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This study explores the behavior of organophosphate esters (OPEs) in different species within marine ecosystems and their potential for bioaccumulation and biomagnification. The concentrations of OPEs were analyzed in marine species (krill (Meganyctiphanes norvegica), jellyfish (Pelagia noctiluca), European sardine (Sardina pilchardus), European anchovy (Engraulis encrasicolus), European hake (Merluccius merluccius), loggerhead turtle (Caretta caretta), European squid (Loligo vulgaris), fin whale (Balaenoptera physalus) and striped dolphin (Stenella coeruleoalba)) from different trophic levels, to understand their distribution and contamination profiles. The study provides insights into the metabolism of OPEs and their biomagnification on species occupying higher trophic levels. The results show that the differences in OPE concentrations among species are influenced by contamination levels at sampling points, as well as species and trophic level characteristics. The study reveals that the sum of OPEs do not exhibit significant biomagnification within the marine food web, with higher trophic level species showing efficient metabolism of these contaminants. However, biomagnification analysis of individual compounds demonstrates that some OPEs, such as tris(2-ethylhexyl) phosphate (TEP), tris(2-butoxyethyl) phosphate (TBOEP), and tris(2-isopropylphenyl) phosphate (T2IPPP) consistently exhibit biomagnification within marine trophic webs, while other show different behaviors depending on the trophic web. The loggerhead turtle shows higher biomagnification for specific OPEs, indicating the influence of diet and direct plastic waste consumption. Furthermore, OPEs prone to metabolism, such as tri-n-butyl phosphate (TNBP) and TBOEP, are present in multiple species across different trophic levels, suggesting a tendency for bioaccumulation. The study highlights the complexity of OPE behavior and the need to evaluate the biomagnification potential of each compound individually. It also emphasizes the toxic effects associated with OPE exposure and the potential risks to organisms within marine ecosystems., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Anthropogenic litter, such as plastic, is investigated by the global scientific community from various fields employing diverse techniques. The goal is to assess and finally mitigate the pollutants' impacts on the natural environment. Plastic litter can accumulate in different matrices of aquatic and terrestrial ecosystems, impacting both biota and ecosystem functioning. Detection and quantification of macroplastics, and other litter, can be realized by jointly using visual census and remote sensing techniques. The primary objective of this research was to identify the most effective approach for monitoring macroplastic litter in riverine and marine environments through a comprehensive survey based on the experiences of the scientific community. Researchers involved in plastic pollution evaluated four litter occurrence and flux investigation methods (visual census, drone-based surveys, satellite imagery, and GPS/GNSS trackers) through a questionnaire. Traditional visual census and drone deployment were deemed as the most popular approaches among the 46 surveyed researchers, while satellite imagery and GPS/GNSS trackers received lower scores due to limited field validation and short performance ranges, respectively. On a scale from 0 to 5, visual census and drone-based surveys obtained 3.5 and 2.0, respectively, whereas satellite imagery and alternative solutions received scores lower than 1.2. Visual and drone censuses were used in high, medium and low-income countries, while satellite census and GPS/GNSS trackers were mostly used in high-income countries. This work provides an overview of the advantages and drawbacks of litter investigation techniques, contributing i) to the global harmonization of macroplastic litter monitoring and ii) providing a starting point for researchers and water managers approaching this topic. This work supports the selection and design of reliable and cost-effective monitoring approaches to mitigate the ambiguity in macroplastic data collection, contributing to the global harmonization of macroplastic litter monitoring protocols., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

In this study, we aimed to quantify the presence of microplastics (MPs) in the stomachs of large pelagic fish (swordfish, Xiphias gladius, Linnaeus, 1758) sampled in the western Mediterranean Sea, and assess temporal trends (2011-2012 vs. 2017-2019) in MP ingestion. MPs were extracted from stomachs and characterized by μ-Fourier transform infrared spectroscopy. Results highlighted the ingestion of MP in 39 out of 49 stomachs analysed. Ingested MPs consisted mostly of small (<1 mm) fibers (88.6 %, mean ± standard deviation = 2.5 ± 6.1 particles per stomach), with a greater frequency of occurrence (FO) in the second period (FO = 90 %, 3.3 ± 8.0 particles per stomach). The predominant colours were purple, black and blue, and polyethylene terephthalate was the most frequently detected polymer. These results are crucial for the development of management actions aimed at the conservation of swordfish in the Mediterranean Sea and the prevention of health risks to humans., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Functional problems such as incontinence and sexual dysfunction after radical prostatectomy (RP) are important outcomes to evaluate surgical quality in prostate cancer (PC) care. Differences in survival after RP between countries are known, but differences in functional outcomes after RP between providers from different countries are not well described., Methods: Data from a multinational database of patients with PC (nonmetastatic, treated by RP) who answered the EPIC-26 questionnaire at baseline (before RP, T0) and 1 year after RP (T1) were used, linking survey data to clinical information. Casemix-adjusted incontinence and sexual function scores (T1) were calculated for each country and provider on the basis of regression models and then compared using minimally important differences (MIDs)., Results: A total of 21,922 patients treated by 151 providers from 10 countries were included. For the EPIC-26 incontinence domain, the median adjusted T1 score of countries was 76, with one country performing more than one MID (for incontinence: 6) worse than the median. Eighteen percent of the variance ( R 2 ) of incontinence scores was explained by the country of the providers. The median adjusted T1 score of sexual function was 33 with no country performing perceivably worse than the median (more than one MID worse), and 34% ( R 2 ) of the variance of the providers' scores could be explained by country., Conclusion: To our knowledge, this is the first comparison of functional outcomes 1 year after surgical treatment of patients with PC between different countries. Country is a relevant predictor for providers' incontinence and sexual function scores. Although the results are limited because of small samples from some countries, they should be used to enhance cross-country initiatives on quality improvement in PC care.

Introduction: We aimed to evaluate the longitudinal relationships, both at between- and within-person levels, that adherence to inhaled corticosteroid-based maintenance treatment and inhalation technique present with symptom control, exacerbations, and health-related quality of life (HRQoL) in children and adolescents with asthma. Methods: Participants (6-14 years old) from the ARCA (Asthma Research in Children and Adolescents) cohort-a prospective, multicenter, observational study (NCT04480242)-were followed for a period from 6 months to 5 years via computer-assisted telephone interviews and a smartphone application. The Medication Intake Survey-Asthma (MIS-A) was administered to assess the implementation stage of adherence, and the Inhalation Technique Questionnaire (InTeQ) was used to assess the five key steps when using an inhaler. Symptom control was measured with the Asthma Control Questionnaire (ACQ), and HRQL was measured with the EQ-5D and the Patient-Reported Outcomes Measurement Information System-Pediatric Asthma Impact Scale (PROMIS-PAIS). Multilevel longitudinal mixed models were constructed separately with symptom control, exacerbation occurrence, EQ-5D, and PROMIS-PAIS as the dependent variables. Results: Of the 360 participants enrolled, 303 (1,203 interviews) were included in the symptom control and exacerbation analyses, 265 (732) in the EQ-5D, and 215 (617) in the PROMIS-PAIS. Around 60% of participants were male subjects, and most of them underwent maintenance treatment with inhaled corticosteroids plus long-acting β-agonists in a fixed dose (73.3%). Within-person variability was 83.6% for asthma control, 98.6% for exacerbations, 36.4% for EQ-5D, and 49.1% for PROMIS-PAIS. At the within-person level, patients with higher adherence had better symptom control ( p = 0.002) and HRQoL over time ( p = 0.016). Patients with a better inhalation technique reported worse HRQoL simultaneously ( p = 0.012), but they showed better HRQoL in future assessments ( p = 0.012). The frequency of reliever use was associated with symptom control ( p < 0.001), exacerbation occurrence ( p < 0.001), and HRQoL ( p = 0.042); and boys were more likely to present better symptom control and HRQoL than girls. Conclusion: Our results confirm longitudinal associations at the within-person level of the two indicators of quality use of inhalers: for adherence to maintenance treatment with symptom control and HRQoL, and for the inhalation technique with HRQoL. Although treatment adherence was shown to be excellent, a third of the participants reported a suboptimal inhalation technique, highlighting the need for actions for improving asthma management of the pediatric population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Lizano-Barrantes, Garin, Mayoral, Dima, Pont, Caballero-Rabasco, Praena-Crespo, Valdesoiro-Navarrete, Guerra, Bercedo-Sanz and Ferrer.)

Background: Older adults present a variety of oral diseases and conditions, in addition to co-morbidities and limited access to dental care, which significantly impact their oral health-related quality of life (OHRQoL). There are many instruments published to measure OHRQoL. However, it is challenging for clinicians and researchers to choose the best instrument for a given purpose., Purpose: To identify OHRQoL instruments available for older adults and summarize the evidence on the conceptual and measurement model, psychometric properties, interpretability, and administration issues of OHRQoL instruments available for older adults through a systematic review., Methods: A systematic search was conducted in MEDLINE, EMBASE, LILACS, and CENTRAL up to February 2023. Articles reporting information on the concept model measurement, psychometric properties, and administration issues of an instrument measuring OHRQoL in older adults were included. Two researchers independently evaluated each instrument using the Evaluating Measures of Patient-Reported Outcomes (EMPRO) tool. The overall score and seven attribute-specific scores were calculated (range 0-100): Conceptual and measurement model, Reliability, Validity, Responsiveness, Interpretability, Burden, and Alternative forms., Results: We identified 14 instruments evaluated in 97 articles. The overall score varied between 73.7 and 8.9, with only six questionnaires over the threshold score 50.0. EORTC QLQ OH-15 (cancer-specific questionnaire) achieved the highest score (73.7), followed by OHIP (generic OHRQoL questionnaire) (66.9), GOHAI (generic OHRQoL questionnaire) (65.5), and OHIDL (generic OHRQoL questionnaire) (65.2). Overall, the Conceptual and measurement model and Validity showed the best performance, while Responsiveness and Interpretability showed the worst. Insufficient information was presented for an overall evaluation of DSQ and OHAI., Conclusion: The evidence supports using EORTC QLQ-OH15 as a specific instrument to assess OHRQoL in cancer patients and the OHIP-49, GOHAI, or OHIDL as generic instruments to assess OHRQoL either for cross-sectional or longitudinal studies in older adults., (© 2024. The Author(s).)

