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The purpose of the present review was to compile and analyze all interventions aimed at improving the sleep–rest pattern of adult caregivers. A database search was performed in PubMed, Embase, Scopus, CINAHL and PsycINFO. Twenty-four papers published between 1998 and 2020 met the inclusion criteria. Informal caregivers can benefit from various types of sleep interventions, including (a) cognitive-behavioral sleep interventions (CBIs), (b) caregiver health interventions (CHIs), and (c) exercise programs. Other types of interventions such as acupressure, back massage, reflexology, music, and heart rate variability biofeedback sessions may have beneficial effects on the sleep of caregivers. Yet, studies on this topic are heterogeneous and often have considerable methodological shortcomings. Few clinical trials have explored sleep problems as a dyadic caregiver–patient relationship. It is necessary to conduct new clinical trials to determine the viability and level of evidence of the various strategies aimed at improving sleep of informal caregivers.

Background Older adults present high risk of involvement in road crashes. Preventive interventions conducted by their primary healthcare physicians (PHPC) could reduce this public health issue. Objective The objective of this study was to design and validate a self-administered questionnaire that measures the knowledge, attitudes, and current practices (CP) of PHCP in Spain regarding the prevention of road injuries in older adults. Methods One thousand eight hundred and ninety-seven PHCP completed a questionnaire piloted previously in an expert panel and two convenience samples of physicians. It comprised 78 items grouped in five sections and was mainly focused on exploring three constructs: knowledge, attitudes, and CP. Exploratory factor analysis was used to obtain evidence of internal structure validity. Reliability was assessed through Cronbach’s α coefficient. Correlation coefficients for the scores constructed for each of the extracted factors were calculated to assess convergent and discriminant validity. Results Factor analysis extracted four factors each for the knowledge and attitudes constructs, and three factors for the CP construct, which explained more than 55% of the variance in each construct. Except for two factors of the knowledge construct regarding existing health problems associated to the risk of involvement in road crashes, the clustering pattern of all other items across the remaining nine factors was consistent and in agreement with previous knowledge. Cronbach’s α values were greater than 0.7 for all constructs. Conclusions Our questionnaire appears to be valid enough to assess the attitudes, CP, and medication-related knowledge of PHCP in Spain regarding the prevention of road injuries in older adults.

This study was supported by the Chair of Teaching and Research in Family Medicine SEMERGEN-UGR, University of Granada., We thank the Chair of Teaching and Research in Family Medicine SEMERG EN-UGR for supporting this work. We also thank all the healthcare professionals of the Preventive Medicine and Public Health services of the Hospital San Cecilio, Reina Sofía, Jaén and Puerto Real for their ideas and support, and Ángela Rivera-Izquierdo for improving the use of English in the manuscript., Background Long-term effects of COVID-19, also called Long COVID, affect more than 10% of patients. The most severe cases (i.e. those requiring hospitalization) present a higher frequency of sequelae, but detailed information on these effects is still lacking. The objective of this study is to identify and quantify the frequency and outcomes associated with the presence of sequelae or persistent symptomatology (SPS) during the 6 months after discharge for COVID-19.MethodsRetrospective observational 6-month follow-up study conducted in four hospitals of Spain. A cohort of all 969 patients who were hospitalized with PCR-confirmed SARS-CoV-2 from March 1 to April 15, 2020, was included. We collected all the SPS during the 6 months after discharge reported by patients during follow-up from primary care records. Cluster analyses were performed to validate the measures. The main outcome measures were return to the Emergency Services, hospital readmission and post-discharge death. Surviving patients' outcomes were collected through clinical histories and primary care reports. Multiple logistic regression models were applied.ResultsThe 797 (82.2%) patients who survived constituted the sample followed, while the rest died from COVID-19. The mean age was 63.0 years, 53.7% of them were men and 509 (63.9%) reported some sequelae during the first 6 months after discharge. These sequelae were very diverse, but the most frequent were respiratory (42.0%), systemic (36.1%), neurological (20.8%), mental health (12.2%) and infectious (7.9%) SPS, with some differences by sex. Women presented higher frequencies of headache and mental health SPS, among others. A total of 160 (20.1%) patients returned to the Emergency Services, 35 (4.4%) required hospital readmission and 8 (1.0%) died during follow-up. The main factors independently associated with the return to Emergency Services were persistent fever, dermatological SPS, arrythmia or palpitations, thoracic pain and pneumonia.ConclusionsCOVID-19 cases requiring hospitalization during the first wave of the pandemic developed a significant range of mid- to long-term SPS. A detailed list of symptoms and outcomes is provided in this multicentre study. Identification of possible factors associated with these SPS could be useful to optimize preventive follow-up strategies in primary care for the coming months of the pandemic., Chair of Teaching and Research in Family Medicine SEMERGEN-UGR, University of Granada

This research was funded by the SEMERGEN-UGR Chair of Teaching and Research in Family Medicine (School of Medicine, University of Granada, Granada, Spain)., This systematic review was conducted to determine the effect of periodic motor vehicle inspections on road crashes and injuries, compared to less exposure to periodic inspections or no inspections. The Medline,Web of Science, and Scopus databases were used to search the literature. Ecological studies were specifically excluded. A reverse search of the results with these databases and of other identified narrative reviews was also performed. Of the 5065 unique references initially extracted, only six of them met the inclusion criteria and were selected for review: one experimental study, two cohort studies with an internal comparison group, two cohort studies without a comparison group, and one case–control study. Two authors independently extracted the information and assessed the quality of each study. Due to the heterogeneity of the designs and the intervention or comparison groups used, quantitative synthesis of the results was not attempted. Except for the case–control study, which showed a significant association between road crashes and the absence of a valid vehicle inspection certificate, the other studies showed either a small reduction in crash rates (around 9%), no association, or a higher crash rate in vehicles with more inspections. In all observational studies, the risk of residual confounding bias was significant and could have explained the results. Therefore, although the research reviewed here suggests that periodic inspection may be associated with a slight reduction in road crashes, the marked heterogeneity along with probable residual confounding in most reports prevented us from establishing causality for this association., SEMERGEN-UGR Chair of Teaching and Research in Family Medicine (School of Medicine, University of Granada, Granada, Spain)

