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IntroductionIn Catalonia caesarean rates have always been analysed as a single percentage. The objective is to estimate caesarean section rates using the Robson classification in publicly funded hospitals in Catalonia between 2013 and 2017, considering sociodemographic, institutional and obstetric characteristics.Materials and methodsCross-sectional population-based study in Catalonia including all women delivering within publicly funded hospitals between 2013-2017 (n = 210 020). The modified Robson classification distribution was estimated, the caesarean rate and the overall contribution, analysed for each year, and by confounders, through logistic regression models.ResultsCS rates decreased steadily between 2013 and 2017 in Catalonia within publicly funded hospitals from 24.3% to 22.8% (cOR 0.92, 95% CI; 0.89 to 0.95). Once adjusted for changes in sociodemographic, institutional and obstetric characteristics the observed decline was even more pronounced (aOR 0.87, 95% CI; 0.84 to 0.90). Within the different groups of Robson once adjusted for confounders, groups 1+2 (aOR 0.88, 95% CI; 0.83 to 0.93), 3+4 (aOR 0.83, 95% CI; 0.78 to 0.89) and 10 (aOR 0.78, 95% CI; 0.68 to 0.90) presented a reduction in caesarean section rates, whereas group 5 showed no significant decrease (aOR 0.95, 95% CI; 0.87 to 1.03%).ConclusionsThe decrease in caesarean section rates in Catalonia is more pronounced when adjusted for known confounders, suggesting retrospective overutilization of caesarean section and percentages of (in)adequacy in the past. In any case, it remains above the recommended by experts. Further efforts should be made to achieve optimum rates, including improvement on obstetric data collection.

Cesarean sections have been associated in the literature with poorer newborn health, particularly with a higher incidence of respiratory morbidity. Most studies suffer, however, from potential omitted variable bias, as they are based on simple comparisons of mothers who give birth vaginally and those who give birth by cesarean section. We try to overcome this limitation and provide credible causal evidence by using variation in the probability of having a c-section that is arguably unrelated to maternal and fetal characteristics: variation by time of day. Previous literature documents that, while nature distributes births and associated problems uniformly, time-dependent variables related to physicians' demand for leisure are significant predictors of unplanned c-sections. Using a sample of public hospitals in Spain, we show that the rate of c-sections is higher during the early hours of the night compared to the rest of the day, while mothers giving birth at the different times are similar in observable characteristics. This exogenous variation provides us with a new instrument for type of birth: time of delivery. Our results suggest that non-medically indicated c-sections have a negative and significant impact on newborn health, as measured by Apgar scores, but that the effect is not severe enough to translate into more extreme outcomes.

Evaluating patient outcomes following cardiac surgery is a means of measuring the quality of that surgery. The present study analyzes survival and the risk factors associated with mid-term mortality of patients undergoing cardiac surgery in Son Dureta University Hospital (Palma, Balearic Islands, Spain).From November 2002 thru December 2007, 1938 patients underwent interventions. Patients were stratified in 4 age groups. Of 1900 patients discharged from hospital, 1844 were followed until December 31, 2008. Following discharge, we constructed Kaplan-Meier survival curves and performed Cox regression analysis to determine which variables associated with mid-term mortality.In-hospital mortality of the 1,938 patients was 1.96% (CI 95%, 1.36%-2.6%). Survival probability at 1, 3 and 5 years follow-up was 98%, 94% and 90%, respectively. Mean follow-up was 3.2 (0.01-6.06) years. Patients aged ≥ 70 years showed a lower survival rate than those aged70 (log rank test, P.0001). At the end of follow-up, mortality was 6.5% (CI 95%, 5.4%-7.7%). Age ≥ 70 years, a history of severe ventricular dysfunction (ejection fraction30%), severe pulmonary hypertension, diabetes mellitus, preoperative anemia, postoperative stroke, and hospital stay were independently associated with mid-term mortality.Mid-term survival after discharge was highly satisfactory. Mid-term mortality varied with age and other pre- and postoperative factors.