Poly- and Perfluoroalkyl Substances (PFAS) are a well-known class of pollutants which can bioaccumulate and biomagnify with a vast majority being highly persistent. This study aims to determine the biomagnification rates of PFAS in sexually mature striped dolphins and to assess temporal trends on PFAS concentrations over the past three decades (1990-2021) in the North-Western Mediterranean Sea. Thirteen and 17 of the 19 targeted PFAS were detected in the samples of the dolphins' digestive content and liver, respectively, at concentrations ranging between 43 and 1609 ng/g wet weight, and 254 and 7010 ng/g wet weight, respectively. The most abundant compounds in both types of samples were linear perfluorooctanesulfonic acid (n-PFOS) and perfluorooctanesulfonamide (FOSA), which were present in all samples, followed by perfluoroundecanoic acid (PFUnDA), perfluorotridecanoic acid (PFTrDA) and perfluorononanoic acid (PFNA). Long-chain PFAS (i.e., PFCAs C ≥ 7 and PFSAs C ≥ 6) biomagnified to a greater extent than short-chain PFAS, suggesting a potential effect on the health of striped dolphins. Environmental Quality Standards concentrations set in 2014 by the European Union were exceeded in half of the samples of digestive content, suggesting that polluted prey may pose potential health risks for striped dolphins. Concentrations of most long-chain PFAS increased from 1990 to 2004-2009, then stabilized during 2014-2021, possibly following country regulations and industrial initiatives. The current study highlights the persistent presence of banned PFAS and may contribute to future ecological risk assessments and the design of management strategies to mitigate PFAS pollution in marine ecosystems., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The World Health Organization Disability Assessment Schedule 2.0 12-item survey (WHODAS-12) is a questionnaire developed by the WHO to measure functioning across health conditions, cultures, and settings. WHODAS-12 consists of a subset of the 36 items of WHODAS-2.0 36-item questionnaire. Little is known about the minimal important difference (MID) of WHODAS-12 in persons with chronic low back pain (LBP), which would be useful to determine whether rehabilitation improves functioning to an extent that is meaningful for people experiencing the condition. Our objective was to estimate an anchor-based MID for WHODAS-12 questionnaire in persons with chronic LBP., Methods: We analyzed data from two cohort studies (identified in our previous systematic review) conducted in Europe that measured functioning using the WHODAS-36 in adults with chronic LBP. Eligible participants were adults with chronic LBP with scores on another measure as an anchor to indicate participants with small but important changes in functioning over time [Short-form-36 Physical Functioning (SF36-PF) or Oswestry Disability Index (ODI)] at baseline and follow-up (study 1: 3-months post-treatment; study 2: 1-month post-discharge from hospital). WHODAS-12 scores were constructed as sums of the 12 items (scored 0-4), with possible scores ranging from 0 to 48. We calculated the mean WHODAS-12 score in participants who achieved a small but meaningful improvement on SF36-PF or ODI at follow-up. A meaningful improvement was an MID of 4-16 on ODI or 5-16 on SF36-PF., Results: Of 70 eligible participants in study 1 (mean age = 54.1 years, SD = 14.7; 69% female), 18 achieved a small meaningful improvement based on SF-36 PF. Corresponding mean WHODAS-12 change score was - 3.22/48 (95% CI -4.79 to -1.64). Of 89 eligible participants in study 2 (mean age = 65.5 years, SD = 11.5; 61% female), 50 achieved a small meaningful improvement based on ODI. Corresponding mean WHODAS-12 change score was - 5.99/48 (95% CI - 7.20 to -4.79)., Conclusions: Using an anchor-based approach, the MID of WHODAS-12 is estimated at -3.22 (95% CI -4.79 to -1.64) or -5.99 (95% CI - 7.20 to -4.79) in adults with chronic LBP. These MID values inform the utility of WHODAS-12 in measuring functioning to determine whether rehabilitation or other health services achieve a minimal difference that is meaningful to patients with chronic LBP., (© 2023. The Author(s).)

Purpose: To assess the validity, reliability, and responsiveness of the Spanish version of the Expanded Prostate cancer Index Composite (EPIC) with 26 items., Methods: Multicentric longitudinal study of patients diagnosed with localized or locally advanced prostate cancer (any T, any N, M0) treated with active surveillance, surgery, external radiotherapy, or brachytherapy. The EPIC-50 was administered initially to the cohort (n = 324 patients), until it was replaced in November 2019 by the EPIC-26 (n = 543), in both groups before treatment and 12 months after. We assessed confirmatory factor analysis (CFA), reliability with Cronbach's alpha coefficient, criterion validity with the intraclass correlation coefficient (ICC), and responsiveness by testing a priori hypotheses on deterioration effect size (ES)., Results: The CFA confirmed the five-domain structure of the EPIC-26 proposed by the original instrument (comparative fit index = 0.95). The agreement between EPIC-50 (gold standard) and EPIC-26 domains was excellent (ICC > 0.90). Cronbach's alpha was > 0.7 in almost all domains, and the floor effect was near zero, although ceiling effect was higher than 50% in urinary incontinence and bowel domains. Hypothesized changes between before and 12 months after treatment were confirmed: ES > 0.8 in both urinary incontinence and sexual domains among patients who underwent surgery; and ES ranging 0.44-0.48 for bowel and sexual domains in patients treated with external radiotherapy., Conclusion: The Spanish version of the EPIC-26 has demonstrated adequate metric properties, similar to those of the original version, with acceptable goodness-of-fit indices, good criterion validity, reliability, and responsiveness to detect changes after radical prostatectomy or external radiotherapy., (© 2023. The Author(s).)

Introduction: Similar Patient-Reported Outcomes (PROs) at diagnosis for localized prostate cancer among countries may indicate that different treatments are recommended to the same profile of patients, regardless the context characteristics (health systems, medical schools, culture, preferences…). The aim of this study was to assess such comparison., Methods: We analyzed the EPIC-26 results before the primary treatment of men diagnosed of localized prostate cancer from January 2017 onwards (revised data available up to September 2019), from a multicenter prospective international cohort including seven regions: Australia/New Zealand, Canada, Central Europe (Austria / Czech Republic / Germany), United Kingdom, Italy, Spain, and the United States. The EPIC-26 domain scores and pattern of three selected items were compared across regions (with Central Europe as reference). All comparisons were made stratifying by treatment: radical prostatectomy, external radiotherapy, brachytherapy, and active surveillance., Results: The sample included a total of 13,483 men with clinically localized or locally advanced prostate cancer. PROs showed different domain patterns before treatment across countries. The sexual domain was the most impaired, and the one with the highest dispersion within countries and with the greatest medians' differences across countries. The urinary incontinence domain, together with the bowel and hormonal domains, presented the highest scores (better outcomes) for all treatment groups, and homogeneity across regions., Conclusions: Patients with localized or locally advanced prostate cancer undergoing radical prostatectomy, EBRT, brachytherapy, or active surveillance presented mainly negligible or small differences in the EPIC-26 domains before treatment across countries. The results on urinary incontinence or bowel domains, in which almost all patients presented the best possible score, may downplay the baseline data role for evaluating treatments' effects. However, the heterogeneity within countries and the magnitude of the differences found across countries in other domains, especially sexual, support the need of implementing the PRO measurement from diagnosis., (© 2023. The Author(s).)

