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Objective: This study aimed to analyse the impact of comprehensive smoke-free legislation (SFL) on the prevalence and incidence of adult smoking in primary healthcare (PHC) patients from three Spanish regions, overall and stratified by sex., Design: Longitudinal observational study conducted between 2008 and 2013., Setting: 66 PHC teams in Catalonia, Navarre and the Balearic Islands (Spain)., Participants: Population over 15 years of age assigned to PHC teams., Primary and Secondary Outcomes Measures: Quarterly age-standardised prevalence of non-smoker, smoker and ex-smoker and incidence of new smoker, new ex-smoker and ex-smoker relapse rates were estimated with data retrieved from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardised prevalence and incidence rates. Trends were expressed as annual percentage change and average annual percent change., Results: The overall standardised smoker prevalence rate showed a significant downward trend (higher in men than women) and the overall standardised ex-smoker prevalence rate showed a significant increased trend (higher in women than men) in the three regions. Standardised smoker and ex-smoker prevalence rates were higher for men than women in all regions. With regard to overall trends of incidence rates, new smokers decreased significantly in Catalonia and Navarre and similarly in men and women, new ex-smokers decreased significantly and more in men in Catalonia and the Balearic Islands, and ex-smoker relapse increased in Catalonia (particularly in women) and decreased in Navarre., Conclusions: Trends in smoking behaviour in PHC patients remain unchanged after the implementation of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the preceding partial SFL., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The aims of this registry were to determine the incidence, predictors, and prognostic value of periprocedural acute kidney injury (AKI) after left atrial appendage closure (LAAC)., Background: No data exist on the occurrence of AKI after LAAC., Methods: A total of 355 patients undergoing LAAC were included in the study. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or ≥50%, respectively, after the procedure or the need for hemodialysis during index hospitalization., Results: The incidence of AKI was 9%, and patients with worse baseline renal function were at higher risk for developing AKI (odds ratio: 1.32; 95% confidence interval [CI]: 1.09 to 1.61; p = 0.004 for each 10 ml/min decrease in glomerular filtration rate). In-hospital bleeding events occurred more frequently in the AKI group (5.3% vs. 15.6%; p = 0.037). After a median follow-up period of 18 months, patients in the AKI group had higher mortality (hazard ratio [HR]: 2.59; 95% CI: 1.36 to 4.92; p = 0.004), more embolic events (HR: 6.14; 95% CI: 2.23 to 16.92; p = 0.001) and major bleeding events (HR: 2.36; 95% CI: 0.89 to 6.24; p = 0.083). The occurrence of AKI was an independent predictor of midterm mortality (HR: 2.00; 95% CI: 1.02 to 3.91; p = 0.044)., Conclusions: The occurrence of AKI was relatively frequent following LAAC, and patients with lower renal glomerular filtration rates were at high risk for developing this complication. AKI identified a group of patients with worse midterm outcomes, highlighting the importance of further preventive strategies in this population., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex., Methods: Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC)., Results: The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: -8.00%, 95% CI: -10.46; -5.47) and Navarre (AAPC: -3.66%, 95% CI: -4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia., Conclusion: No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL.

