[Inter-episode continuity of primary health care: proposal for an indicator]. / La continuidad interepisodios en atención primaria de salud: propuesta de un indicador.

The objective of this study was to assess the quality of the data included in patients' personal histories and to prepare an indicator of the continuity of health care between episodes of illness based on the information contained in these records. The study was descriptive. Public health specialists from the Department of Preventive Medicine of the University of Granada, Spain, participated in the design and analysis, and the field work was carried out by specialists from family and community medicine from the Zaidín-Sur Health Center of Granada, where the research was conducted in April to December 1989. For the study, 1581 personal histories were analyzed. The most complete records were those having to do with personal background (37% of the personal histories evaluated) and the most complete histories were those of pediatric patients, women, and persons who participated in programs organized by the health center. The degree of completeness of the records was low. Based on the indicator developed, only 16% of the histories at the Center contained sufficient information to allow continuity of care. It is recommended that simple records systems be created and that primary care physicians be educated in the collection of essential data.

Preoperative stay as a risk factor for nosocomial infection.

To evaluate the relationship between duration of preoperative stay and the risk of nosocomial infection, we studied 449 patients who underwent surgery at the University Hospital of Granada during the first six months of 1986. Patients were chosen from two cross-sectional surveys. Nosocomial infection was studied throughout each patient's hospital stay. Other variables included preoperative stay, age, severity and total length of stay. The data were analyzed by comparing nosocomial infection for different lengths of preoperative hospitalization, age and severity by calculating the Odds Ratio. The effects of age and severity were studied by stratifying patients by duration of preoperative stay. Two multivariate regression models were used to confirm the results of the stratified analysis. The results suggest that lengthening the preoperative stay may increase the risk of nosocomial infection in surgical wounds and in other sites, and may simultaneously potentiate the effects of other risk factors such as age and severity of the patient's condition, whose influence on susceptibility to infection increases with the duration of preoperative stay.

[Studying the levels of endotoxemia in meningococcal sepsis. Its relations to pregnancy and antibiotic treatment]. / Estudio de los niveles de endotoxemia en las sepsis meningococias. Su relación con la gravedad del proceso y el tratamiento antibiótico.

The most frequent cause of toxic shock in our area is meningococcal sepsis. It is currently assumed that endotoxin produce by this bacteria, a lipopolysaccharide with toxic properties, is able to trigger shock and DIC by stimulating both arachidonic acid pathways, among other actions. Previous studies in our laboratory demonstrated significant differences (p +/- 0.001) in the amounts of endotoxins released in vitro by strains from patients and healthy carriers and statistically related criteria of severity with mortality in 256 patients in our center over the last 10 years. In the present study we attempted to establish whether plasma levels of endotoxin were correlated with the severity of the disease. We studied 32 patients with meningococcal sepsis, dividing the subjects into two groups: those in whom six or more criteria of severity were present, and those in whom less than six criteria were found. Blood levels of endotoxin were determined upon admission and after the administration of antibiotics (penicillin and chloramphenicol) using the limulus test with a chromogenic substrate (Coatest, Endotoxin, Kabivitrum, Sweden). Levels of endotoxins were significantly higher in patients with more than six criteria of severity both upon admission (0.6 +/- 0.03) ng/ml) and 4 h. afterward (0.74 +/- 0.006 ng/ml) in comparison to children in whom the clinical picture was less serious (0.27 +/- 0.18 ng/ml and 0.27 +/- 0.18 ng/ml and 0.27 +/- 0.16 ng/ml7 t = 5.8 y t = 5.6 respectively. Endotoxin levels were highest in patients presenting shock, disseminated intravascular coagulation in the hypocoagulability phase and more than 8 criteria.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of penicillin and chloramphenicol on the growth and endotoxin release by N. meningitidis.

The action of two antibiotics, penicillin and chloramphenicol, on bacterial growth and endotoxin liberation was studied in 18 strains of Neissevia meningitidis isolated from blood and CSF of patients with meningococcal infections. The antibiotics were administered both separately and in combined form in doses equivalent to 1 MIC and 100 MIC. Penicillin was found to produce a faster and more intense bactericidal effect than chloramphenicol during the first hour, whereas at 12 h these differences were not significant. This could explain the initial worsening observed in some infected patients when large doses of penicillin are administered. An increased liberation of endotoxin after adding penicillin was observed in six of the strains studied, whereas the remaining 12 did not show significant increases. The six strains (belonging to serogroup B) were known to have an enhanced capacity for spontaneous endotoxin liberation.

Endotoxin liberation by strains of N. meningitidis isolated from patients and healthy carriers.