Purpose: There is scarce comparative effectiveness research on the new treatment modalities for localized prostate cancer. We aim to compare through Patient-Reported Outcome Measures (PROMs) the impact of active surveillance, robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and real-time brachytherapy, considering side effects (incontinence, irritative/obstructive urinary symptoms, sexual dysfunction and bowel symptoms) and physical and mental health., Materials and Methods: Prospective cohort of men diagnosed with clinically localized prostate cancer (age 50-75y, T1-T2, and low risk including Gleason 3 + 4 in T1c) from 18 Spanish hospitals, followed up to 24 months. Treatment decisions were jointly made by patients and physicians (n = 572). The Expanded Prostate cancer Index Composite (EPIC-26) and Short-Form 36 (SF-36v2) were administered through telephone interviews before and three, six, 12, and 24 months after treatment. To account for correlation among repeated measures, generalized estimating equation models were constructed. All analyses were performed with propensity score weights to solve treatment selection bias., Results: The PROMs completion rate at 24 months was 95.0 %. Active surveillance entails the fewest side effects, but with significant sexual (0.4 standard deviations [SD], p < 0.001) and physical health deterioration (0.5 SD, p < 0.001); and moderate mental health improvement (0.4 SD, p = 0.001) at 24 months. Compared with active surveillance, RARP presented greater urinary incontinence (p = 0.030), and IMRT and real-time brachytherapy worse bowel symptoms (p = 0.027 and p = 0.007) at 24 months., Conclusions: Most side effects of the new treatment modalities seem to be limited to short-term deteriorations, except for moderate-large urinary incontinence in patients who had undergone RARP and moderate bowel deterioration in patients treated with IMRT or with real-time brachytherapy. Furthermore, patients under active surveillance, IMRT, and real-time brachytherapy showed a moderate improvement in mental health., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Marine debris pollution poses a significant global threat to biodiversity, with plastics being the primary debris type found in oceans due to their low-cost production and high demand worldwide. Microplastics (MPs, <5 mm in size) are highly bioavailable to a wide range of marine taxa, including marine mammals, through direct and indirect ingestion routes (i.e., trophic transfer). Recently, MP pollution has been detected on the Galapagos Marine Reserve, so in this study we developed a baseline framework for MP pollution in the Galapagos sea lion (GSL, Zalophus wollebaeki) through scat-based analysis. We collected 180 GSL scat samples from the southeast region following strict quality assurance/quality control protocols to detect, quantify and characterize physical-chemical properties of MPs through visual observations and μFT-IR spectroscopy. We recovered 81 MPs of varying sizes and colors in 37 % of samples (n = 66/180), consisting mostly of fibers (69 %, x¯ = 0.31 ± 0.57 particles scat -1 ). The number of particles per gram of sample wet weight ranged from 0.02 to 0.22 (x¯ = 0.04 ± 0.05 particles scat wet g -1 ). El Malecón and Punta Pitt rookeries at San Cristobal Island had the highest number of MPs (x¯ = 0.67 ± 0.51 and 0.43 ± 0.41 particles scat -1 , respectively), and blue-colored particles were the most common in all samples. We identified eleven polymers in 46 particles, consisting mostly of polypropylene-polyethylene copolymer, polypropylene, cellulose, polyethylene, and polyvinyl chloride. The textile, fishing, and packaging industries are likely significant sources of microfibers into this insular ecosystem. Our results suggest that the GSL is exposed to MPs due to anthropogenic contamination that is subsequently transferred through trophic processes. These findings provide an important baseline framework and insights for future research on MP pollution in the region, as well as for management actions that will contribute to the long-term conservation of the GSL., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: We aim to assess the impact of montelukast on paediatric patients with asthma/allergic rhinitis, measured using patient-reported outcome measures, compared with other treatments or placebo., Methods: Protocol registration CRD42020216098 (www.crd.york.ac.uk/PROSPERO). MEDLINE and Embase databases were used to conduct the search. Two authors independently selected studies and extracted data, and a third reviewer resolved discrepancies. Meta-analyses were constructed to estimate the standardised mean difference (SMD) using a random-effects model., Results: Out of 3937 articles identified, 49 studies met the inclusion criteria, mostly randomised clinical trials (sample sizes: 21-689 patients). The SMD of change pooled estimators for the global, mental and physical domains of health-related quality of life were not statistically significant. For daytime and night-time symptoms scores, the SMD (95% CI) was in favour of inhaled corticosteroids (-0.12, -0.20- -0.05 and -0.23, -0.41- -0.06, respectively). The pooled estimator for global asthma symptoms was better for montelukast when compared with placebo (0.90, 0.44-1.36)., Conclusions: The synthesis of the available evidence suggests that, in children and adolescents, montelukast was effective in controlling asthma symptoms when compared with placebo, but inhaled corticosteroids were superior in controlling symptoms, especially at night-time. These findings of our systematic review concur with current guidelines for asthma treatment., Competing Interests: Conflict of interest: All authors have nothing to disclose., (Copyright ©The authors 2023.)

Bisphenols (BPs) and phthalate esters (PAEs) are important compounds for the plastics industry, also called "everywhere chemicals" due to their ubiquity in daily use products. Both chemical groups are well-known environmental contaminants, whose presence has been reported in all environmental compartments, and whose effects, mainly associated to endocrine disruption, are detrimental to living organisms. Cetaceans, due to their long life-span, low reproduction rate and high position in the trophic web, are especially vulnerable to the effects of contaminants. However, little is known about BP and PAE concentrations in cetacean tissues, their potential relation to individual biological variables, or their trends over time. Here, the concentration of 10 BPs and 13 PAEs was assessed in the muscle of 30 striped dolphins (Stenella coeruleoalba) stranded along the Spanish Catalan coast (NW Mediterranean) between 1990 and 2018. Six BP and 6 PAE compounds were detected, of which only 4,4'-(cyclohexane-1,1-diyl)diphenol (BPZ) was detected in all the samples, at the highest concentration (mean 16.06 μg g -1 lipid weight). Sex or reproductive condition were largely uninfluential on concentrations: only dimethylphthalate (DMP) concentrations were significantly higher in immature individuals than in adults, and the overall PAE concentrations were significantly higher in males than in females. Temporal variations were only detected in bis(4-hydroxyphenyl)ethane (BPE), diethylphthalate (DEP) and dimethylphthalate (DMP), whose concentrations were lower, and 9,9-Bis(4-hydroxyphenyl)fluorene (BPFL), which were higher, respectively, in samples taken between 2014 and 2018, probably reflecting shifts in the production and use of these chemicals. These results provide the first assessment of concentrations of several BP and PAE compounds in the muscle of an odontocete cetacean., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interestsOdei Garcia-Garin reports financial support was provided by European Social Fund., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Functional social support is one of the most established predictors of health, and the Duke-UNC Functional Social Support Questionnaire (DUFSS) is one of the most commonly used instruments to measure this parameter. The objective of this study is to systematically review the available evidence on the psychometric and administration characteristics of the different versions of the DUFSS and perform a standardized assessment though to a specifically designed tool., Methods: A systematic review was performed in the PubMed/MEDLINE, SCOPUS, WOS and SCIELO databases. All articles that contained information on the development process of the instrument, the psychometric properties and aspects related to its administration were included, without restrictions based on publication date, language, or the version of the questionnaire that was studied. The selection and extraction procedure were carried out by two researchers. The articles finally included were peer-reviewed through a standardised assessment using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool. PROSPERO registration number: CRD42022342977., Results: A total of 54 articles were identified. After eliminating duplicates and screening articles based on the selection criteria, 15 studies that examined the DUFSS questionnaire resulting in 4 different versions: 3 articles obtained the 8-item version; 11 the 11-item version; and a single article obtained two versions, the 14-item version and the 5-item version. At least 60% of them did so in a young adult population, predominantly female and with a medium-low socio-economic level or with characteristics of social vulnerability. The EMPRO evaluation showed that the 11-item version (54.01 total score) was the only one that had been studied on all recommended attributes and had higher total scores than the other versions: 8 items (36.31 total score), 14 items (27.48 total score) and 5 items (23.81 total score). This difference appears in all attributes studied, with the highest scores in "reliability (internal consistency)" and "validity"., Conclusions: Of the 4 versions identified in the DUFSS questionnaire, the 11-item version was found to be optimal based on the EMPRO standardized tool. Although, a priori, we could prioritise its use in epidemiological studies over the other versions, it should be noted that this version should also be used with caution because there are attributes that have not been studied., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lozano-Hernández et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Although aluminum is widely distributed in the earth's crust, its environmental availability and wildlife assimilation rates are only partially known. Here we analyze aluminum concentrations in bone from 10 species of marine mammals inhabiting 3 geographic areas subject to different aluminum inputs: the Río de la Plata estuary (Uruguay), the coastal waters of Mauritania and the Galapagos archipelago (Ecuador). Overall, concentrations were unusually high as compared to those of terrestrial animals, with lowest concentrations in the Galapagos archipelago, then the Río de la Plata estuary and finally Mauritania. The aluminum source varied between regions, prevailing anthropogenic sources in the Río de la Plata Estuary and natural sources (wind-blown dust) in Mauritanian waters. The type of source determined contamination levels: anthropogenic sources were most significant for coastal species and showed a decline with distance of habitat from shoreline, while natural sources had a higher influence on open waters because of the dearth of biogenic silica that eliminates aluminum from the water column. Since aluminum remains in bone for several decades, marine mammal bone reflects historical levels of aluminum and therefore is a good bioindicator of the aluminum concentration of the marine environment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The number of published articles on Patient-Reported Outcomes Measures (PROMs) in Coronary Heart Disease (CHD), a leading cause of disability-adjusted life years lost worldwide, has been growing in the last decades. The aim of this study was to identify all the disease-specific PROMs developed for or used in CHD and summarize their characteristics (regardless of the construct), to facilitate the selection of the most adequate one for each purpose., Methods: A systematic review of reviews was conducted in MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews. PROQOLID and BiblioPRO libraries were also checked. PROMs were classified by construct and information was extracted from different sources regarding their main characteristics such as aim, number of items, specific dimensions, original language, and metric properties that have been assessed., Results: After title and abstract screening of 1224 articles, 114 publications were included for full text review. Finally, we identified 56 PROMs: 12 symptoms scales, 3 measuring functional status, 21 measuring Health-Related Quality of Life (HRQL), and 20 focused on other constructs. Three of the symptoms scales were specifically designed for a study (no metric properties evaluated), and only five have been included in a published study in the last decade. Regarding functional status, reliability and validity have been assessed for Duke Activity Index and Seattle Angina Questionnaire, which present multiple language versions. For HRQL, most of the PROMs included physical, emotional, and social domains. Responsiveness has only been evaluated for 10 out the 21 HRQL PROMs identified. Other constructs included psychological aspects, self-efficacy, attitudes, perceptions, threats and expectations about the treatment, knowledge, adjustment, or limitation for work, social support, or self-care., Conclusions: There is a wide variety of instruments to assess the patients' perspective in CHD, covering several constructs. This is the first systematic review of specific PROMs for CHD including all constructs. It has practical significance, as it summarizes relevant information that may help clinicians, researchers, and other healthcare stakeholders to choose the most adequate instrument for promoting shared decision making in a trend towards value-based healthcare., (© 2022. The Author(s).)