Objective & para;& para;To increase discriminatory accuracy (DA) for emergency cesarean sections (ECSs).& para;& para;Study design & para;& para;We prospectively collected data on and studied all 6,157 births occurring in 2014 at four public hospitals located in three different autonomous communities of Spain. To identify risk factors (RFs) for ECS, we used likelihood ratios and logistic regression, fitted a classification tree (CTREE), and analyzed a random forest model (RFM). We used the areas under the receiver-operating-characteristic (ROC) curves (AUCs) to assess their DA.& para;& para;Results & para;& para;The magnitude of the LR+ for all putative individual RFs and ORs in the logistic regression models was low to moderate. Except for parity, all putative RFs were positively associated with ECS, including hospital fixed-effects and night-shift delivery. The DA of all logistic models ranged from 0.74 to 0.81. The most relevant RFs (pH, induction, and previous C-section) in the CTREEs showed the highest ORs in the logistic models. The DA of the RFM and its most relevant interaction terms was even higher (AUC = 0.94; 95% CI: 0.93-0.95).& para;& para;Conclusion & para;& para;Putative fetal, maternal, and contextual RFs alone fail to achieve reasonable DA for ECS. It is the combination of these RFs and the interactions between them at each hospital that make it possible to improve the DA for the type of delivery and tailor interventions through prediction to improve the appropriateness of ECS indications., The Spanish Ministry of Health approved and financed this study under the Strategy for Assistance at Normal Childbirth in the National Health System (PI/01445).

Objectives:The aim of this study was to describe 8-year results from post-implementation surveillance of neuroreflexotherapy (NRT), a health technology proven effective for treating neck and back pain.Methods:Post-implementation surveillance included all patients undergoing NRT across five regions within the Spanish National Health Service (SNHS). Validated methods were used to assess pain, disability, adverse events, use of health resources, and patient satisfaction. Logistic regression models were developed to identify the variables associated with the risk of a pain episode requiring more than one NRT intervention. The number of relapses among discharged patients during the 8-year period was calculated.Results:Between January 1, 2004, and June 30, 2012, 9,023 patients (median age: 53 years), presenting 11,384 subacute (25.2 percent) and chronic (74.8 percent), neck or back pain episodes, were discharged after receiving NRT. Spinal pain improved in 89 percent of cases, 83 percent abandoned drugs, and 0.02 percent required spine surgery. The only adverse event was skin discomfort (8.0 percent of patients). Number of patient complaints was 0, and answers to a standardized questionnaire reflected a high degree of satisfaction (response rate: 76.7 percent). Of the pain episodes, 18.9 percent required more than one NRT intervention; logistic regression models identified the variables associated with this. Over the 8-year period, the proportion of discharged patients referred for treatment due to relapse at the same level for neck, thoracic, and low back pain, was 16.4 percent, 6.5 percent, and 14.5 percent respectively.Conclusions:Post-marketing surveillance for a non-pharmacological technology is feasible within the SNHS. These results support generalizing NRT across the entire SNHS under the current validated application conditions.

To explore demographic and epidemiological characteristics surrounding menopause among women of Majorca, estimate their health related quality of life (QOL), and ascertain wheather they differ from those of the mainland population of menopausal women.A cross-sectional population-based study was conducted with a sample of 428 women. The Cervantes questionnaire for measuring QOL during menopause was used.Among women in Majorca, the mean QOL is better than the national mean of the Spain reference population. It declines with age and levels off at menopause. In menopausal women, QOL improves slightly in tandem with educational level. 29% of menopausal women were on some form of therapy, most commonly a mix of estrogens and gestagens (36%). Only a weak association was detected between being menopausal and QOL.The Cervantes questionnaire allows periodic study sample cut-offs to determine whether changes in sociodemographic and disease-related variables are also accompanied by changes in self-perceived QOL. It is much better in menopausal women in Majorca than in those in the Spanish mainland.

Primary care interventions directed at drinking and alcohol problems today constitute a highly important issue for service development, training and research. WHO has clone much to encourage work in this area, and in this journal feature we publish a summary by Thomas Babor, Marcus Grant et al. of a WHO multi-national clinical trial on the treatment of alcohol problems in the primary care setting. This summary is followed by comments from, Canada, Australia, Scotland, Norway, Denmark and Sweden and a reply from THomas Babor. We are grateful to the WHO investigators and the expert group of commentators, and to Robert West who took responsibility for organizing this series of contributions