Psoriasis is a major global health problem. There is a need to develop techniques to help physicians select the most appropriate cost-effective therapy for each patient. The main objectives of this study are (1) to evaluate changes in epidermal barrier function and skin homeostasis after phototherapy and (2) to explore potentially predictive values in epidermal barrier function and skin homeostasis to assess clinical improvement after fifteen sessions of phototherapy. A total of 76 subjects, 38 patients with plaque-type psoriasis and 38 gender- and age-matched healthy volunteers, were included in the study. Erythema, transepidermal water loss (TEWL), temperature, stratum corneum hydration (SCH), pH, sebum, and antioxidant capacity were measured before and after the first and fifteenth phototherapy session. Erythema (401.09 vs. 291.12 vs. 284.52 AU, p &lt, 0.001) and TEWL (18.23 vs. 11.44 vs. 11.41 g·m−2·h−1, p &lt, 0.001) were significantly higher at psoriatic plaques than in uninvolved psoriatic skin and healthy volunteers, respectively, while SCH was lower (9.71 vs. 44.64 vs. 40.00 AU, p &lt, 0.001). After fifteen phototherapy sessions, TEWL (–5.19 g·m−2·h−1, p = 0.016) decreased while SCH (+7.01 AU, p = 0.013) and erythema (+30.82 AU, p = 0.083) increased at psoriatic plaques. An erythema increase exceeding 53.23 AU after the first phototherapy session, with a sensitivity of 71.4% and specificity of 84.2%, indicates that a patient may improve Psoriasis Area and Severity Index (PASI) by ≥3 points after fifteen phototherapy sessions. In conclusion, phototherapy improves epidermal barrier function in psoriatic patients and the erythema increase after one phototherapy session could help doctors select psoriasis patients who are more likely to respond to phototherapy.

This work was supported by the SEMERGEN-UGR Chair of Teaching and Research in Family Medicine (Catedra de Docencia e Investigacion en Medicina de Familia SEMERGEN-UGR), University of Granada, Spain., Background: People over 64 years have a high fatality rate when they are involved in traffic accidents. Besides, older victims of road crashes are expected to rise in the future due to population aging. The purpose of the study was to document their perception on the role of the family doctor, the main facilitating factors, and the perceived barriers to the temporary or permanent restriction of their driving. Methods: This qualitative study used focus group methodology. A sample of 16 people over 65 years old was obtained through a series of segmentation criteria at an active participation centre for older adults in a small town in Jaén province (Spain). All were invited to participate in a discussion during which they were asked to express their opinions and subjective experiences concerning the role of their family doctor. The group conversation was taped, fully transcribed and analysed, and codes were generated with both deductive and inductive methods. Results: After merging the codes to generate themes, we identified 9 relevant categories: perception of age-related risk, road safety, role of public authorities, driver assessment centre, role of the family doctor, role of the family, proposals for addressing traffic accidents in older adults, consequences of the driving prohibition, and public transport. All categories help to explain the subjective driving and traffic safety experiences of older road users. Conclusions: Although family doctors do not usually ask their older patients about road driving, they are highly valued by these patients. Thus, family doctors have a great potential to act, along with the family members, for the benefit of older patients’ traffic safety, in ways that can prevent their involvement in road crashes and reduce the negative consequences of having to stop driving if necessary., SEMERGEN-UGR Chair of Teaching and Research in Family Medicine (Catedra de Docencia e Investigacion en Medicina de Familia SEMERGEN-UGR), University of Granada, Spain

Carbapenemase-producing Enterobacterales (CPE) are significant contributors to the global public health threat of antimicrobial resistance. OXA-48-like enzymes and their variants are unique carbapenemases with low or null hydrolytic activity toward carbapenems but no intrinsic activity against expanded-spectrum cephalosporins. CPEs have been classified by the WHO as high-priority pathogens given their association with morbidity and mortality and the scarce number of effective antibiotic treatments. In Spain, the frequency of OXA-48 CPE outbreaks is higher than in other European countries, representing the major resistance mechanism of CPEs. Horizontal transfer of plasmids and poor effective antibiotic treatment are additional threats to the correct prevention and control of these hospital outbreaks. One of the most important risk factors is antibiotic pressure, specifically carbapenem overuse. We explored the use of these antibiotics in Spain and analyzed the frequency, characteristics and prevention of CPE outbreaks. Future antibiotic stewardship programs along with specific preventive measures in hospitalized patients must be reinforced and updated in Spain., Chair of Teaching and Research in Family Medicine SEMERGEN-UGR