Objectives: This study sought to evaluate the long-term clinical impact of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR)., Background: Conduction disturbances leading to PPI are common following TAVR. However, no data exist regarding the impact of PPI on long-term outcomes post-TAVR., Methods: This was a multicenter study including a total of 1,629 patients without prior PPI undergoing TAVR (balloon- and self-expandable valves in 45% and 55% of patients, respectively). Follow-up clinical, echocardiographic, and pacing data were obtained at a median of 4 years (interquartile range: 3 to 5 years) post-TAVR., Results: PPI was required in 322 (19.8%) patients within 30 days post-TAVR (26.9% and 10.9% in patients receiving self- and balloon-expandable CoreValve and Edwards systems, respectively). Up to 86% of patients with PPI exhibited pacing >1% of the time during follow-up (>40% pacing in 51% of patients). There were no differences between patients with and without PPI in total mortality (48.5% vs. 42.9%; adjusted hazard ratio [HR]: 1.15; 95% confidence interval [CI]: 0.95 to 1.39; p = 0.15) and cardiovascular mortality (14.9% vs. 15.5%, adjusted HR: 0.93; 95% CI: 0.66 to 1.30; p = 0.66) at follow-up. However, patients with PPI had higher rates of rehospitalization due to heart failure (22.4% vs. 16.1%; adjusted HR: 1.42; 95% CI: 1.06 to 1.89; p = 0.019), and the combined endpoint of mortality or heart failure rehospitalization (59.6% vs. 51.9%; adjusted HR: 1.25; 95% CI: 1.05 to 1.48; p = 0.011). PPI was associated with lesser improvement in LVEF over time (p = 0.051 for changes in LVEF between groups), particularly in patients with reduced LVEF before TAVR (p = 0.005 for changes in LVEF between groups)., Conclusions: The need for PPI post-TAVR was frequent and associated with an increased risk of heart failure rehospitalization and lack of LVEF improvement, but not mortality, after a median follow-up of 4 years. Most patients with new PPI post-TAVR exhibited some degree of pacing activity at follow-up., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate hospitalizations from pneumococcal pneumonia in older adults with specific underlying chronic conditions, evaluating the influence of these conditions in developing pneumonia., Methods: Population-based cohort study involving 27,204 individuals ≥ 60 years old in Southern Catalonia, Spain. All cases of hospitalization from pneumococcal pneumonia (bacteremic and nonbacteremic) were collected since 01/12/2008 until 30/11/2011. Cox regression was used to calculate hazards ratio (HR) and estimate the association between baseline conditions and the risk of developing pneumococcal pneumonia., Results: Maximum incidences (per 1000 person-years) appeared among patients with history of prior pneumonia (14.6), nursing home residents (12.8), persons with immunodeficiency/asplenia (7.7) and patients with chronic pulmonary disease (7.6). In multivariable analysis, age (HR: 1.05), nursing home residence (HR: 4.59), history of prior pneumonia (HR: 3.58), stroke (HR: 2.50), chronic heart disease (HR: 1.53), chronic pulmonary disease (HR: 4.09), diabetes mellitus (HR: 1.66), smoking (HR: 1.69) and immunosuppressive medication (HR: 1.87) appeared significantly associated with an increased risk of pneumococcal pneumonia., Conclusion: Our data support that nursing home residence, chronic pulmonary disease and immunocompromising conditions are the underlying conditions most strongly associated with an increasing risk of pneumococcal pneumonia in older adults. This data underline the need for better prevention strategies among these persons.

Objective: The purpose of this study was to identify clusters of diagnoses in elderly patients with multimorbidity, attended in primary care., Design: Cross-sectional study., Setting: 251 primary care centres in Catalonia, Spain., Participants: Individuals older than 64 years registered with participating practices., Main Outcome Measures: Multimorbidity, defined as the coexistence of 2 or more ICD-10 disease categories in the electronic health record. Using hierarchical cluster analysis, multimorbidity clusters were identified by sex and age group (65-79 and ≥80 years)., Results: 322,328 patients with multimorbidity were included in the analysis (mean age, 75.4 years [Standard deviation, SD: 7.4], 57.4% women; mean of 7.9 diagnoses [SD: 3.9]). For both men and women, the first cluster in both age groups included the same two diagnoses: Hypertensive diseases and Metabolic disorders. The second cluster contained three diagnoses of the musculoskeletal system in the 65- to 79-year-old group, and five diseases coincided in the ≥80 age group: varicose veins of the lower limbs, senile cataract, dorsalgia, functional intestinal disorders and shoulder lesions. The greatest overlap (54.5%) between the three most common diagnoses was observed in women aged 65-79 years., Conclusion: This cluster analysis of elderly primary care patients with multimorbidity, revealed a single cluster of circulatory-metabolic diseases that were the most prevalent in both age groups and sex, and a cluster of second-most prevalent diagnoses that included musculoskeletal diseases. Clusters unknown to date have been identified. The clusters identified should be considered when developing clinical guidance for this population.