Background context Conflicting reports exist regarding the prevalence of Modic changes among low back pain (LBP) patients and factors associated with their existence. Purpose To assess the prevalence of Modic changes and other findings on lumbar magnetic resonance imaging (MRI) among Spanish adult chronic LBP patients and the patient characteristics and radiological findings associated with Modic changes. Study design A cross-sectional imaging study among chronic LBP patients. Patient sample Four hundred eighty-seven patients (263 women and 224 men) undergoing lumbar spine MRI examination for chronic LBP. Outcome measures Gender, age, body mass index (BMI), lifetime smoking exposure, degree of physical activity, and image features (disc degeneration, type and extension of Modic changes, disc contour, annular tears, spinal stenosis, and spondylolisthesis). Methods Ten radiologists from six hospitals across six cities in Spain consecutively recruited adult patients in whom lumbar MRI had been prescribed for LBP lasting ≥3 months. Patients' characteristics and imaging findings were assessed through previously validated instruments. A multivariate logistic regression model was developed to assess the features associated with Modic changes. Results Modic changes were found in 81% of the patients. The most common was Type II (51.3%), affecting only the end plate. Variables associated with Type I changes were disc contour abnormalities, spondylolisthesis, and disc degeneration. The same variables were associated with a higher risk of Type II or any type of Modic changes, as well as being male, and having a higher BMI. Conclusions Modic changes are found in 81% (95% confidence interval, 77–85) of adult Spanish patients in whom an MRI is prescribed for chronic LBP. Modic changes are more likely to be found in males with a high BMI, who also show disc contour abnormalities, spondylolisthesis, or disc degeneration.

BACKGROUND AND PURPOSE: The CTF nomenclature had not been tested in clinical practice. The purpose of this study was to compare the reliability and diagnostic confidence in the interpretation of disk contours on lumbar 1.5T MR imaging when using the CTF and the Nordic nomenclatures. MATERIALS AND METHODS: Five general radiologists from 3 hospitals blindly and independently assessed intravertebral herniations (Schmorl node) and disk contours on the lumbar MR imaging of 53 patients with low back pain, on 4 occasions. Measures were taken to minimize the risk of recall bias. The Nordic nomenclature was used for the first 2 assessments, and the CTF nomenclature, in the remaining 2. Radiologists had not previously used either of the 2 nomenclatures. κ statistics were calculated separately for reports deriving from each nomenclature and were categorized as almost perfect (0.81–1.00), substantial (0.61–0.80), moderate (0.41–0.60), fair (0.21–0.40), slight (0.00–0.20), and poor ( RESULTS: Categorization of intra- and interobserver agreement was the same across nomenclatures. Intraobserver reliability was substantial for intravertebral herniations and disk contour abnormalities. Interobserver reliability was moderate for intravertebral herniations and fair to moderate for disk contour. CONCLUSIONS: In conditions close to clinical practice, regardless of the specific nomenclature used, a standardized nomenclature supports only moderate interobserver agreement. The Nordic nomenclature increases self-confidence in an individual observer9s report but is less clear regarding the classification of disks as normal versus bulged.

To evaluate intra- and interobserver agreement for the interpretation of lumbar 1.5-T magnetic resonance (MR) images in a community setting.The study design was approved by the Institutional Review Board of the Ramón y Cajal Hospital. According to Spanish law, for this type of study, no informed consent was necessary. Five radiologists from three hospitals twice interpreted lumbar MR examination results in 53 patients with low back pain, with at least a 14-day interval between assessments. Radiologists were unaware of the clinical and demographic characteristics of the patients and of their colleagues' assessments. At the second assessment, they were unaware of the results of the first assessment. Reports on Modic changes, osteophytes, Schmorl nodes, diffuse defects, disk degeneration, annular tears (high-signal-intensity zones), disk contour, spondylolisthesis, and spinal stenosis were collected by using the Spanish version of the Nordic Modic Consensus Group classification. The kappa statistic was used to assess intra- and interobserver agreement for findings with a prevalence of 10% or greater and 90% or lower. kappa was categorized as almost perfect (0.81-1.00), substantial (0.61-0.80), moderate (0.41-0.60), fair (0.21-0.40), slight (0.00-0.20), or poor (0.00).Endplate erosions and spondylolisthesis were observed in less than 10% of images. Intraobserver reliability was almost perfect for spinal stenosis; substantial for Modic changes, Schmorl nodes, disk degeneration, annular tears, and disk contour; and moderate for osteophytes. Interobserver reliability was moderate for Modic changes, Schmorl nodes, disk degeneration, annular tears, and disk contour; fair for osteophytes; and poor for spinal stenosis.In conditions close to those of clinical practice, there was only moderate interobserver agreement in the reporting of findings at 1.5-T lumbar MR imaging.http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090706/-/DC1.