Purpose: To obtain reference norms of EORTC QLQ-C30, EORTC QLQ-BR23, and EQ-5D-5L, based on a population of Spanish non-metastatic breast cancer patients at diagnosis and 2 years after, according to relevant demographic and clinical characteristics., Methods: Multicentric prospective cohort study including consecutive women aged ≥ 18 years with a diagnosis of incident non-metastatic breast cancer from April 2013 to May 2015. Health-related quality of life (HRQoL) questionnaires were administered between diagnosis and beginning the therapy, and 2 years after. HRQoL differences according to age, comorbidity and stage were tested with ANOVA or Chi Square test and multivariate linear regression models., Results: 1276 patients were included, with a mean age of 58 years. Multivariate models of EORTC QLQ-C30 summary score and EQ-5D-5L index at diagnosis and at 2-year follow-up show the independent association of comorbidity and tumor stage with HRQoL. The standardized multivariate regression coefficient of EORTC QLQ-C30 summary score was lower (poorer HRQoL) for women with stage II and III than for those with stage 0 at diagnosis (- 0.11 and - 0.07, p < 0.05) and follow-up (- 0.15 and - 0.10, p < 0.01). The EQ-5D-5L index indicated poorer HRQoL for women with Charlson comorbidity index ≥ 2 than comorbidity 0 both at diagnosis (- 0.13, p < 0.001) and follow-up (- 0.18, p < 0.001). Therefore, we provided the reference norms at diagnosis and at the 2-year follow-up, stratified by age, comorbidity index, and tumor stage., Conclusion: These HRQoL reference norms can be useful to interpret the scores of women with non-metastatic breast cancer, comparing them with country-specific reference values for this population., (© 2023. The Author(s).)

Marine mammals are one of the groups of animals most affected by marine pollution including that by organic compounds which, besides bearing recognised harmful effects to adults, they may also affect foetuses through placental transfer. In this study we analysed samples of fin whale (Balaenoptera physalus) females and their foetuses collected in the western Iceland summer feeding grounds in 2018. Three different families of organic pollutants: organophosphate esters (OPEs); halogenated flame retardants (HFRs); and short chain chlorinated paraffins (SCCPs), were analysed and their placental transfer investigated. HFRs were detected in 87.5% of females and 100% of foetus samples with concentrations that ranged between nd-15.4 and 6.37-101 ng/g lipid weight (lw), respectively. OPEs were detected in all samples, both from females (85.8-567 ng/g lw) and foetuses (nq-1130 ng/g lw). SCCPs were detected in 87.5% of female samples and 100% of foetal samples with concentrations that ranged between nd-30.9 and nq-574 ng/g lw, respectively. For OPE compounds, a significant negative correlation was observed between the logarithm maternal transfer ratio and their log K ow, indicating that a high lipophilicity reduced placental transfer rate. Interestingly, the decabromodiphenyl ethane (DBDPE) was the compound with the highest log K ow but also the one that was transferred the most from mothers to foetuses, calling for in-depth research on this pollutant. These results constitute the first evidence of mother-calf transfer of plasticizers and flame retardants in fin whales. Further investigations are needed to determine their potential effects on this species and other groups of animals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The fin whale (Balaenoptera physalus) is a migratory filter-feeding species that is susceptible to ingest plastics while lunge feeding across the oceans. Plastic additives, such as phthalates, are compounds that are added to plastics to give them specific characteristics, such as flexibility. These so-called plasticizers are currently raising major concern because of their potential adverse effects on marine fauna. However, little is known about phthalate concentrations in tissues of baleen whales as well as their potential relation with biological variables (i.e., sex, body length and age) and their trends with time. In this study, we assessed the concentration of 13 phthalates in the muscle of 31 fin whales sampled in the feeding grounds off western Iceland between 1986 and 2015. We detected 5 of the 13 phthalates investigated, with di-n-butylphthalate (DBP), diethylphthalate (DEP) and bis(2-ethylhexyl) phthalate (DEHP) being the most abundant. None of the biological variables examined showed a statistically significant relationship with phthalate concentrations. Also, phthalate concentrations did not significantly vary over the 29-year period studied, a surprising result given the global scenario of increasing plastic pollution in the seas. The lack of time trends in phthalate concentration may be due in part to the fact that phthalates also originate from other sources. Although no adverse effects of phthalates on fin whales have been detected to date, further monitoring of these pollutants is required to identify potential toxic effects in the future., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

To compare the effectiveness at ten years of follow-up of radical prostatectomy, brachytherapy and external radiotherapy, in terms of overall survival, prostate cancer-specific mortality and biochemical recurrence. Cohort of men diagnosed with localized prostate cancer (T1/T2 and low/intermediate risk) from ten Spanish hospitals, followed for 10 years. The treatment selection was decided jointly by patients and physicians. Of 704 participants, 192 were treated with open radical retropubic prostatectomy, 317 with 125 I brachytherapy alone, and 195 with 3D external beam radiation. We evaluated overall survival, prostate cancer-specific mortality, and biochemical recurrence. Kaplan-Meier estimators were plotted, and Cox proportional-hazards regression models were constructed to estimate hazard ratios (HR), adjusted by propensity scores. Of the 704 participants, 542 patients were alive ten years after treatment, and a total of 13 patients have been lost during follow-up. After adjusting by propensity score and Gleason score, brachytherapy and external radiotherapy were not associated with decreased 10-year overall survival (aHR = 1.36, p = 0.292 and aHR = 1.44, p = 0.222), but presented higher biochemical recurrence (aHR = 1.93, p = 0.004 and aHR = 2.56, p < 0.001) than radical prostatectomy at ten years of follow-up. Higher prostate cancer-specific mortality was also observed in external radiotherapy (aHR = 9.37, p = 0.015). Novel long-term results are provided on the effectiveness of brachytherapy to control localized prostate cancer ten years after treatment, compared to radical prostatectomy and external radiotherapy, presenting high overall survival, similarly to radical prostatectomy, but higher risk of biochemical progression. These findings provide valuable information to facilitate shared clinical decision-making.Study identifier at ClinicalTrials.gov: NCT01492751., (© 2022. The Author(s).)

Background: Asthma impacts children's physical, emotional, and psychosocial Health-Related Quality of Life (HRQL). The EQ-5D-Y is a generic econometric instrument developed to measure HRQL in children., Objective: Evaluation of feasibility, validity, reliability, and responsiveness of EQ-5D-Y descriptive system and utility index to allow the assessment of HRQL in children with asthma, aged 8-11 years (self-response version) or under 8 years old (proxy-response version)., Methods: We used data from baseline to 10 months of follow-up of an observational, prospective study of children with persistent asthma recruited by pediatricians in Spain (2018-2020). HRQL instruments were administered through a smartphone application: ARCA app. The EQ-5D-Y is composed of a 5-dimension descriptive system, a utility index ranging from 1 to - 0.5392, and a general health visual analogue scale (EQ-VAS). The Pediatric Asthma Impact Scale (PROMIS-PAIS) includes 8 items, providing a raw score. Construct validity hypotheses were stated a priori, and evaluated following two approaches, multitrait-multimethod matrix and known groups' comparisons. Reliability and responsiveness subsamples were defined by stability or change in EQ-VAS and the Asthma Control Questionnaire (ACQ), to estimate the intraclass correlation coefficient (ICC) and the magnitude of change over time., Results: The EQ-5D-Y was completed at baseline for 119 children (81 self-responded and 38 through proxy response), with a mean age of 9.1 (1.7) years. Mean (SD) of the EQ-5D-Y utility index was 0.93 (0.11), with ceiling and floor effects of 60.3% and 0%, respectively. Multitrait-multimethod matrix confirmed the associations previously hypothesized for the EQ-5D-Y utility index [moderate with PROMIS-PAIS (0.38) and weak with ACQ (0.28)], and for the EQ-5D-Y dimension "problems doing usual activities" [moderate with the ACQ item (0.35) and weak with the PROMIS-PAIS item (0.17)]. Statistically significant differences were found in the EQ-5D-Y between groups defined by asthma control, reliever inhalers use, and second-hand smoke exposure, with mostly moderate effect sizes (0.45-0.75). The ICC of the EQ-5D-Y utility index in the stable subsamples was high (0.81 and 0.79); and responsiveness subsamples presented a moderate to large magnitude of change (0.68 and 0.78), though without statistical significance., Conclusions: These results support the use of the EQ-5D-Y as a feasible, valid, and reliable instrument for evaluating HRQL in children with persistent asthma. Further studies are needed on the responsiveness of the EQ-5D-Y in this population., (© 2022. The Author(s).)