Background: The prevalence of osteoarthritis and knee osteoarthritis in the Spanish population is estimated at 17% and 10.2%, respectively. The clinical guidelines concur that the first line treatment for knee osteoarthritis should be non-pharmacological and include weight loss, physical activity and self-management of pain. Health Coaching has been defined as an intervention that facilitates the achievement of health improvement goals, the reduction of unhealthy lifestyles, the improvement of self-management for chronic conditions and quality of life enhancement. The aim of this study is to analyze the effectiveness, cost-effectiveness and cost-utility of a health coaching intervention on quality of life, pain, overweight and physical activity in patients from 18 primary care centres of Barcelona with knee osteoarthritis., Methods/design: Methodology from the Medical Research Council on developing complex interventions. Phase 1: Intervention modelling and operationalization through a qualitative, socioconstructivist study using theoretical sampling with 10 in-depth interviews to patients with knee osteoarthritis and 4 discussion groups of 8-12 primary care professionals, evaluated using a sociological discourse analysis. Phase 2: Effectiveness, cost-effectiveness and cost-utility study with a community-based randomized clinical trial., Participants: 360 patients with knee osteoarthritis (180 in each group). Randomization unit: Primary Care Centre. Intervention Group: will receive standard care plus 20-hour health coaching and follow-up sessions., Control Group: will receive standard care., Main Outcome Variable: quality of life as measured by the WOMAC index. Data Analyses: will include standardized response mean and multilevel analysis of repeated measures. Economic analysis: based on cost-effectiveness and cost-utility measures. Phase 3: Evaluation of the intervention programme with a qualitative study. Methodology as in Phase 1., Discussion: If the analyses show the cost-effectiveness and cost-utility of the intervention the results can be incorporated into the clinical guidelines for the management of knee osteoarthritis in primary care., Trial Registration: ISRCTN57405925. Registred 20 June 2014.

Introduction: Burnout is a very prevalent type of stress among health professionals. It affects their well-being, performance, and attitude toward patients. This study assessed the effectiveness of a training program for primary health care professionals designed to reduce burnout and mood disturbance, increase empathy, and develop mindfulness., Methods: Pragmatic randomized controlled trial with pre- and postintervention measurements of 68 primary health care professionals (43 in the intervention and 25 in the control group) in Spain. The intervention consisted of presentations of clinically relevant topics, mindfulness-based coping strategies, mindfulness practice, yoga, and group discussions (8 sessions of 2.5 hours per week plus a 1-day session of 8 hours). Outcome measures included the Maslach Burnout Inventory, Profile of Mood States, Jefferson Scale of Physician Empathy, Baer's Five Facets Mindfulness Questionnaire, and a questionnaire on changes in personal habits and mindfulness practice. Measurements were performed at baseline and after 8 weeks., Results: The intervention group improved in the 4 scales measured. The magnitude of the change was large in total mood disturbance (difference between groups -7.1; standardized effect-size [SES] 1.15) and mindfulness (difference between groups 11; SES 0.9) and moderate in the burnout (difference between groups -7; SES 0.74) and empathy scales (difference between groups 5.2; SES 0.71). No significant differences were found in the control group., Discussion: Our study supports the use of mindfulness-based programs as part of continuing professional education to reduce and prevent burnout, promote positive attitudes among health professionals, strengthen patient-provider relationships, and enhance well-being., (© 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.)

Purpose: This study compares the ability of two simpler severity rules (classical CRB65 vs. proposed CORB75) in predicting short-term mortality in elderly patients with community-acquired pneumonia (CAP)., Methods: A population-based study was undertaken involving 610 patients ≥ 65 years old with radiographically confirmed CAP diagnosed between 2008 and 2011 in Tarragona, Spain (350 cases in the derivation cohort, 260 cases in the validation cohort). Severity rules were calculated at the time of diagnosis, and 30-day mortality was considered as the dependent variable. The area under the receiver operating characteristic curves (AUC) was used to compare the discriminative power of the severity rules., Results: Eighty deaths (46 in the derivation and 34 in the validation cohorts) were observed, which gives a mortality rate of 13.1 % (15.6 % for hospitalized and 3.3 % for outpatient cases). After multivariable analyses, besides CRB (confusion, respiration rate ≥ 30/min, systolic blood pressure <90 mmHg or diastolic ≤ 60 mmHg), peripheral oxygen saturation (≤ 90 %) and age ≥ 75 years appeared to be associated with increasing 30-day mortality in the derivation cohort. The model showed adequate calibration for the derivation and validation cohorts. A modified CORB75 scoring system (similar to the classical CRB65, but adding oxygen saturation and increasing the age to 75 years) was constructed. The AUC statistics for predicting mortality in the derivation and validation cohorts were 0.79 and 0.82, respectively. In the derivation cohort, a CORB75 score ≥ 2 showed 78.3 % sensitivity and 65.5 % specificity for mortality (in the validation cohort, these were 82.4 and 71.7 %, respectively)., Conclusions: The proposed CORB75 scoring system has good discriminative power in predicting short-term mortality among elderly people with CAP, which supports its use for severity assessment of these patients in primary care.