In the last months great efforts have been developed to evaluate the more efficient therapeutic agents in the management of patients with COVID-19. Currently, no specific drug combination has consistently demonstrated an association with mortality. The aim of this study was to assess the pattern of associations observed between the different in-hospital treatments administered to a series of 238 patients admitted for COVID-19 and their relationship with mortality.The electronic medical records of patients that discharged or died from COVID-19 in the Hospital Universitario San Cecilio (Granada, Spain) between March 16 and April 10, 2020 were analysed. From these records, information was obtained on sex, age, comorbidities at admission, clinical information, analytical parameters, imaging tests and empirical treatments used. The outcome variable was the in-hospital mortality. To estimate the associations between the different therapeutic alternatives and the risk of mortality, Hazard Ratios adjusted for age, sex, previous pathologies and severity at discharge were estimated using Cox Regression models.The most frequently used combination of drugs was low molecular weight heparins, hydroxychloroquine, and ritonavir/lopinavir. None of the analysed treatments showed independent association with mortality. The drugs that showed a greater inverse association with mortality were tocilizumab and corticoids.The observed association patterns are consistent with previous literature. It seems necessary to design randomized controlled clinical trials that evaluate the possible protector effect of tocilizumab and corticoids in the risk of mortality for some subgroups of COVID-19 hospitalized patients.En los últimos meses se han realizado grandes esfuerzos para evaluar las terapias más eficaces en el manejo de pacientes con COVID-19. Actualmente ninguna combinación ha demostrado de manera consistente una relación clara con la mortalidad. Nuestro objetivo fue valorar el patrón de asociaciones observado entre los distintos tratamientos intrahospitalarios administrados a 238 pacientes ingresados por COVID-19 y la mortalidad.Se analizaron las historias clínicas electrónicas de aquellos pacientes dados de alta o que fallecieron por COVID-19 entre el 16 de marzo y el 10 de abril de 2020 en el Hospital Universitario San Cecilio (Granada, España). Se obtuvo información sobre sexo, edad, comorbilidades al ingreso, parámetros clínicos, analíticos, pruebas de imagen y tratamientos empíricos empleados. La variable de desenlace fue la mortalidad intrahospitalaria. Para estimar las asociaciones entre los diferentes tratamientos y el riesgo de mortalidad se estimaron, mediante modelos de regresión de Cox,La combinación de fármacos más frecuentemente empleada fue la formada por heparinade bajo peso molecular (HBPM), hidroxicloroquina y ritonavir/lopinavir. Ninguno de los tratamientos utilizados mostró una asociación independiente con la mortalidad. Los fármacos que mostraron una asociación inversa de mayor magnitud fueron el tocilizumab y los corticoides.El patrón se asociaciones obtenido es consistente con lo reportado en la bibliografía. Parece oportuno diseñar ensayos aleatorizados que valoren el posible efecto protector de los corticoides y el tocilizumab sobre el riesgo de muerte en algunos subgrupos de pacientes hospitalizados por COVID-19.

The aim of this study was to estimate the association between each cause of driving without a valid license (DWVL) and the risk of causing a road crash, considering driver, vehicle and environmental factors. A case-control study based on data from the Spanish Register of Road Accidents with Victims was carried out between 2014 and 2017. Cases included 28,620 drivers of moving private cars, vans and off-road vehicles involved in single crashes plus 50,100 drivers deemed responsible for clean collisions (i.e. those in which only one driver was labeled as responsible). In accordance with the quasi-induce exposure approach, drivers not responsible for clean collisions comprised the control group (N = 51,656). Logistic and multinomial regression models were used to estimate crude and adjusted Odds Ratios or Relative Risk Ratios between each reason for DWVL and the risk of being a case of all, single and multi-vehicle collisions. A significant association was found between all reasons for DWVL and the risk of causing a road crash. This association was particularly high for drivers with a suspended license and drivers who had never obtained a license. In these subgroups of drivers, the proportion of the relationship explained by high-risk driving behaviors is high. Our results support the need for applying continued strategies to identify and control these subgroups of drivers.

Background To identify and quantify associations between baseline characteristics on hospital admission and mortality in patients with COVID-19 at a tertiary hospital in Spain. Methods and findings This retrospective case series included 238 patients hospitalized for COVID-19 at Hospital Universitario Clı´nico San Cecilio (Granada, Spain) who were discharged or who died. Electronic medical records were reviewed to obtain information on sex, age, personal antecedents, clinical features, findings on physical examination, and laboratory results for each patient. Associations between mortality and baseline characteristics were estimated as hazard ratios (HR) calculated with Cox regression models. Series mortality was 25.6%. Among patients with dependence for basic activities of daily living, 78.7% died, and among patients residing in retirement homes, 80.8% died. The variables most clearly associated with a greater hazard of death were age (3% HR increase per 1-year increase in age; 95%CI 1–6), diabetes mellitus (HR 2.42, 95%CI 1.43–4.09), SatO2/ FiO2 ratio (43% HR reduction per 1-point increase; 95%CI 23–57), SOFA score (19% HR increase per 1-point increase, 95%CI 5–34) and CURB-65 score (76% HR increase per 1- point increase, 95%CI 23–143). Conclusions The patients residing in retirement homes showed great vulnerability. The main baseline factors that were independently associated with mortality in patients hospitalized for COVID-19 were older age, diabetes mellitus, low SatO2/FiO2 ratio, and high SOFA and CURB-65 scores., Fondos Estructurales de la Union Europea (FEDER), Unit of Excellence on Exercise and Health (UCEES), University of Granada

The authors thank K. Shashok for improving the use of English in the manuscript., The novel coronavirus disease (COVID-19) outbreak has quickly spread around the world, with Spain being one of the most severely affected countries. Healthcare professionals are an important risk group given their exposure. The aims of this study were to determine the prevalence of symptoms, main concerns as patients, preventive behaviours of healthcare professionals, and the different temporal outcomes associated with the negativization of PCR results. A total of 238 professionals were analysed and follow-up was conducted from 11 March to 21 April 2020 through clinical records, in-depth surveys, and telephone interviews. Symptoms, concerns, and preventive measures were documented, and temporal outcomes (start and end of symptoms, first positive PCR, and negativization of PCR) were analysed through survival analyses. A high prevalence of gastrointestinal symptoms (especially in women and older professionals), fever, cough, and fatigue were reported. The main concern was contagion in the work and home environment. Professionals (especially men) reported low use of face masks before the pandemic. Our analysis indicates that the median times for the negativization of PCR testing to confirm the resolution of infection is 15 days after the end of symptoms, or 25 days after the first positive PCR test. Our results suggest that these times are longer for women and for professionals aged ≥55 years, therefore follow-up strategies should be optimized in light of both variables. This is the first study we are aware of to report factors associated with the time to negativization of PCR results. We present the first rigorous estimates of time outcomes and hope that these data can be valuable to continue feeding the prediction models that are currently being developed. Similar studies are required to corroborate our results., Chair of Teaching and Research in Family Medicine SEMERGEN-UGR. University of Granada

