospital between February and November of 1994. The association between NI (diagnosed using CDC criteria) and mortality was studied using multivariable logistic regression. RESULTS: The cummulative incidence of mortality in the ICU was 11.2% (CI95% = 9.9-12.5). This incidence was significantly higher in infected patients with a crude mortality relative risk of 2.2 (CI95% = 1.5-3.1). In the multivariable analysis, the effect of NI (global, pneumonias, of the urinary tract and bacteriemias) on adjusted mortality depended on the patient's Acute Pysiology and Chronic Health Evaluation II (APACHE II) score. With low APACHE II scores, NI was associated with an increased mortality risk. Conversely, with higher APACHE II scores, the relevance of NI as a determinant of mortality decreased and prognosis was mainly associated with the patient's severity of illness. CONCLUSIONS: The association between NI and mortality, adjusting for other prognostic factors for mortality, is confirmed.