Background: The benefits of using the 23-valent pneumococcal polysaccharide vaccine (PPV23) are controversial. This study assessed clinical effectiveness of PPV23 in preventing community-acquired pneumonia (CAP) among the general population aged ≥ 60 years., Methods: This was a population-based cohort study involving 27 204 individuals aged ≥ 60 years in Tarragona, Spain, who were prospectively followed from 1 December 2008 until 30 November 2011. Primary outcomes were hospitalization for pneumococcal CAP (bacteremic and nonbacteremic cases) and all-cause CAP. All CAP cases were radiographically confirmed and validated by checking clinical records. Cox regression was used to evaluate the association between pneumococcal vaccination and the risk of each outcome., Results: Cohort members were followed for a total of 76 033 person-years (29 065 person-years for vaccinated subjects). Incidence rates (per 1000 person-years) were 0.21 for bacteremic pneumococcal CAP (0.14 vs 0.26 among vaccinated and unvaccinated subjects, respectively), 1.45 for nonbacteremic pneumococcal CAP (1.46 vs 1.44), and 7.51 for all-cause CAP (7.19 vs 7.71). In primary analyses including all cohort members, PPV23 did not appear to be effective against any analyzed outcome. However, a beneficial effect emerged in sensitive and stratified analyses. After multivariable adjustments, as compared with those never vaccinated, recent vaccination with PPV23 (<5 years ago) was associated with reduced risks of bacteremic pneumococcal CAP (hazard ratio [HR], 0.38; 95% confidence interval [CI], .09-1.68), nonbacteremic pneumococcal CAP (HR, 0.52; 95% CI, .29-.92), overall pneumococcal CAP (HR, 0.49; 95% CI, .29-.84), and all-cause CAP (HR, 0.75; 95% CI, .58-.98)., Conclusions: Our data support a protective effect of recent PPV23 vaccination (within previous 5 years) against both pneumococcal and all-cause CAP.

Background: Cardiovascular benefits using the 23-valent pneumococcal polysaccharide vaccine (PPV23) are controversial. This study assessed clinical effectiveness of PPV23 in preventing acute myocardial infarction in people over 60-years., Methodology: We conducted a population-based cohort study involving 27,204 individuals ≥60 years-old in Tarragona, Spain, who were prospectively followed from 01/12/2008 until 30/11/2011. Outcomes were hospitalization for AMI, 30-day mortality from AMI and all-cause death. Cox regression was used to evaluate the association between pneumococcal vaccination and the risk of each outcome., Results: Cohort members were followed for a total of 76,033 person-years, of which 29,065 were for vaccinated subjects. Overall, 359 cases of AMI, 55 deaths from AMI and 2465 all-cause deaths were observed. Pneumococcal vaccination did not alter the risk of AMI (multivariable hazard ratio [HR]: 0.95; 95% confidence interval [CI]: 0.76-1.18; p=0.630), death from AMI (HR: 1.32; 95% CI: 0.76-2.28; p=0.321) and all-cause death (HR: 0.97; 95% CI: 0.89-1.05; p=0.448). In analyses focused on people with and without history of prior coronary artery disease, pneumococcal vaccination did not emerge effective in preventing any analyzed event., Conclusions: This study supports that PPV23 does not provide any relevant benefit against AMI in the general population over 60 years, as in primary as well as in secondary prevention, although it is underpowered to exclude a small benefit of vaccination against rare outcomes., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To determine the prevalence of negative mood states in adolescents according to gender, to analyze variability among schools, and to evaluate the associated factors., Methods: A cross-sectional study with a cluster design was carried out. We administered the High-school students health survey to a sample of 9,340 students (aged 14-16 years) in the third and fourth year of Compulsory Secondary Education in Catalonia, Spain, during the 2005-6 academic year. The main outcome measure was evidence of a negative mood state. A multilevel logistic regression model stratified by gender was used to identify the factors associated with negative mood states and to determine variability among distinct schools., Results: Approximately 19% of adolescents reported evidence of a negative mood state, with a higher prevalence in girls (25%). The most significant factors associated with negative mood states were "use of tranquilizers" and "having eating disorders" in girls and "not exercising" and "poor self-perception of health status" in boys. In both genders, variability was found among schools in the prevalence of negative mood states (girls: variance = 0.078; p <0.001; boys: variance = 0.079; p = 0.012)., Conclusions: The prevalence of negative mood states in adolescent boys and girls was high. Differences were observed between genders in the factors related to these health states. The variability observed in the prevalence of negative mood states among distinct schools could not be explained by the study variables. Our results emphasize the association between the use of tranquilizers and negative mood states., (Copyright © 2011 SESPAS. Published by Elsevier Espana. All rights reserved.)