Objective: To compare the main academic characteristics and contents of the different master's programs in public health currently offered in Spain., Method: A systematic search has been carried out in the Register of Universities, Centers and Degrees of the Ministry of Education, Culture and Sports. The main academic characteristics and the contents (mandatory and optional) of the programs of 11 official master's degrees with the renewed accreditation in 2018 were analyzed based on the data published on the universities' web pages., Results: Most programs are 60 ECTS (European Credit Transfer and Accumulation System), face-to-face, taught in Spanish, include in their curriculum the completion of a master's thesis but not professional practices. Only contents related to statistics and basic epidemiology, and the training activity of master's thesis, are offers by all programs., Conclusions: The majority of public health master's programs in Spain shows a certain homogeneity regarding their academic characteristics, but a great heterogeneity in relation to their contents. There is also a great heterogeneity in the credits granted to the different subjects, especially optional subjects. It would be advisable to standardize a common core, especially in the mandatory contents., (Copyright © 2020 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

There is a need for instruments designed for patients with asthma to self-report their performance of inhaling steps. We aimed to develop an accessible and easy-to-use patient-reported tool for inhaler technique assessment, which could also serve as a training and monitoring resource for any type of inhaler device, and to evaluate its feasibility, validity, and reliability in adults with asthma. The development was based on literature review and pilot testing with clinicians and patients. The Inhaler Technique Questionnaire (InTeQ) asks about the frequency of performing five steps when using inhalers (on a five-point Likert scale). We analyzed data from adults with persistent asthma ( n = 361). We examined the measurement model using Mokken scaling analysis, construct validity by assessing hypotheses on expected discrimination among known groups, and reliability based on internal consistency and reproducibility. Means of the InTeQ items were in the range of 0.23-1.61, and coefficients of homogeneity were above the cutoff point, demonstrating the unidimensionality of the scale. Known groups' global score differences were statistically significant between patients reporting having "Discussed in detail" or having "Not discussed/Only in general" the inhaler technique with their healthcare providers ( p = 0.023). The Cronbach's alpha coefficient was 0.716, and the intraclass correlation coefficient was 0.775. The InTeQ is a feasible, valid, and reliable instrument for self-reporting inhaler technique on any type of device.

Objectives: This study aimed to develop mapping algorithms from the Expanded Prostate Cancer Index Composite (EPIC) and the Short-Form (SF) Health Surveys to the Patient-Oriented Prostate Utility Scale (PORPUS), an econometric instrument specifically developed for patients with prostate cancer., Methods: Data were drawn from 2 cohorts concurrently administering PORPUS, EPIC-50, and SF-36v2. The development cohort included patients who had received a diagnosis of localized or locally advanced prostate cancer from 2017 to 2019. The validation cohort included men who had received a diagnosis of localized prostate cancer from 2014 to 2016. Linear regression models were constructed with ln(1 - PORPUS utility) as the dependent variable and scores from the original and brief versions of the EPIC and SF as independent variables. The predictive capacity of mapping models constructed with all possible combinations of these 2 instruments was assessed through the proportion of variance explained (R 2 ) and the agreement between predicted and observed values. Validation was based on the comparison between estimated and observed utility values in the validation cohort., Results: Models constructed with EPIC-50 with and without SF yielded the highest predictive capacity (R 2  = 0.884, 0.871, and 0.842) in comparison with models constructed with EPIC-26 (R 2  = 0.844, 0.827, and 0.776). The intraclass correlation coefficient was excellent in the 4 models (>0.9) with EPIC and SF. In the validation cohort, predicted PORPUS utilities were slightly higher than those observed, but differences were not statistically significant., Conclusions: Mapping algorithms from both the original and the abbreviated versions of the EPIC and the SF Health Surveys allow estimating PORPUS utilities for economic evaluations with cost-utility analyses in patients with prostate cancer., (Copyright © 2021 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Purpose: The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them., Methods: The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights)., Results: The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application., Conclusions: Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients., (© 2021. Springer Nature Switzerland AG.)

The estuary of Río de la Plata, in the eastern coast of South America, is a highly anthropized area that brings a high load of contaminants to the surrounding waters, which may have detrimental effects on the local marine fauna. The franciscana dolphin (Pontoporia blainvillei) is a small cetacean species endemic of the southwestern Atlantic Ocean listed as Vulnerable in the IUCN red list. In this study, we assessed the concentrations of 13 trace elements in bone samples from 100 franciscana dolphins that were found stranded dead or incidentally bycaught in the Río de la Plata and adjacent coast between 1953 and 2015. Elements were, in decreasing order of mean concentrations: Zn > Sr > Fe > Al > Mn > Cu > Pb > Cr > Ni > As > Hg > Cd > Se. The concentrations of Al, Cr and Fe were slightly higher in females than in males. The concentrations of As, Ni, and Pb significantly decreased with body length. Throughout the study period, the concentrations of Al, Cr, Cu, Fe, Mn and Ni significantly increased, while the concentrations of As, Pb and Sr significantly decreased. The increasing trends may be due to increased inputs from river discharges, the leather industry and petroleum refineries, while the decrease in Pb may be due to the ban in the use of this element as an additive in gasoline and as component of car batteries. This investigation supports the validity of analysing trace element in bone, a tissue available in scientific collections and museums, to retrospectively examine variation over long temporal scales and thus assess long-term trends in pollution., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

In this study we aim to assess the daily ingestion rates of synthetic particles by the fin whales (Balaenoptera physalus) that feed off the western coast of Iceland. To do so, we collected and analysed samples from the stomach content of 25 fin whales, consisting solely of northern krill (Meganyctiphanes norvegica). The particles found consisted of fibres and fragments, mainly blue, black and red, with an average size of 1.2 ± 1.3 mm. To confirm the synthetic nature of these particles, we used Micro-Fourier Transform Infrared Spectroscopy and comparison with a polymer library. The mean concentration of synthetic particles in the krill samples found in the stomachs of whales was 0.057 particles per gram, a value much lower than that previously reported for particle uptake by krill. From this concentration in krill, we estimated that the daily intake of synthetic particles for the North Atlantic fin whale would be ranging from 38,646 ± 43,392 to 77,292 ± 86,784 particles per day. Although at this level it is not possible to assess the impact of synthetic particles and their associated chemicals on the North Atlantic fin whale population, concentrations of these contaminants are likely to increase in the future, potentially causing adverse effects on whales and other marine mammals., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: Long-term comparative effectiveness research on localized prostate cancer treatments is scarce, and evidence is lacking especially for brachytherapy. The aim of this study was to assess the long-term impact of the side effects of radical prostatectomy, brachytherapy, and external radiation therapy on patients with localized prostate cancer at 10 years, using propensity score analyses., Methods and Materials: This was a prospective observational study of a cohort of men who received a diagnosis of clinically localized prostate cancer (clinical stage T1 or T2, low and intermediate risk group) and were treated with radical prostatectomy (n = 139), brachytherapy (n = 317), or external radiation therapy (n = 194). Treatment decisions were jointly made by patients and physicians. Patient-reported outcome (PRO) evaluation included the Expanded Prostate Cancer Index Composite and Short Form-36, administered centrally by telephone interviews before and annually after treatment. The Expanded Prostate Cancer Index Composite covers urinary, bowel, sexual, and hormonal domains. To assess PRO changes over time, while accounting for correlation among repeated measures, generalized estimating equation models adjusted by propensity scores were constructed., Results: The PRO completion rate at 10 years was 85.8%. Generalized estimating equation models showed that the pattern of radical prostatectomy side effects, with substantial urinary incontinence and sexual dysfunction, remained until 10 years after treatment (standard deviation [SD], -1.1 and -1.3, respectively). Brachytherapy produced late deterioration in urinary continence (SD, -0.4) and sexual function (SD, -0.9) that appeared midterm, but the differences from radical prostatectomy remained statistically significant at 10 years (P < .001 after adjusting by propensity score). External radiation therapy showed similar results to brachytherapy, but with bowel bother (SD, -0.3)., Conclusions: Although late deterioration in radiation therapy groups attenuated differences from radical prostatectomy, relevant PRO differences still remained after 10 years. Our findings support that brachytherapy is the treatment option that causes the least impact on PROs; it is therefore an alternative to be considered when making evidence-based decisions on localized prostate cancer treatment., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Brachytherapy (BT) and external beam radiation therapy (EBRT) are effective treatments for high-risk prostate cancer (PCa). However, the impact of these treatments on health-related quality of life (HRQL) remains unclear. In this study, we compared EBRT alone with EBRT plus a boost with high-dose rate (HDR)-BT to determine the impact on HRQL in patients with high-risk PCa., Material and Methods: Prospective, multicenter study comparing patients with high-risk PCa treated with EBRT alone or EBRT + HDR-BT from 2004 to 2006. HRQL was assessed at baseline (pre-treatment) and periodically over the 5-year follow-up, using the SF-36 (v.2), EPIC, and FACT-G and FACT-P questionnaires., Results: A total of 129 patients were included in the study, of these, 41 received EBRT alone and 88 EBRT + HDR-BT. All patients received hormonotherapy. Baseline clinical characteristics were similar, except for a slightly higher mean number of comorbidities in the EBRT group. During follow-up, the only significant between-group difference was a greater worsening on EPIC hormonal domain in the EBRT alone group ( p = 0.028). There were no significant differences in time and interaction of treatment in SF-36, and FACT-G and FACT-P questionnaires or EPIC urinary incontinence, urinary irritative-obstructive, and bowel and sexual domains over the 5-year follow-up. Oncological outcomes were similar in both groups., Conclusions: After five years of follow-up, EBRT alone or combined with HDR-BT boost had a similar impact on HRQL in patients with high-risk localized PCa. However, patients in the EBRT alone group experienced greater worsening of hormonal domain according to EPIC questionnaire., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Termedia.)