Background: Correlation between clinical features and magnetic resonance imaging (MRI) findings is essential in low-back-pain patients. Most previous studies have analyzed concordance in the interpretation of lumbar MRI among a few radiologists who worked together. This may have overestimated concordance. Purpose: To evaluate intra- and interobserver agreement in the interpretation of lumbar MRI performed in an open 0.2T system. Material and Methods: Seven radiologists from two different geographic settings in Spain interpreted the lumbar MRIs of 50 subjects representative of the general Danish population aged 40 years. The radiologists interpreted the images in routine clinical practice, having no knowledge of the clinical and demographic characteristics of the subjects and blinded to their colleagues’ assessments. Six of the radiologists evaluated the same MRIs 14 days later, having no knowledge of the previous results. Data on the existence of disc degeneration, high-intensity zones, disc contour, Schmorl nodes, Modic changes, osteophytes, spondylolisthesis, and spinal stenosis were collected in the Nordic Modic Consensus Group Classification form. Intra- and interobserver agreement was analyzed for variables with a prevalence ≥10% and ≤90% by means of the kappa statistic. Results: Intra- and interobserver agreement was excellent for variables related to Modic changes, and fair to good for disc contour, high-intensity zones, and Schmorl nodes. The evaluations for disc degeneration and osteophytes were found to have fair to good intraobserver agreement and poor interobserver agreement. The agreement for the evaluations of spondylolisthesis and spinal stenosis was not analyzed because they were observed in Conclusion: Images from 0.2T MRIs appear to lead to good agreement in the reporting of disc contour, high-intensity zones, Schmorl nodes, and, in particular, Modic changes, suggesting that they can possibly be reliably used for clinical research purposes. In contrast, assessment of osteophytes and disc degeneration is not reliable.

The association between the APOE gene and Alzheimer's disease and other forms of dementia has been widely documented, but its relevance as a genetic risk factor in specific ethnic groups other than Caucasians in the United States and Europe is limited. The aim of this work was to describe the distribution of the APOE genotype in 80 subjects of Spanish origin, over 60 years old, who were institutionalized in the Spanish Hospital of Mexico City. Thirty-eight subjects who met the DSM-IV and ICD-10 criteria for Alzheimer's disease or vascular dementia and 42 controls without dementia underwent genotyping. APOE ε allele frequencies were as follows: for affected individuals, ε2, 7.9%, ε3, 69.7%, and ε4, 22.4%; for controls, ε2, 4.8%, ε3, 91.6%, and ε4, 3.6%. The higher frequency of the ε4 allele in the affected group (χ2 = 14.5; df = 4, p = .006) confirms an association between this APOE molecular variant and dementia in elderly Spaniards.

Background: To report results obtained by combining risk sharing tools with post-adoption surveillance mechanisms in order to control quality of care and implement a value-based reimbursement scheme for Neuroreflexotherapy (NRT), a non-pharmacological treatment proven effective for neck pain (NP), thoracic pain (TP) and low back pain (LBP). Methods: Pre-post prospective cohort study in routine clinical practice, carried out in primary care centers in the Spanish National Health Service in the Balearic Islands (Ib-Salut). Eight-hundred and seventy-one subacute and chronic NP, TP and LBP patients treated in Ib-Salut, who underwent NRT during 2011. A shared risk contract (SRC) was developed, where payments for NRT were linked to results on patients’ clinical evolution, reduction in medication and proportion of patients undergoing spinal surgery. Main outcome measures were local pain (NP, TP or LBP), referred pain, LBP-related disability and NP-related disability, measured using previously validated instruments at referral and 3 months later, use of medication assessed at referral and discharge, and rates of spinal surgery prescription after undergoing NRT. Results: Median improvements at discharge corresponded to 57.1% of baseline value for local pain, 75.0% for referred pain, 53.8% for LBP-related disability and 45.0% for NP-related disability. Patients taking medication at discharge represented 29.0% of those taking it at referral. The proportion of patients in whom spinal surgery was prescribed after undergoing NRT was 0%. These results were consistent with those from previous randomised controlled trials (RCTs) and studies in routine practice, and complied with the standards set in the SRC. Conclusions: It is feasible and effective to enhance post adoption surveillance methods with risk sharing tools to improve quality control and support value-based reimbursement decisions for NRT. The feasibility of generalising this approach to other settings and to other non-pharmacological treatments should be explored.