Antimicrobial resistance is a growing global health problem. Patients living in care homes are a vulnerable high-risk population colonized by multidrug-resistant organisms (MDRO). We identified a case series of 116 residents of care homes from a cohort of 540 consecutive patients admitted to the internal medicine service of our hospital. We performed early diagnostic tests of MDRO through anal exudates in our sample. The prevalence of MDRO colonization was 34.5% of residents and 70% of them had not been previously identified in the clinical records. Previous hospitalizations and in-hospital antibiotic administration were significantly associated with the presence of MDRO. Our results emphasize the need to consider care homes in the planning of regional and national infection control measures and for implementing surveillance systems that monitor the spread of antimicrobial resistance in Spain. Systematic early testing upon admission to hospital services with a high prevalence of patients with MDRO colonization (e.g., internal medicine) could contribute to the adoption of adequate prevention measures. Specific educational programs for care home staff should also be implemented to address this increasing problem., Catedra de Docencia e Investigacion SEMERGEN-Medicina de Familia, University of Granada, Spain

This study was supported by the National Drug Plan, Ministry of Health, Social Services and Equality of Spain (Grants: 2010|145 and 2013|034)., Pulses such as peas, beans or lentils are one of the most complete foods at the nutritional level, however, it is one of the most often neglected in the diets of university students. Entrance to university translates to a major lifestyle change for many young people and the habits acquired or cemented at this time will remain into adulthood. The objective of this study is to analyze the association between personal/sociodemographic factors, dietary intake of other food groups and the consumption of pulses in first-year university students. This cross-sectional study is part of the UniHcos project, a multicenter study of multipurpose prospective cohorts in 11 Spanish universities. Data from 9862 university students was collected through an online self-questionnaire completed by all students who met the selection criteria and agreed to participate in the project during the 2011–2018 academic years. 75.8% of students presented an inadequate (≤ 2 times / week) consumption of pulses. Living outside the family home in either a student residence [OR = 0.76; 95%CI: (0.69 – 0.84)] or rental [OR = 0.81; 95%CI: (0.70 – 0.95)] decreased compliance with recommendations on the consumption of pulses. Low consumption of pulses is seemingly not restricted to a specific profile or dietary pattern among university students and no specific focus group for intervention can be identified. Policies promoting the consumption of pulses among the university population as a whole are necessary to increase compliance rates with the dietary recommendations., National Drug Plan, Ministry of Health, Social Services and Equality of Spain 2010|145 2013|034

The purpose of this study was to assess the effect of the Penalty Point System (PPS) on road traffic accident mortality by gender and socioeconomic status. We conducted a nationwide prospective study covering adult people living in Spain on November 2001. They were followed up until 30 Nov 2007 to determine vital status and cause of death. An interrupted time-series analysis was used to assess whether PPS (explanatory variable) had both immediate and long-term effect on the rates of road traffic accident mortality (RTAMs) separately by gender. Subjects were classified by socioeconomic status (low and high) using two indicators: educational attainment (up to lower secondary education; upper secondary education or more) and occupation (manual and non-manual workers). We performed several segmented Poisson regression models, controlling for trend, seasonality, 2004 road safety measures and fuel consumption as proxy for traffic exposure. Among men, we found a decrease on the RTAMs immediately after PPS in those with low educational level (16.2 %, IC95 %: 6.1 %–25.2 %) and manual workers (16.3 %, IC95 %: 2.8 %–27.8 %), and a non-significant increase among those with high education level and non-manual workers (6.2 % and 1.8 %). Among women, there were no significant differences in the immediate effect of PPS by socioeconomic status. We did not identify significant trend changes between pre-PPS and post-PPS periods in any socioeconomic group. In a context of downward trend of traffic mortality, the PPS implementation led to an immediate reduction on death rates only among men with a low socioeconomic status.

AIM: Part of the differences by age and gender in driver death rates from traffic injuries depends on the amount of exposure (km/year travelled). Unfortunately, direct indicators of exposure are not available in many countries. Our aim was to compare the age and gender differences in death rates with and without adjustment by exposure using a quasi-induced exposure approach in Spain, during 2004-2012. METHODS: Crude and adjusted death rate ratios (CDRR and ADRR, respectively) were calculated for each age and gender group. To obtain the latter estimates, in accordance with quasi-exposure reasoning, the number of registered drivers was replaced by the number of non-infractor drivers, passively involved in collisions with another vehicle whose driver committed an infraction. 18-29 years and female drivers were chosen as the reference categories for age and gender. RESULTS: Striking differences were found between CDRR and ADRR estimates. When CDRR were estimated, we found the highest traffic mortality among the youngest drivers, except for females in non-urban roads. ADRR however showed the highest mortality among the oldest groups, especially in females, peaking among drivers >74 years in all types of roads. Regarding differences by gender, both estimates revealed higher traffic mortality in males, although the differences were much smaller when using ADRR. CDRR and ADRR for males tended to converge as age increased. CONCLUSIONS: Death risk from traffic injuries among drivers is clearly influenced by the amount of exposure. These findings further emphasize the need to obtain direct traffic exposure estimates by subgroups of drivers.Copyright © 2016 Elsevier Ltd. All rights reserved. Language: en

This study aimed to quantify the association between pedestrian- and driver-related factors and the risk of causing road crashes involving pedestrians in urban areas in Spain between 1993 and 2011. From the nationwide police-based registry of road crashes with victims in Spain, we analyzed all 63,205 pairs of pedestrians and drivers involved in crashes in urban areas in which only the pedestrian or only the driver was at fault. Logistic regression models were used to obtain adjusted odds ratios to assess the strength of association between each individual-related variable and the pedestrian's odds of being at fault for the crash (and conversely, the driver's odds of not being at fault). The subgroups of road users at high risk of causing a road crash with a pedestrian in urban areas were young and male pedestrians, pedestrians with psychophysical conditions or health problems, the youngest and the oldest drivers, and drivers with markers of high-risk behaviors (alcohol use, nonuse of safety devices, and driving without a valid license). These subgroups should be targeted by preventive strategies intended to decrease the rate of urban road crashes involving pedestrians in Spain.