The threats posed by floating marine macro-litter (FMML) of anthropogenic origin to the marine fauna, and marine ecosystems in general, are universally recognized. Dedicated monitoring programmes and mitigation measures are in place to address this issue worldwide, with the increasing support of new technologies and the automation of analytical processes. In the current study, we developed algorithms capable of detecting and quantifying FMML in aerial images, and a web-oriented application that allows users to identify FMML within images of the sea surface. The proposed algorithm is based on a deep learning approach that uses convolutional neural networks (CNNs) capable of learning from unstructured or unlabelled data. The CNN-based deep learning model was trained and tested using 3723 aerial images (50% containing FMML, 50% without FMML) taken by drones and aircraft over the waters of the NW Mediterranean Sea. The accuracies of image classification (performed using all the images for training and testing the model) and cross-validation (performed using 90% of images for training and 10% for testing) were 0.85 and 0.81, respectively. The Shiny package of R was then used to develop a user-friendly application to identify and quantify FMML within the aerial images. The implementation of this, and similar algorithms, allows streamlining substantially the detection and quantification of FMML, providing support to the monitoring and assessment of this environmental threat. However, the automated monitoring of FMML in the open sea still represents a technological challenge, and further research is needed to improve the accuracy of current algorithms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The aim of the present study was twofold: (i) to validate the drone methodology for floating marine macro-litter (FMML) monitoring, by comparing the results obtained through concurrent drone surveys and visual observations from vessels, and (ii) to assess FMML densities along the North Western Mediterranean Sea using the validated drone surveys. The comparison between monitoring techniques was performed based on 18 concurrent drone/vessel transects. Similar densities of FMML were detected through the two methods (16 items km -2 from the drone method vs 19 items km -2 from the vessel-based visual method). The assessment of FMML densities was done using 40 additional drone transects performed over the waters off the Catalan coast. The densities of FMML observed ranged 0-200 items km -2 . These results provide a validation of the use of drones to monitor FMML and contribute to increasing the knowledge about the density of FMML in the North Western Mediterranean Sea., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Microplastics are present in almost all seas and oceans, including the Southern Ocean. To the south of the Antarctic Polar Front, microplastics are present mainly west to the Antarctic Peninsula, but information is scarce about their impact on the pelagic food web. Here, we analysed 42 scats of male Antarctic fur seals (Arctocephalus gazella) collected in late summer at Deception Island (South Shetland Islands), which allowed us to assess the presence of microplastics in the pelagic food web of the Bransfield Strait (Western Antarctica). Furthermore, we analysed the hard remains of prey in the scats to characterize the diet of fur seals. Hard remains recovered from the scats revealed that male Antarctic fur seals foraged on krill and myctophid fishes during late summer. Fourier-transform infrared spectroscopy (FT-IR) revealed that none of the seven fragments and three fibres recovered from their scats were microplastics, but rather were silicate minerals and chitin. These results suggest that the levels of microplastic pollution in the pelagic food web of the Bransfield Strait are extremely low., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

This study assesses microplastic ingestion in Boops boops at different geographical areas in the Mediterranean Sea. A total of 884 fish were caught at 20 coastal sites in Spain, France, Italy and Greece and analyzed using a common methodological protocol. Microplastics were found in 46.8% of the sampled fish, with an average number of items per individual of 1.17 ± 0.07. Filaments were the predominant shape type, while polyethylene and polypropylene were indicated by FTIR as the most common polymer types of ingested microplastics. The frequency of occurrence, as well as the abundance and proportion of types (size, shape, color and polymer) of ingested microplastics, varied among geographical areas. The spatial heterogeneity of the abundance of ingested microplastics was mainly related to the degree of coastal anthropogenic pressure at the sampling sites. Our findings further support the suitability of B. boops as bioindicator of microplastic pollution in the Mediterranean Sea., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Nurses play an important part in the education of patients with HF. To prepare patients with HF for self-care maintenance behaviours, nurses must have knowledge of basic self-care maintenance principles., Aim Study: The aim of this study was to determine the degree of knowledge of primary care (PC) nurses on the principles of self-management of HF and variables associated with this., Methodology: This is an observational, cross-sectional descriptive study, carried out in 2014, in the city of Barcelona (Catalonia). Nurses' Knowledge of Heart Failure Education Principles questionnaire (NKHFEP) was used to assess the principles of HF self-care education. Instrument items assess knowledge of nurses on 5 themes: diet, liquids/weight, worsening signs or symptoms, medication and exercise. Factors related to adequate knowledge were evaluated., Results: Of 216 PC nurses, who completed the questionnaire, the average score was 15.6 (SD: 2.2). Only 36 (16.7%) obtained an adequate level of knowledge and defined as a score ≥ 18 points. In multivariate logistic regression, nurse factors associated with an adequate knowledge of principles of self-care of HF were having achieved a PhD degree (OR: 36.4, 95% CI: 2.8-468.2, p = 0.006) and previous specific training in HF (OR: 19.8, 95% CI: 1.4-279.3, p = 0.026)., Conclusions: The degree of knowledge of PC nurses in the principles of self-care in HF was higher among nurses who had completed the doctorate and in nurses who had received specific training in HF., (© 2019 Nordic College of Caring Science.)

Plastic litter pollution is increasing in the seas and oceans worldwide, raising concern on the potential effects of plasticizer additives on marine fauna. In this study, muscle samples of 30 bogues (Boops boops; Linneaus, 1758) from the North Western Mediterranean Sea were analysed to assess the concentrations of 19 organophosphate flame retardant (OPFR) compounds and to inspect any relationship with microplastic ingestion and relative levels of anthropization. Out of the 19 OPFRs analysed, 6 compounds were detected, being tri-n-butyl phosphate (TNBP), 2-ethylhexyldiphenyl phosphate (EHDPP) and triphenylphosphine oxide (TPPO) the most abundant. As expected, OPFR concentrations were higher in samples collected off the most anthropized area of the city of Barcelona than in those from the Cap de Creus Marine Protected Area, while no significant correlation was detected between OPFR concentrations and microplastic ingestion. The results of this manuscript provide a first evidence of OPFR presence in the muscle of the bogue and identify the coastal area off Barcelona as a possible concentration area for contaminants, further supporting the use of the bogue as an indicator species of plastic pollution in the Mediterranean Sea., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Pollution of the marine environment by litter composed of plastics is a growing concern. Chemical additives such as organophosphate flame retardants (OPFRs), which are added to plastics to improve their qualities, are in focus because they allegedly cause adverse effects on marine fauna. Here we analyse OPFR levels in the muscle of fin whales because, as a mysticete, this cetacean obtains its food by filter-feeding and is thus highly vulnerable to marine litter. Moreover, the fin whale performs long-range migrations from low-latitude areas in winter to high-latitude areas in summer, a trait that makes it a potentially good large-scale biomonitor of pollution. We also analyse OPFR levels in its main prey, the krill Meganyctiphanes norvegica, to assess transfer through diet. The samples analysed consisted of muscle tissue from 20 fin whales and whole-body homogenates of 10 krill samples, all collected off West Iceland. From the 19 OPFRs analysed, we detected 7 in the fin whale and 5 in the krill samples. Tri-n-butyl phosphate (TNBP), Isopropylated triphenyl phosphate (IPPP) and Triphenylphosphine oxide (TPPO) were the most abundant compounds found in both species. Mean ∑OPFR concentration, expressed on a lipid weight basis, was 985 (SD = 2239) ng g -1 in fin whale muscle, and 949 (SD = 1090) ng g -1 in krill homogenates. These results constitute the first evidence of the presence of OPFRs in the tissues of fin whales. Furthermore, they seem to support the non-significance of bioaccumulation of OPFRs through lifespan and of biomagnification trough the food web., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To compare pre- and post-radical prostatectomy (RP) responses in the urinary incontinence domain of Expanded Prostate Cancer Index Composite-26 (EPIC-26) in cohorts from the USA, Norway and Spain., Methods: A prospective study of pre- and 1-year post-treatment responses in American ( n =537), Norwegian ( n =520) and Spanish ( n =111) patients, establishing the prevalence of urinary incontinence defined according to published dichotomization. Thereafter we focused on the response alternatives "occasional dribbling", pad use and problem experience. A multivariate logistic regression analysis (significance level ≤ 0.01) considered risk factors for "not retaining total control"., Results: Compared to the European men, the American patients were younger, healthier and more presented with lower risk tumors. Before RP no inter-country differences emerged the prevalence of urinary incontinence (6%). One-year post-treatment urinary incontinence was described by 30% of the American and 41% of the European patients, occasional dribbling being the most frequent type of urinary leakage. In the multivariate analysis the risk of "not retaining total control" increased almost 3-fold in European compared to American patients, with age and co-morbidity being additional independent risk factor., Conclusion: After RP patients from Spain and Norway reported more unfavorable outcomes by EPIC-26 than the American patients to most of the urinary incontinence items, the difference between the European and American patients remaining in the multivariate analysis. The most frequent post-RP response alternative "occasional dribbling" needs to be validated with pad weighing as "gold standard"., (© 2020 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V.)