The main objective of this study was to assess whether the capacity of Neisseria meningitidis to release endotoxin depends upon the type of strain or upon bacterial mass. Endotoxin release was studied in 32 strains isolated from patients with meningococcal infections and in 49 from asymptomatic carriers, using a quantitative test (limulus test with a chromogenic substrate). The results show that the strains from patients release significantly higher amounts of endotoxin than strains from carriers regardless of serogroup and isolation site. No correlation was found between stage of bacterial growth and the amount of endotoxin liberated. These findings suggest that endotoxin liberation is a characteristic of certain strains of N. meningitidis and is not determined simply by bacterial mass.

[Adhesiveness in Neisseria meningitidis. A virulence factor?]. / Adhesividad en Neisseria meningitidis. Un factor de virulencia?

The role of adhesivity as a factor of virulence in cases of N. meningitidis has not yet been established. Unlike other bacteria in which the presence of adhesivity reflects an enhanced virulence, a high capacity of adherence is associated with a low virulence and invasive capacity in cases of meningococcus. In order to gain more insight into the knowledge of this phenomenon we have studied the adhesivity of 109 strains of N. meningitidis to human pharyngeal epithelial cells. Twenty nine out of the 109 strains were isolated from blood or spinal fluid of patients with meningococcal infection (meningitis or septicemia), whereas the remaining 80 strains were obtained from pharyngeal smears of healthy carriers. The adhesivity was measured as the number of meningococci adhered to 50 epithelial cells according to Craven's scale. Strains of healthy carriers showed a greater adhesivity than that of patients (p less than 0.001). The relevance of the pharyngeal area in the evaluation of the adhesive capacity is in accordance with the hypothesis that meningococcal adhesivity decreases when the microorganism crosses the pharyngeal epithelium. The results would support the concept that the virulence of N. meningitidis is related to its adhesiveness.

[Oral contraceptives and breast cancer: analysis of the statistical power of the association]. / Anticonceptivos orales y cáncer de mama: análisis de la potencia estadística de la asociación.

The power of the association between oral contraceptives and breast cancer was analysed in all the papers published up to date. Seventy-seven publications (from 44 studies) were collected and graded as to quality using meta-analytical methods. Power achieved a figure of greater than or equal to 0.8 in a 10.8% of the associations studied. It showed a significant relationship with the existence of a significant relative risk of the oral contraceptives for breast cancer. The relationship with the sample size of a study was not linear. Power did not show any significant relationship to other variables related to the design of a study (apart from matching, being the power higher in unmatched studies), or to the biases detected, although studies considered as unbiased yielded a higher power. Logistic regression analysis included as predictors of a power greater than or equal to 0.80 the existence of a significant relative risk and the lack of biases in a research.

Patterns of research. Oral contraceptives and cervical cancer.

Original papers on the oral contraceptive use-cervical cancer relationship are analysed. The purpose of this study was to ascertain the biases of the original articles collected in relation to various characteristics of any investigation. Papers were located by using MEDLINE, reviewing the references of each article identified by MEDLINE, and then reviewing the contents of those journals in which an original could be published. Fifty-five publications (from 49 original studies) were graded as to quality and classified as biased or unbiased. Nineteen studies were considered unbiased. The most common biases identified were confounding, detection bias, and misclassification bias. The pattern of research/publication has changed since the association began to be analysed: articles shift from gynecological to cancer and epidemiological journals; the number of studies performed by gynecologists alone and pathologists alone decreases, while studies performed by epidemiologists alone or in collaboration with gynecologists increase. This collaboration produced studies with fewer biases. It is suggested that the above mentioned collaboration should be increased to improve access to, and then the application of the results obtained in the original studies on oral contraceptives and cervical cancer.

Oral contraceptives and breast cancer. A meta-analysis.

Since the relationship between oral contraceptive use and breast cancer has not been consistent we undertook a meta-analysis of studies published to date. Papers were located by searching the MEDLINE data base, supplemented by a hand search of all the references in the articles recovered. Studies were graded as to quality. Those judged as probably unbiased were included in the analysis. The method of Woolf was used to combine relative risks. Forty-seven studies were collected: 40 case-control and 7 cohort studies. Thirty-nine of these were considered unbiased. The main results observed were: RR was 1.06 (1.02-1.10) for all studies and 1.14 for premenopausal cancer. For premenopausal cancer, higher RRs were observed in women who early used oral contraceptives with a significant linear dose-response effect: 1.25 (1.10-1.44) in OC users before age 25, and 1.17 (1.06-1.30) in users before the first full-term pregnancy. We conclude oral contraceptive use may be a risk factor for premenopausal breast cancer. Limitations to our research are discussed.