Aim To show the usefulness of joinpoint trend analysis for assessing changes in traffic safety policies. Methods Trends in driver death rates from traffic injury stratified by alcohol involvement in Spain during 2001–2011 were characterized with joinpoint regression to observe how changes in these rates match in time with the implementation of traffic regulations and interventions. Results Both alcohol-related (blood alcohol concentration >0.3 g/l) and non-alcohol-related rates decreased similarly (10–11% annually) during 2001–2011, although the former showed an earlier (2003 joinpoint) acceleration of the downward trend than the latter (2006 joinpoint); both joinpoints matched in time with relevant road safety interventions. Conclusions These results, which are consistent with results from previous analytical studies, show that joinpoint trend analysis, although not valid for causal inference, is useful for assessing changes in traffic safety policies. This methodology can be easily extended to other risk factors, such as excessive speeding or not wearing a seat belt.

Although mortality from traffic accident-related injuries is known to be higher in males especially among young drivers, the influence of gender on each link in the causal chain that leads to this outcome is not well understood, particularly in Spain. The aim of this study was to analyse gender-related differences in distances travelled, driving behaviour and the frequency of involvement in traffic accidents in a sample of undergraduate students at the University of Granada. This cross-sectional study involved a sample of 1574 students recruited during three consecutive academic years from 2007–2008 to 2009–2010 who agreed to complete a questionnaire which evaluated patterns in distances travelled, use of safety devices, risky driving behaviours and involvement in traffic accidents. The results showed that men drove more kilometres than women, and described themselves as better and faster drivers than women. Male drivers used all safety devices less frequently than women, and were involved in risky driving behaviours more often. Although the crude analysis showed no differences between genders in reported accidents, the adjusted analysis showed a trend for men to report accidents less frequently than women.

The aim of this study was to evaluate the effect of problem-based learning (PBL) on university students’ satisfaction with and academic performance in a course on epidemiology and social and demographic health. The participants in this interventional study were 529 students (272 in the intervention group and 257 in the control group) enrolled in a medical degree programme during the academic years 2010–2011 and 2011–2012 in Spain. The intervention consisted of the use of a list of problems designed for small-group study in one of the practical sessions (Interpretation of Epidemiological Parameters). We compared students’ satisfaction and performance after either PBL or conventional teaching methods. Students’ satisfaction and academic performance were significantly better in the PBL group than in the traditional-learning group. Satisfaction with teaching was the main predictor of academic performance. After adjustment for level of satisfaction, the difference between groups in academic performance disappe...

Objective To quantify the magnitude of associations between cyclist fatalities and both cyclist and environment related characteristics in Spain during the first 24 hours after a crash. Results Non-use of a helmet was directly associated with death (IDR 1.43, 95% CI 1.25 to 1.64). Among other cyclist characteristics, age after the third decade of life was also directly associated with death, especially in older cyclists (‘over 74’ category, IDR 4.61, 95% CI 3.49 to 6.08). The association with death did not differ between work-related cycling and other reasons for cycling. There was an inverse association with death for crashes in urban areas and on community roads. Any adverse meteorological condition also showed a direct association with death, whereas altered road surfaces showed an inverse association. Crashes during nighttime were directly associated with death, with a peak between 3:00 and 5:59 am (IDR 1.58, 95% CI 1.03 to 2.41). Conclusions We found strong direct and inverse associations between several cyclist and environment related variables and death. These variables should be considered in efforts to prioritise public health measures aimed at reducing the number of cycling-related fatalities., This work was partially supported by the National Council of Science and Technology of Mexico [doctorate grant number 410668].

This study aimed to estimate the association of cyclists' age and sex with the risk of being involved in a crash with and without adjustment for their amount of exposure. We used the distribution of the entire population and cyclists (total and non-responsible) involved in road crashes in Spain between 1993 and 2009 held by the Spanish National Institute of Statistics and the Spanish General Traffic Directorate to calculate rates of exposure and involvement in a crash. Males aged 45-49 years were used as the reference category to obtain exposure rate ratios (ERR) and unadjusted crash rate ratios (URR). We then used these values in decomposition analysis to calculate crash rate ratios adjusted for exposure (ARR). The pattern of ARR was substantially different from URR. In both sexes the highest values were observed in the youngest age groups, and the values decreased as age increased except for a slight increase in the oldest age groups. In males, a slight increase in the lowest and highest age categories was observed for crashes resulting in severe injury or death, and a decrease was observed for the youngest cyclists who were wearing a helmet. The large differences between age and sex groups in the risk of involvement in a cycling crash are strongly dependent on differences in their exposure rates. Taking exposure rates into account, cyclists younger than 30 years and older than 65 years of age had the highest risk of being involved in a crash.