Background: Conflicting results have been recently reported evaluating the relationship between pneumococcal vaccination and the risk of thrombotic vascular events. This study assessed the clinical effectiveness of the 23-valent polysaccharide pneumococcal vaccine (PPV23) against acute myocardial infarction and ischaemic stroke in older adults., Methods: Population-based prospective cohort study conducted from December 1, 2008 until November 30, 2009, including all individuals ≥ 60 years-old assigned to nine Primary Care Centres in Tarragona, Spain (N = 27,204 individuals). Primary outcomes were hospitalisation for acute myocardial infarction and/or ischaemic stroke. All cases were validated by checking clinical records. The association between pneumococcal vaccination and the risk of each outcome was evaluated by Multivariable Cox proportional-hazard models (adjusted by age, sex, influenza vaccine status, presence of comorbidities and cardiovascular risk factors)., Results: Cohort members were followed for a total of 26,444 person-years, of which 34% were for vaccinated subjects. Overall incidence rates (per 1000 person-years) were 4.9 for myocardial infarction and 4.6 for ischaemic stroke. In the multivariable analysis, vaccination was associated with a marginally significant 35% lower risk of stroke (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42-0.99; p = 0.046). We found no evidence for an association between pneumococcal vaccination and reduced risk of myocardial infarction (HR: 0.83; 95% CI: 0.56-1.22; p = 0.347)., Conclusions: Our data supports a benefit of PPV23 against ischaemic stroke among the general population over 60 years, suggesting a possible protective role of pneumococcal vaccination against some acute thrombotic events.

Aim: This study compares the ability of the Pneumonia Severity Index (PSI) and the British Thoracic Society CURB-65 and CRB-65 rules in predicting short-term mortality among elderly patients with community-acquired pneumonia (CAP)., Methods: It is a population-based study including all people over 65 years old with a radiographically confirmed CAP in the region of Tarragona (Spain) between 2002 and 2008. Treatment setting and clinical variables were considered for each patient. PSI, CURB-65 and CRB-65 scores were calculated at the moment of diagnosis and 30-day mortality was considered as a main dependent variable. The rules were compared based on sensitivity, specificity and area under the receiver operating characteristic curve (AUC)., Results: Of the total 590 CAP cases, mortality rate was 13.6% (15.3% in hospitalised and 1.4% in outpatient cases; p = 0.001). Mortality increased with increasing PSI score (None in class II, 6,9% in class III, 14,4% in class IV and 29,5% in class V), CURB-65 score (7.5%, 14.5%, 26.7%, 53.3% and 100% for scores 1,2,3,4 and 5 respectively) and CRB-65 score (6.6%, 26.1%, 40.5% and 50% for scores 1,2,3 and 4 respectively). The three rules performed too similarly to predict 30-day mortality, with a ROC area of 0.727 [95% confidence interval (CI): 0.67-0.79] for the PSI, 0.672 (95% CI: 0.61-0.74) for the CURB-65, and 0.719 (95% CI: 0.65-0.78) for the CRB-65., Conclusion: Our data shows that the analysed rules perform equally well among elderly people with CAP which supports the recommendation for using the simplified CRB-65 severity score among elderly patients in primary care or emergency visits., (© 2011 Blackwell Publishing Ltd.)