Pollution by marine litter is raising major concerns due to its potential impact on marine biodiversity and, above all, on endangered mega-fauna species, such as cetaceans and sea turtles. The density and distribution of marine litter and mega-fauna have been traditionally monitored through observer-based methods, yet the advent of new technologies has introduced aerial photography as an alternative monitoring method. However, to integrate results produced by different monitoring techniques and consider the photographic method a viable alternative, this 'new' methodology must be validated. This study aims to compare observations obtained from the concurrent application of observer-based and photographic methods during aerial surveys. To do so, a Partenavia P-68 aircraft equipped with an RGB sensor was used to monitor the waters off the Spanish Mediterranean coast along 12 transects (941 km). Over 10000 images were collected and checked manually by a photo-interpreter to detect potential targets, which were classified as floating marine macro-litter, mega-fauna and seabirds. The two methods allowed the detection of items from the three categories and proved equally effective for the detection of cetaceans, sea turtles and large fish on the sea surface. However, the photographic method was more effective for floating litter detection and the observer-based method was more effective for seabird detection. These results provide the first validation of the use of aerial photography to monitor floating litter and mega-fauna over the marine surface., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: In asthma, short- and long-acting β-agonists (SABAs and LABAs) should be used together with inhaled corticosteroids (ICS), and regular use is inappropriate., Objective: To assess the relationship between patterns of use of therapy and asthma exacerbations (AEx)., Methods: Patients with asthma (6-40 years) were enrolled in France and the United Kingdom. Prescribing data, computer-assisted telephone interviews (CATIs), and text messages assessed medication use and AEx over a maximum period of 24 months. Generalized linear mixed models provided AEx risks associated with therapy., Results: Among the 908 patients (median age: 20.0 years, 46.6% women, 24.5% children) answering a total of 4248 CATIs over 486 (±235) days, regular (ie, daily) use was more frequent for single LABAs and fixed dose combinations (FDCs) than for single ICS (75.6%, 70.1%, and 65.4% of investigated periods of use, respectively). Regular (ie, daily or almost daily) SABA use was observed for 21.1% of periods of use. Altogether, 265 patients (29.2%) experienced 1 or more AEx. The ORs for AEx risk related to regular vs no use of FDCs, single ICS, and single LABAs were 0.98 (95% CI = [0.73-1.33]), 0.90 (95% CI = [0.61-1.33]), and 1.29 (95% CI = [0.76-2.17]), respectively, after adjustment for cotherapy, sociodemographic, and disease characteristics. The OR was 2.09 (95% CI = [1.36-3.21]) in regular SABA users., Conclusion: Inhaled corticosteroids and FDCs were often used intermittently, whereas SABAs and LABAs could be used regularly, and exacerbations were frequent. Compared with non-users, the risk of exacerbation increased moderately under regular use of single LABAs, whereas it doubled, significantly, in regular SABA users, likely in relationship with poor overall asthma control., (Copyright © 2019 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: We assessed differences between gay and bisexual men in enacted stigma, and how the association between stigma and depressive symptoms may vary according to sexual orientation identity. Methods: Participants (671 gay and 331 bisexual men who have sex with men) in Baltimore's 2011 and 2014 National HIV Behavioral Surveillance completed an anonymous survey, including 3 enacted stigma dimensions and the Center for Epidemiologic Studies Depression Scale. Adjusted prevalence ratios were calculated through Generalized Estimating Equation models adjusting for theorized confounders (demographic, socioeconomic, and relational factors). Results: Bisexual men reported stigma experiences less frequently than did gay men (verbal harassment 22.7% vs. 32.3%, and discrimination 15.7% vs. 23.0%). Relevant depressive symptoms were reported by 43.1% of bisexual men and 34.2% of gay men ( p  < 0.001). Statistically significant differences in depressive symptoms between bisexual and gay men disappeared after adjusting for socioeconomic factors. The three enacted stigma dimensions were significantly associated with depressive symptoms, but their interaction with sexual orientation identity was not. Conclusion: This study confirms the association between enacted stigma and depressive symptoms among gay and bisexual men. However, sexual orientation identity did not modify this association as hypothesized. The bisexual men presented other psychosocial stressors that may explain their higher prevalence of depressive symptoms. The high levels of verbal harassment, discrimination, and physical assault reported by gay and bisexual men and their negative effect on mental health indicate the need to develop new effective public health strategies to avoid these consequences of homophobic and biphobic culture.

Background: The lack of continuity between health-related quality of life (HRQoL) instruments designed for children and adults hinders change analysis with a life course approach. To resolve this gap, EuroQol (EQ) developed the EQ-5D-Youth (EQ-5D-Y), derived from the EQ-5D for adults. Few studies have assessed the metric properties of EQ-5D-Y in children with specific chronic conditions, and none have done so for children with type I diabetes mellitus (T1DM)., Objective: This study aimed to evaluate the acceptability, validity, reliability, and responsiveness of the EQ-5D-Y in children and adolescents with T1DM, when administered online., Methods: Participants with T1DM were consecutively recruited from July to December 2014, from a list of potential candidates aged 8-19 years, who attended outpatient pediatric endocrinology units. Before every quarterly routine visit, participants received an email/telephone reminder to complete the online version of two generic HRQoL questionnaires: EQ-5D-Y and KIDSCREEN-27. The EQ-5D-Y measures five dimensions, from which an equally weighted summary score was constructed (range: 0-100). Completion rate and distribution statistics were calculated. Construct validity was evaluated through known group comparisons based on general health, acute diabetic decompensations, mental health, family function, and a multitrait, multimethod matrix between EQ-5D-Y and KIDSCREEN by using Spearman correlations. Construct validity hypotheses were stated a priori. Reliability was assessed with the intraclass correlation coefficient and responsiveness by testing changes over time and calculating the effect size. Reliability and responsiveness were tested among the stable and improved subsamples defined by a KIDSCREEN-10 index change of <4.5 points or ≥4.5 points, respectively, from the first to the fourth visit., Results: Of the 136 participants, 119 (87.5%) responded to the EQ-5D-Y at the last visit. The dimensions that showed higher percentages of participants with problems were "having pain/discomfort" (34.6%) and "worried/sad/unhappy" (28.7%). The mean (SD) of the EQ-5D-Y summary score was 8.5 (10.9), with ceiling and floor effects of 50.7% and 0%, respectively. Statistically significant HRQoL differences between groups defined by their general health (excellent/very good and good/regular/bad) and mental health (Strengths and Difficulties Questionnaire score ≤15 and >16, respectively) were found in three EQ-5D-Y dimensions ("doing usual activities," "having pain/discomfort," and "feeling worried/sad/unhappy"), summary score (effect size for general health and mental health groups=0.7 and 1.5, respectively), and KIDSCREEN-10 index (effect size for general health and mental health groups=0.6 and 0.9, respectively). Significant differences in the EQ-5D-Y dimensions were also found according to acute diabetic decompensations in "looking after myself" (P=.005) and according to family function in "having pain/discomfort" (P=.03). Results of the multitrait, multimethod matrix confirmed three of the four relationships hypothesized as substantial (0.21, 0.58, 0.50, and 0.46). The EQ-5D-Y summary score presented an intraclass correlation coefficient of 0.83. Statistically significant change between visits was observed in the improved subsample, with an effect size of 0.7 (P<.001)., Conclusions: These results support the use of the EQ-5D-Y administered online as an acceptable, valid, reliable, and responsive instrument for evaluating HRQoL in children and adolescents with T1DM., (©Karina Mayoral, Luis Rajmil, Marta Murillo, Olatz Garin, Angels Pont, Jordi Alonso, Joan Bel, Jacobo Perez, Raquel Corripio, Gemma Carreras, Javier Herrero, Jose-Maria Mengibar, Dolors Rodriguez-Arjona, Ulrike Ravens-Sieberer, Hein Raat, Vicky Serra-Sutton, Montse Ferrer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 12.11.2019.)