Objective To identify key factors involved in modifying leisure time physical activity (LTPA) during early pregnancy. Methods A prospective study was conducted of 1175 pregnant women who attended a scheduled visit at Virgen de las Nieves University Hospital, Granada, Spain, at 20–22 weeks of pregnancy. The Paffenbarger Physical Activity Questionnaire was used to collect data regarding participation in any LTPA or physical activity performed according to society recommendations during early pregnancy and in the year before pregnancy. A polytomous regression model was used to identify factors associated with LTPA. Results Approximately 20.0% of the women did not engage in any LTPA, and 68.0% did not achieve the recommendations for exercise, either before or during pregnancy. Desirable changes related to performing any LTPA or the society recommendations for LTPA during pregnancy were associated with university level of education (aOR, 3.64 [95% CI, 1.54–8.56] and aOR, 1.75 [95% CI, 0.67–4.57], respectively) and smoking cessation at pregnancy (aOR, 2.05 [95% CI, 0.97–4.35] and aOR, 4.83 [95% CI, 1.31–17.83], respectively). Conclusion Few women achieved the minimum recommendations for exercise before or during pregnancy. Nevertheless, adoption of healthy lifestyle choices during pregnancy seemed to promote other healthy habits, such as participation in LTPA.

Objective To quantify the association between the maternal country of birth and inadequacy in the use of prenatal care, and to identify factors that might explain this association. Study design A retrospective case series was carried out in a public hospital in southern Spain, including 6873 women who delivered between 2005 and 2007. The maternal country of birth was categorised into four regional groups: Spain, Maghreb (north-west Africa), Eastern Europe and Others (non-Spain), while the use of prenatal care was quantified according to a modified Kotelchuck index: APNCU-1M and APNCU 2M. The effect of country of birth on inadequate prenatal care was analysed using a multiple logistic regression model designed to accommodate factors such as age, parity, previous miscarriages, and pre-gestational and gestational risks. Likelihood ratio tests were performed to assess any interactions. Results A significant association was found between maternal country of birth and inadequate prenatal care regardless of the index used. Under APNCU 1-M the strength of association was strongest for Eastern European origin (odds ratio (OR) 6.17, 95% confidence interval (CI) 5.2–7.32), followed by the Maghreb (OR: 5.58, 95% CI: 4.69–6.64). These associations remained virtually unchanged after adjusting for potential confounders. Interactions were observed between age and parity, with the highest risk of inadequacy seen among the Eastern European childbearing women over 34 years of age having 1–2 previous children (OR: 7.63, 95% CI: 3.65–15.92). Conclusion Prenatal health care initiatives would benefit from the study of a larger number of variables to address the differences between different groups of women. We recommend the widespread use of standardised indices for the study of prenatal care utilisation.

Background This study aimed to assess the association between cannabis use and unintended non-fatal injuries other than those caused by road crashes. Methods Cross-sectional data were collected from a nationwide sample of 27,934 subjects surveyed in 2005 in Spain: 14,699 persons aged 15–34 years and 13,235 aged 35–64 years. Logistic regression was used to obtain odds ratios (OR) between patterns of cannabis use and frequency of non-traffic injuries, adjusted for sociodemographic factors and for the use of alcohol, tobacco and other drugs. Results Cannabis use in the last 12 months was associated with a higher frequency of injuries (OR = 1.4; 95% CI: 1.2–1.7). The OR in older adults (35–64 year age group) was 1.8 and 1.3 in younger people (15–34 year age group). The strongest associations found were between weekly use of cannabis and injuries from knocks and bumps (OR = 5.1; 95% CI 2.9–8.9) and those occurring outside work (OR = 3.0; 95% CI 1.8–4.9) in the older adult population. Conclusion Although our analysis did not control for behavioural factors, cannabis use is independently associated with an increased frequency of non-traffic injuries, especially in the older adult population. These associations emphasise the need to carry out longitudinal studies addressing the causal links between cannabis use and unintended injuries.

Introduction: The objective of this paper is to amend the bias included in our previous work, presenting a corrected estimation of the need and coverage of syringes/needles in Spanish prisons between 1992 and 2009. Methods: Data on the provision of the needles exchange programs (NEPs) in prison is taken from official publications. The need was calculated by applying multiplicative methods to secondary data from several sources. Coverage was estimated as the quotient between provision and need and the difference between these magnitudes. The detected need estimate bias has been corrected. Results: NEP's in prisons started in 1997. Their maximum coverage reached 36% in 2005, which is much higher than the initially estimated value. However, it decreased by half in the next four years, reaching 17.4% in 2009. Conclusion: The remarkable coverage reached by these programmes must be valued, but more recent evolution leads us to emphasize the need to be imaginative so that new epidemiological and economic circumstances do not lead to their disappearance. Key words: needle-exchange programs; prisons; program evaluation; harm reduction; substance abuse, intravenous; Spain; HIV; hepatitis C; corrected and respublished article.

Objective:To estimate the efficacy of antibiotic prophylaxis to prevent urinary tract infection in patients (both gender) who undergo a cystoscopy with sterile urine.Materials and Methods:Search strategy (January 1980-December 2013) in Medline via PubMed, CENTRAL, and EMBASE. Additionally, we searched databases for registered trials and conference abstracts, as well as reference lists of systematic reviews and included studies. Seven published randomized clinical trials (January 1, 1980 to December 31, 2013) were included in quantitative analyses with no language restrictions. Two independent reviewers collected data. Risk of bias was evaluated with the Cochrane Collaboration tool. We performed a fixed effect analyses due to statistical homogeneity. The primary outcome was urinary tract infection and the secondary was asymptomatic bacteriuria. The effect measure was the risk difference (RD) with 95% confidence interval. The planned interventions were: Antibiotic vs placebo; Antibiotic vs no intervention and Antibiotic vs any other intervention.Results:3038 patients were found in seven studies. For the primary outcome, we included 5 studies and we found a RR 0.53 CI95% (0.31, 0.90) and a RD-0.012 CI95% (-0.023,-0.002), favoring antibiotic prophylaxis. For asymptomatic bacteriuria we included 6 studies and we found a RR 0.28 CI95% (0.20, 0.39) and a RD-0.055 CI95% (-0.07,-0.039), was found favoring prophylaxis. According to GRADE evaluation, we considered moderate quality of evidence for both outcomes. The subgroup analysis showed that only two studies were classified as having low risk of bias: Cam 2009 and García-Perdomo 2013. They showed no statistical differences (RD-0.009 CI95% -0.03, 0.011).Conclusions:Based on studies classified as low risk of bias, we found moderate evidence to not recommend the use of antibiotic prophylaxis to prevent urinary tract infection and asymptomatic bacteriuria in patients who undergo cystoscopy with sterile urine in an ambulatory setting.