Aim: To evaluate the effectiveness in primary care of a stepped smoking cessation intervention based on the transtheoretical model of change., Design: Cluster randomized trial; unit of randomization: basic care unit (family physician and nurse who care for the same group of patients); and intention-to-treat analysis., Setting: All interested basic care units (n = 176) that worked in 82 primary care centres belonging to the Spanish Preventive Services and Health Promotion Research Network in 13 regions of Spain., Participants: A total of 2,827 smokers (aged 14-85 years) who consulted a primary care centre for any reason, provided written informed consent and had valid interviews., Measurements: The outcome variable was the 1-year continuous abstinence rate at the 2-year follow-up. The main variable was the study group (intervention/control). Intervention involved 6-month implementation of recommendations from a Clinical Practice Guideline which included brief motivational interviews for smokers at the precontemplation-contemplation stage, brief intervention for smokers in preparation-action who do not want help, intensive intervention with pharmacotherapy for smokers in preparation-action who want help and reinforcing intervention in the maintenance stage. Control group involved usual care. Among others, characteristics of tobacco use and motivation to quit variables were also collected., Findings: The 1-year continuous abstinence rate at the 2-year follow-up was 8.1% in the intervention group and 5.8% in the control group (P = 0.014). In the multivariate logistic regression, the odds of quitting of the intervention versus control group was 1.50 (95% confidence interval = 1.05-2.14)., Conclusions: A stepped smoking cessation intervention based on the transtheoretical model significantly increased smoking abstinence at a 2-year follow-up among smokers visiting primary care centres., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Background: Low back pain (LBP), with high incidence and prevalence rate, is one of the most common reasons to consult the health system and is responsible for a significant amount of sick leave, leading to high health and social costs. The objective of the study is to assess the cost-effectiveness and cost-utility analysis of a multidisciplinary biopsychosocial educational group intervention (MBEGI) of non-specific sub-acute LBP in comparison with the usual care in the working population recruited in primary healthcare centres., Methods/design: The study design is a cost-effectiveness and cost-utility analysis of a MBEGI in comparison with the usual care of non-specific sub-acute LBP.Measures on effectiveness and costs of both interventions will be obtained from a cluster randomised controlled clinical trial carried out in 38 Catalan primary health care centres, enrolling 932 patients between 18 and 65 years old with a diagnosis of non-specific sub-acute LBP. Effectiveness measures are: pharmaceutical treatments, work sick leave (% and duration in days), Roland Morris disability, McGill pain intensity, Fear Avoidance Beliefs (FAB) and Golberg Questionnaires. Utility measures will be calculated from the SF-12. The analysis will be performed from a social perspective. The temporal horizon is at 3 months (change to chronic LBP) and 12 months (evaluate the outcomes at long term).Assessment of outcomes will be blinded and will follow the intention-to-treat principle., Discussion: We hope to demonstrate the cost-effectiveness and cost-utility of MBEGI, see an improvement in the patients' quality of life, achieve a reduction in the duration of episodes and the chronicity of non-specific low back pain, and be able to report a decrease in the social costs. If the intervention is cost-effectiveness and cost-utility, it could be applied to Primary Health Care Centres., Trial Registration: ISRCTN: ISRCTN58719694.

Background: The prevalence of smoking in Spain is high in both men and women. The aim of our study was to evaluate the role of gender in the effectiveness of a specific smoking cessation intervention conducted in Spain., Methods: This study was a secondary analysis of a cluster randomized clinical trial in which the randomization unit was the Basic Care Unit (family physician and nurse who care for the same group of patients). The intervention consisted of a six-month period of implementing the recommendations of a Clinical Practice Guideline. A total of 2,937 current smokers at 82 Primary Care Centers in 13 different regions of Spain were included (2003-2005). The success rate was measured by a six-month continued abstinence rate at the one-year follow-up. A logistic mixed-effects regression model, taking Basic Care Units as random-effect parameter, was performed in order to analyze gender as a predictor of smoking cessation., Results: At the one-year follow-up, the six-month continuous abstinence quit rate was 9.4% in men and 8.5% in women (p = 0.400). The logistic mixed-effects regression model showed that women did not have a higher odds of being an ex-smoker than men after the analysis was adjusted for confounders (OR adjusted = 0.9, 95% CI = 0.7-1.2)., Conclusions: Gender does not appear to be a predictor of smoking cessation at the one-year follow-up in individuals presenting at Primary Care Centers. CLINICALTRIALS.GOV IDENTIFIER: NCT00125905.