PIP: 40 case control and 7 cohort studies of the link between oral contraceptives and breast cancer were combined in a meta-analysis by the method of Woolf to estimate overall relative risks. Articles were found by a Medline search from January 1966-June 1990, a hand search of the references, and a journal search for 1990. Papers were graded for bias by 2 blinded readers. The analysis of the 39 studies considered unbiased generated a global relative risk of 1.06, and an increased risk of 1.06, and an increased risk of 1.14 for premenopausal breast cancer. For premenopausal cancer, risks were 1.25 for use before age 24, and 1.17 for use before the 1st term pregnancy. A significant linear dose response was seen, in terms of months of exposure. There was an indication of latency, since risk estimates were higher from data collected after 1981. There was no evidence of a relationship between pill use and parity, family history, or history of benign breast disease. The dad are consistent with the theory that oral contraceptives can be acting as cancer initiators or promoters. There was not enough data to judge whether users of current lower dose pills have lower risks for premenopausal breast cancer. Future studies should address the difference between premenopausal and postmenopausal cancer.

Usefulness of severity indices in intensive care medicine as a predictor of nosocomial infection risk.

To evaluate the relationship between severity and nosocomial infection in critical patients, we have conducted a prospective study at the Intensive Care Unit of the University of Granada Hospital (Spain). Patients' severity was evaluated by APACHE II and TISS. We found a positive association with nosocomial infection risk for an APACHE II score greater than 12 points (RR = 2.45) and for first-day TISS greater than 20 points (RR = 2.51). With a multivariate analysis we did not find an association between APACHE II and nosocomial infection risk, but each TISS point suggests an infection risk increment of 6%. We concluded TISS may be considered a good infection risk predictor. TISS could also be taken into account when nosocomial infection rates from several ICUs are compared.

[Oral contraceptives and cancer of the cervix uteri. Analysis of the strength of the association]. / Contraconceptivos orales y cáncer de cuello uterino. Análisis del poder de la asociación.

The power of the association between oral contraceptives and cervical cancer was analysed in all the papers published up to date. Fifty-three publications (from 48 studies) wer collected and graded as to quality using meta-analytical methods. Power achieved a figure of greater than or equal to 0.8 in a 24% of the associations studied. It showed a significant relationship with the existence of a significant relative risk of the oral contraceptives for cervical cancer, with the quotient between sample sizes of reference and index groups, and with the sample size of a study, although the relationship was not linear to these two latter variables. Power did not show any significant relationship to other variables related to the design of a study, or to the biases detected. Logistic regression analysis included as predictors of a power greater than or equal to 0,80 the existence of a significant relative risk and the use of adjusted relative risk.

C-reactive protein as a prognostic indicator in acute brucellosis.

Pre- and post-treatment measurements of C-reactive protein (CRP) in 85 patients with acute brucellosis were useful in predicting the disease's evolution and response to treatment. A positive value for CRP (greater than 1 microgram/dl) was significantly associated with an unfavorable course, with a negative predictive value of 0.95.

Hospital stay length as an effect modifier of other risk factors for nosocomial infection.

This paper addresses the problem of hospital stay length as a risk factor for nosocomial infection and as a modifier of the effect of other risk factors for hospital infection. Patients were selected form two cross-sectional studies done in two different seasons of 1986. Risk of infection rose fairly steadily as hospital stay length increased (correlation coefficient: 0.83, p less than 0.01). Several risk factors (operation, underlying disease, and age) were analyzed on the basis of 1) raw data and 2) data stratified by length of stay. The results showed that hospital stay length is a strong modifier of the remaining risk factors, generally reducing, their effect on the development of hospital infection as length of stay increases.

Quantification of risk factors in hospital infection at a surgical service.

In this paper we have analyzed several risk factors for developing nosocomial infections at a Surgical Service of the Hospital Clinico Universitario "San Cecilio", based on a retrospective follow-up program designed specifically for this study. Of all patients admitted to the Service from January 1 to June 17, 1987, we examined the following variables: age, sex, cause of admission, emergency or non-emergency admission, operation and related variables. The overall rate of nosocomial infections was 16.46%. The most significant risk factors we found were "operation", which had a linear correlation coefficient of 0.929 (p less than 0.01) with hospital infection when stratified by its length, "advanced age" (greater than 60 years old), especially in non-operated patients, and chemoprophylaxis. Such risk factors were ascertained taking into account the confounding effect produced by the variables studied in this survey.

[Prevalence of dental caries in a coastal zone of Granada]. / Prevalencia de la caries dental en una zona costera granadina.

In the present study, the problem of caries and its actual state in a seaside region of Granada is analyzed. 1.001 aged 5 to 15 scholars from three towns--Motril, Itrabo and Molvizar--were studied. In the descriptive survey, the prevalence of the illness by CO, CAOD, CAOS and CAOM epidemiologic indexes is registered, and also its distribution by place, age and sex. A general 1.45 CO, global 1.22 CAOD, 1.36 total CAOS and 0.94 CAOM were estimated. The relation of sweets taken out of the eating time, buccodental hygiene degree and fluorization drinking water levels with caries are studied in the analitic part. Straight connection was observed of sweets consuming to the total of caries (in both temporary and permanent teeth). A significant clear correlation was also observed between the levels of fluor and the prevalence of caries in temporary teeth, which was higher than in permanent teeth.