Introduction: Pregnant women are recommended to participate in ‘moderate to vigorous’ physical activity (MVPA), each day, to promote and maintain health. The aim of this study was to assess the changes in Total Energy Expenditure (TEE), MVPA, physical activity levels in four different domains (leisure time, transportation, household/ caregiver, occupational), time spent watching TV, and numbers of women meeting the recommendations, before compared with during pregnancy, by body mass index category. Method: A systematic sample of otherwise healthy pregnant women attending their scheduled 20-22nd week assessment at a hospital in Spain during a 4 year period, 2004-2007, were asked for information on socio-demographic and medical information. They completed the Paffenbarger questionnaire and provided an estimate of their height and weight, both during the first half of their pregnancy and during the 12 months prior to their pregnancy. Results: 1.175 women agreed to take part. TEE decreased from pre-pregnancy in all BMI categories (21.77 to 18.89 in ideal; 24.20 to 21.56 in overweight; and 23.82 to 21.21 in obese women) (p

This study was designed to quantify the percent contribution of exposure, risk of collision and fatality rate to the association of age and sex with the mortality rates among cyclists in Spain, and to track the changes in these contributions with time. Data were analyzed for 50,042 cyclists involved in road crashes in Spain from 1993 to 2011, and also for a subset of 13,119 non-infractor cyclists involved in collisions with a vehicle whose driver committed an infraction (used as a proxy sample of all cyclists on the road). We used decomposition and quasi-induced exposure methods to obtain the percent contributions of these three components to the mortality rate ratios for each age and sex group compared to males aged 25–34 years. Death rates increased with age, and the main component of this increase was fatality (around 70%). Among younger cyclists, however, the main component of increased death rates was risk of a collision. Males had higher death rates than females in every age group: this rate increased from 6.4 in the 5–14 year old group to 18.8 in the 65–79 year old group. Exposure, the main component of this increase, ranged between 70% and 90% in all age categories, although the fatality component also contributed to this increase. The contributions of exposure, risk of crash and fatality to cyclist death rates were strongly associated with age and sex. Young male cyclists were a high-risk group because all three components tended to increase their mortality rate.

Objective: to determine incidence of adverse effects related to antibiotic prophylaxis compared to other interventions in patients who undergo cystoscopy with sterile urine. Methods: Search strategy (January 1980-January 2014) in Medline via PubMed, CENTRAL, and EMBASE. Additionally, we searched databases for registered trials and conference abstracts, as well as reference lists of systematic reviews and included studies. Two published randomized placebo-controlled trials (January 1, 1980 and January 31, 2014) were included in qualitative analysis with no language restrictions. Two independent reviewers collected Data. Risk of bias was evaluated with the Cochrane Collaboration recommendations. The primary outcome was incidence of adverse effects (AE). Results: 2448 patients were found in the studies of Garcia-Perdomo et al., and Jimenez-Cruz et al. The incidence of AE in one study was 0.7% in intervention group (nausea), no AE in control group or in the other study included. A meta-analysis was not performed. Conclusions: There is a low incidence of adverse effects associated with antibiotic prophylaxis in cystoscopy besides we found inadequate conducting and report of this outcome in studies included.

We tried to obtain preliminary evidence to test the hypothesis that the association between driving exposure and the frequency of reporting a road crash can be decomposed into two paths: direct and indirect (mediated by risky driving patterns). In a cross-sectional study carried out between 2007 and 2010, a sample of 1114 car drivers who were students at the University of Granada completed a questionnaire with items about driving exposure during the previous year, risk-related driving circumstances and involvement in road crashes. We applied the decomposition procedure proposed by Buis for logit models. The indirect path showed a strong dose-response relationship with the frequency of reporting a road crash, whereas the direct path did not. The decomposition procedure was able to identify the indirect path as the main explanatory mechanism for the association between exposure and the frequency of reporting a road crash.

To quantify changes in leisure time physical activity (LTPA) type, frequency, duration and intensity during the first half of pregnancy as compared with the year prior to pregnancy. A cross sectional study was conducted at the Maternal University Hospital in Granada, Spain. A total of 1,175 healthy pregnant women attending a scheduled visit during the 20-22nd gestational week were enrolled in the study. Information about socio-demographic, obstetric and life-style variables during the previous year and the first half of pregnancy were collected. LTPA was quantified by assigning metabolic equivalents to each activity according to frequency, intensity and duration. The prevalence of women who met the optimal physical activity recommendations before and during pregnancy was calculated, and the McNemar-Bowker symmetry test was used to assess changes in type, frequency, intensity and duration of activities between the two periods. Some sort of LTPA was performed before and during pregnancy by 68.6% of the pregnant women. Respectively, just 27.5% and 19.4% of women fulfilled LTPA recommendations prior to pregnancy and during pregnancy; 12.6% of the women meeting recommendations prior to pregnancy later did not meet those recommendations during gestation, and 4.5% showed the reverse trend. A light increase in walking as a LTPA, and a decrease in the rest of the LTPA type activities, were seen during pregnancy. Some 13.4% of women changed from moderate--the year before- to light LTPA- during pregnancy. Pregnancy involved a decrease in LTPA, not only regarding frequency, but also duration and intensity.