Background: The EuroQol-5 Dimension (EQ-5D), developed in 1990, is a most widely used generic tool to measure the health-related quality of life (HRQoL) and considered suitable for patients with asthma. In 2009, the EuroQol Group developed a new EQ-5D version to overcome limitations related to its consistently reported high ceiling effect. To enhance the sensitivity for assessing the HRQoL in further patient populations, the number of responses of EQ-5D was increased from 3 to 5 levels (EQ-5D-5L). Moreover, the availability of well-defined requirements for its Web-based administration allows EQ-5D-5L use to monitor the HRQoL in electronic health (eHealth) programs. No study has evaluated the metric properties of the new EQ-5D-5L in patients with asthma yet., Objective: This study aims to examine the distribution, construct validity, and reliability of the new EQ-5D-5L questionnaire administered online to adults with asthma., Methods: We evaluated patients with asthma (age: 18-40 years) from a primary care setting in France and England, who self-completed the EQ-5D-5L questionnaire online. The inclusion criteria were persistent asthma defined as >6 months of prescribed inhaled corticosteroids and long-acting beta-agonists or inhaled corticosteroids alone during the 12 months prior to inclusion. The EQ-5D index was obtained by applying the English preference value set for the new EQ-5D-5L and the French 3L-5L crosswalk value set. Both value sets produced single preference-based indices ranging from 1 (best health state) to negative values (health states valued as worse than death), where 0=death, allowing the calculation of quality-adjusted life years. Responses to dimensions and index distribution, including ceiling and floor effects, were examined. The construct validity was assessed by comparing the means of known groups by analyses of variance and calculation of effect sizes., Results: Of 312 patients answering the baseline Web-based survey, 290 completed the EQ-5D-5L (93%). The floor effect was null, and the ceiling effect was 26.5% (74/279). The mean EQ-5D-5L index was 0.88 (SD 0.14) with the English value set and 0.83 (SD 0.19) with the French 3L-5L crosswalk value set. In both indices, large effect sizes were observed for known groups defined by the Asthma Control Questionnaire (1.06 and 1.04, P<.001). Differences between extreme groups defined by chronic conditions (P=.002 and P=.003 for the English value set and French 3L-5L crosswalk value set, respectively), short-acting beta-agonists (SABAs) canisters in the last 12 months (P=.02 and P=.03), or SABA use during the previous 4 weeks (P=.03 and P=.01) were of moderate magnitude with effect sizes around 0.5., Conclusions: The new EQ-5D-5L questionnaire has an acceptable ceiling effect, a good construct validity based on the discriminant ability for distinguishing among health-related known groups, and high reliability, supporting its adequacy for assessing the HRQoL in patients with asthma. EQ-5D-5L completion by most Web-based respondents supports the feasibility of this administration form., (©Gimena Hernandez, Olatz Garin, Alexandra L Dima, Angels Pont, Marc Martí Pastor, Jordi Alonso, Eric Van Ganse, Laurent Laforest, Marijn de Bruin, Karina Mayoral, Vicky Serra-Sutton, Montse Ferrer, ASTRO-LAB Group. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 23.01.2019.)

Objectives: To obtain a systematic and standardized evaluation of the current evidence on development process, metric properties, and administration issues of oral health-related quality of life instruments available for children and adolescents., Materials and Methods: A systematic search until October 2016 was conducted in PubMed, Embase, Lilacs, SciELO, and Cochrane databases. Articles with information regarding the development process, metric properties, and administration issues of pediatric instruments measuring oral health-related quality of life were eligible for inclusion. Two researchers independently evaluated each instrument applying the Evaluating Measures of Patient-Reported Outcomes (EMPRO) tool. An overall and seven attribute-specific EMPRO scores were calculated (range 0-100, worst to best): measurement model, reliability, validity, responsiveness, interpretability, burden, and alternative forms., Results: We identified 18 instruments evaluated in 132 articles. From five instruments designed for preschoolers, the Early Childhood Oral Health Impact Scale (ECOHIS) obtained the highest overall EMPRO score (82.2). Of nine identified for schoolchildren and adolescents, the best rated instrument was the Child Perceptions Questionnaire 11-14 (82.1). Among the four instruments developed for any age, the Family Impact Scale (FIS) obtained the highest scores (80.3)., Conclusion: The evidence supports the use of the ECOHIS for preschoolers, while the age is a key factor when choosing among the four recommended instruments for schoolchildren and adolescents. Instruments for specific conditions, symptoms, or treatments need further research on metric properties., Clinical Relevance: Our results facilitate decision-making on the correct oral health-related quality of life instrument selection for any certain study purpose and population during the childhood and adolescence life cycle.

Introduction: Ambulatory blood pressure monitoring (ABPM) is fundamental to diagnosing and monitoring arterial hypertension (HTN), yet it is not known how effective training could be in improving knowledge of ABPM., Purpose: The purpose of this study was to evaluate ABPM knowledge before and after a training activity., Methodology: A before-and-after intervention study of 116 professionals. Data was collected on age, sex, occupational category, work setting, and work experience. ABPM knowledge was determined by a questionnaire to evaluate expertise in understanding and interpreting ABPM results., Results: Multivariate regression analysis showed that, pre-intervention, having more than 20 years' experience (odds ratio (OR): 5.9; 95% confidence interval (CI): 1.3-33.9; p = 0.049) and being a doctor (OR: 5.7; 95% CI: 1.8-18.3; p = 0.004) were associated with greater ABPM knowledge. Training increased the number of professionals with adequate ABPM knowledge: 85.3% after training vs 26.7% before training. Training increased the questionnaire mean (SD) score by almost 3 (1.7) points: 9 (2.2) after training vs 6.3 (2.2) before training ( p < 0.05). Of the 116 professionals, 90.5% achieved a higher overall score after training. The impact of the intervention was greatest on women nurses older than 45 years and with more years of experience, employed in primary care, and with prior experience of ABPM., Conclusions: Knowledge of ABPM is deficient but can be easily improved by training that is most effective in primary care and among nurses.

Purpose: The objective of this study was to evaluate the psychometric properties of the Constant-Murley Score (CMS) in various shoulder pathologies, based on a systematic review and expert standardized evaluations., Methods: A systematic review was performed in MEDLINE and EMBASE databases. Titles and abstracts were reviewed and finally the included articles were grouped according to patients' pathologies. Two expert evaluators independently assessed the CMS properties of reliability, validity, responsiveness to change, interpretability and burden score in each group, using the EMPRO (Evaluating Measures of Patient Reported Outcomes) tool. The CMS properties were assessed per attribute and overall for each considered group. Only the concept and measurement model was assessed globally., Results: Five individual pathologies (i.e. subacromial, fractures, arthritis, instability and frozen shoulder) and two additional groups (i.e. various pathologies and healthy subjects) were considered. Overall EMPRO scores ranged from 58.6 for subacromial to 30.6 points for instability. Responsiveness to change was the only quality to obtain at least 50 points across all groups, but for frozen shoulder. Insufficient information was obtained in relation to the concept and measurement model and great variability was seen in the other evaluated attributes., Conclusions: The current evidence does not support the CMS as a gold standard in shoulder evaluation. Its use is advisable for subacromial pathology; but data are inconclusive for other shoulder conditions. Prospective studies exploring the psychometric properties of the scale, particularly for fractures, arthritis, instability and frozen shoulder are needed., Level of Evidence: Systematic review.

Background and Objective: The EuroQol 5 dimensions 5 levels (EQ-5D-5L) is the new version of EQ-5D, developed to improve its discriminatory capacity. This study aims to evaluate the construct validity of the Spanish version and provide index and dimension population-based reference norms for the new EQ-5D-5L., Methods: Data were obtained from the 2011/2012 Spanish National Health Survey, with a representative sample (n = 20,587) of non-institutionalized Spanish adults (≥ 18 years). The EQ-5D-5L index was calculated by using the Spanish value set. Construct validity was evaluated by comparing known groups with estimators obtained through regression models, adjusted by age and gender. Sampling weights were applied to restore the representativeness of the sample and to calculate the norms stratified by gender and age groups. We calculated the percentages and standard errors of dimensions, and the deciles, percentiles 5 and 95, means, and 95% confidence intervals of the health index., Results: All the hypotheses established a priori for known groups were confirmed (P < 0.001). The EQ-5D-5L index indicated worse health in groups with lower education level (from 0.94 to 0.87), higher number of chronic conditions (0.96-0.79), probable psychiatric disorder (0.94 vs 0.80), strong limitations (0.96-0.46), higher number of days of restriction (0.93-0.64) or confinement to bed (0.92-0.49), and hospitalized in the previous 12 months (0.92 vs 0.81)., Conclusions: The EQ-5D-5L is a valid instrument to measure perceived health in the Spanish-speaking population. The representative population-based norms provided here will help improve the interpretation of results obtained with the new EQ-5D-5L.

Background: The aim was to evaluate the impact of asthma on patients' Health-Related Quality of Life (HRQoL) by comparing asthmatic women and men with reference norms, to examine the factors which contributed to an impaired HRQoL, and to identify groups at higher risk., Methods: Cross-sectional evaluation of 222 primary care patients with persistent asthma (18-40 years old). HRQoL impact was estimated with the EuroQol-5 Dimensions (EQ-5D), which allows calculating Quality-Adjusted Life-Years (QALYs) by applying society preferences. Participants self-completed the EQ-5D questionnaire online. Telephonic interviews collected information on medication and adherence, and administered the Asthma Control Questionnaire. Severity markers included asthma-related comorbidity, previous oral corticosteroids course prescription, and inhaled corticosteroids daily dose. After bivariate analyses, multiple linear regression models were constructed to examine the relations between HRQoL asthma impact and socio-demographic and clinical variables, using as dependent variable the deviation from general population-based EQ-5D reference norms., Results: Deviation from the EQ-5D index norms was moderate in most age/gender groups (-0.1, which corresponds to 0.6 standard deviations), while it was large in women aged 18-24 years (-0.18, corresponding to 1.1 standard deviations). In regression models, a poor asthma control was the only factor independently associated to HRQoL impact in both women and men: β -0.18 (p<0.001) and -0.15 (p = 0.01) respectively. Translating these β coefficients to QALYs, they are interpretable as 66 fewer days of full health per year in women with uncontrolled asthma and 55 for men, compared with those with controlled asthma., Conclusion: Persistent asthma has a moderately negative HRQoL impact on patients of both genders, and the youngest women have been identified as a high risk group which merits further research. We identified asthma control as the major contributor to impaired HRQoL in patients, regardless of their gender, suggesting that asthma HRQoL impact could be alleviated by achieving a good control of symptoms., Competing Interests: The authors have declared that no competing interests exist.