A quasi-induced exposure approach was applied to the Spanish Register of Traffic Crashes to identify driver- and vehicle-related factors associated with the risk of causing a road crash involving a cyclist in Spain from 1993 to 2009. We analyzed 19,007 collisions between a bicycle and another vehicle in which only one of the drivers committed an infraction, and 13,540 records that included the group of non-infractor cyclists in the above collisions plus cyclists involved in single-bicycle crashes. Adjusted odds ratios were calculated for being responsible for each type of crash for each factor considered. Age from 10 to 19 years, male sex, alcohol or drug consumption and non-helmet use were cyclist-related variables associated with a higher risk of crash, whereas cycling more than 1h increased only the risk of single crashes. Bicycles with brake defects and ridden by two occupants were also at higher risk of involvement in a crash, whereas light defects were associated only with collisions with another vehicle. For drivers of the other vehicle, age more than 60 years, alcohol, not using safety devices and nonprofessional drivers were at higher risk. The risk of colliding with a bicycle was higher for mopeds than for passenger cars.

Background This study was designed to compare two methods (direct measurement of exposure and quasi-induced exposure) for assessing the effect of age and sex on the risk of being involved in a car crash in Spain. Methods Spanish crash rates (per 10,000,000 driver-km) for age and sex groups of drivers aged 18–64 years old were obtained for 2004–2007, using information from the Spanish General Traffic Office (census of reported car crashes) and the Spanish Household Survey on Alcohol and Drugs (estimate of the mean km driven for each car driver). The rate ratios estimated by direct exposure estimates were compared to those obtained with the quasi-induced exposure method, which compares the age and sex of responsible and non-responsible drivers involved in the same clean collision (in which only one of the drivers committed a driving infraction). Results Both methods detected an increased risk of involvement in a crash for the youngest (18–20 years) and the oldest drivers (60–64 years), compared to middle-aged drivers (45–49 years). However, the rate ratios obtained with the quasi-induced method for the youngest group (2.0 for men, 1.6 for women) were much lower than those obtained with crash rates (13.4 for men, 5.7 for women). Both methods detected a similar increase in the risk of involvement of male drivers compared to women in the youngest age group. This excess risk for men was maintained with increasing age up to 45–49 years when the quasi-induced method was used. However, direct comparisons of crash rates revealed an increased risk of involvement in women compared to men of the same age from 25–29 years onward. Conclusions Both direct measurement of driving exposure and the quasi-induced exposure method detected some well-known patterns of risk associated with driver's age and sex. However, factors that could explain important differences between the two methods deserve attention, especially those related with the excess risk for the youngest drivers as well as sex-related risk.

Objetivos. Comparar las diferencias en las circunstancias de riesgo al volante en universitarios de Guatemala y España. Materiales y métodos. Estudio transversal realizado durante el 2007 a 2011 en una muestra de 2130 conductores (1016 en Guatemala y 1114 en España), quienes respondieron un cuestionario autoadministrado que valoraba: patrones de movilidad, uso de dispositivos de seguridad, estilos de conducción e implicación en accidentes de tránsito. Resultados. Los estudiantes de Guatemala se implicaron con mayor frecuencia en circunstancias de riesgo como hablar por el teléfono móvil (74,4% vs 24,3%), distraerse (47,1% vs 18,8%) o no usar el cinturón de seguridad (23,9% vs 5,9%) con respecto a los españoles; en el análisis ajustado el reporte de haber tenido algún accidente fue 4,8 veces mayor (IC 95% 3,1-7,4) en universitarios de Guatemala. Conclusiones. Existen factores dependientes del vehículo, entorno físico y de índole social, que podrían tener un rol importante en las diferencias detectadas en ambas poblaciones Objective. The purpose of this study was to compare the frequency of involvement in risky driving circumstances between Guatemalan and Spanish university students and identify in both populations the differences between the involvement in such circumstances and road crashes. Materials and methods. A cross sectional study was conducted during the academic courses 2007 to 2011 on a sample of 2 130 drivers (1 016 in Guatemala and 1 114 in Spain), who completed a self-administered questionnaire that assessed: mobility patterns, use of safety devices, driving styles and involvement in road traffic crashes. Results: Furthermore, they were involved more frequently in almost all the risky-driving circumstances compared with Spanish students, principally in: mobile use (74.4 % versus 24.3 %), distraction (47.1 % versus 18.8 %) or not using seatbelt (23.9% vs 5.9). Finally, the adjusted analysis yields an accident rate 4.8 times higher among Guatemalans (CI 95% 3.1-7.4). Conclusions: Considering the factors more frequently associated with suffer road traffic crashes dependent on human factor, it is noted physical and social factors as well as that the car-dependent issues, must play an important role in the marked differences detected in both populations

Background This ecological study aimed i) to quantify the association of age and gender with the three components of pedestrians’ death rates after a pedestrian-vehicle crash: exposure, risk of crash and fatality, and ii) to determine the contribution of each component to differences in death rates according to age and gender in Spain. Methods We analyzed data for 220 665 pedestrians involved in road crashes recorded in the Spanish registry of road crashes with victims from 1993 to 2011, and a subset of 39 743 pedestrians involved in clean collisions (in which the pedestrian did not commit an infraction). Using decomposition and quasi-induced exposure methods, we obtained the proportion of increase in death rates for each age and gender group associated with exposure, risk of collision and fatality. Results Death rates increased with age. The main contributor to this increase was fatality, although exposure also increased with age. In contrast, the risk of collision decreased with age. Males had higher death rates than females, especially in the 24–54 year old group. Higher fatality rates in males were the main determinant of this difference, which was also related with a higher risk of collision in males. However, exposure rates were higher in females. Conclusions The magnitude and direction of the associations between age and gender and each of the three components of pedestrians’ death rates differed depending on the specific component explored. These differences need to be taken into account in order to prioritize preventive strategies intended to decrease mortality among pedestrians. Electronic supplementary material The online version of this article (doi:10.1186/s40621-016-0079-2) contains supplementary material, which is available to authorized users.