The 23-valent polysaccharide pneumococcal vaccine is currently recommended in elderly and high-risk adults. Its efficacy against invasive pneumococcal disease has been demonstrated, but its effectiveness in preventing pneumonia remains uncertain. This study assessed the clinical effectiveness of vaccination against pneumonia among middle-aged and older adults. We conducted a population-based case-control study including 304 case patients over 50 years old with radiographically confirmed pneumococcal pneumonia (94 bacteremic and 210 nonbacteremic cases) and 608 outpatient control subjects (matched by primary care centre, age, sex and risk stratum). Adjusted odds ratios (ORs) for vaccination were calculated using conditional logistic regression, controlling for underlying conditions. Vaccine effectiveness against all pneumococcal pneumonia was 48% (OR: 0.52; 95% confidence interval [CI]: 0.37-0.73). Vaccination was effective against bacteremic cases (OR: 0.34; 95% CI: 0.27-0.66) as well as nonbacteremic cases (OR: 0.58; 95% CI: 0.39-0.86). Vaccine effectiveness was highest against bacteremic infections caused by vaccine types (OR: 0.24; 95% CI: 0.09-0.66). These findings confirm the effectiveness of the vaccine against invasive disease, but they also support the benefit of vaccination in preventing nonbacteremic pneumococcal pneumonia.

Objective: This study assessed incidence, aetiology, clinical outcomes and risk factors for community-acquired pneumonia (CAP) in older adults., Methods: This was a population-based cohort study that included 11,241 community-dwelling individuals aged 65 years or more, who were followed between 2002 and 2005 in the region of Tarragona, Spain. Primary endpoints were all-cause CAP (hospitalised and outpatient) and 30-day mortality after the diagnosis. All cases were radiographically proved and validated by checking clinical records., Results: Incidence rate of overall CAP was 14 cases per 1000 person-years (10.5 and 3.5 for hospitalised and outpatient cases, respectively). Incidence was almost three-fold higher among immunocompromised patients (30.9 per 1000) than among immunocompetent subjects (11.6 per 1000). Maximum incidences were observed among patients with chronic lung disease and long-term corticosteroid therapy (46.5 and 40.1 cases per 1000 person-years, respectively). Overall 30-day case-fatality rate was 12.7% (2% in cases managed as outpatient and 15% in hospitalised patients). Among 358 patients with an aetiological work-up, a total of 142 pathogens were found (single pathogen in 121 cases and mixed pathogens in 10 cases). Streptococcus pneumoniae was the most common pathogen (49%), followed by Pseudomonas aeruginosa (15%), Chlamydia pneumoniae (9%) and Haemophilus influenzae (6%). In multivariable analysis, the variables most strongly associated with increasing risk of CAP were history of hospitalisation for CAP in the previous 2 years and presence of any chronic lung disease., Conclusions: CAP remains a major cause of morbidity and mortality in older adults. Incidence rates in this study largely doubled prior rates reported in Southern European regions.

A prospective cohort study evaluating the clinical effectiveness of the 23-valent pneumococcal polysaccharide vaccine was conducted among 1298 Spanish older adults with chronic respiratory diseases (bronchitis, emphysema or asthma) who were followed between 2002 and 2005. Main outcomes were all-cause community-acquired pneumonia (CAP) and 30 days mortality from CAP. The association between vaccination and the risk of each outcome was evaluated by multivariable Cox proportional-hazard models adjusted for age and comorbidity pneumococcal vaccination did not alter significantly the risk of overall CAP (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.56-1.07) and 30 days mortality from CAP (HR: 0.87; 95% CI: 0.33-2.28). However, a borderline significant reduction of 30% in the risk of all-cause hospitalisation for CAP was observed among vaccinated subjects (HR: 0.70; 95% CI: 0.48-1.00; p=0.052). The effectiveness of the vaccine on the combined endpoint of pneumococcal and unknown organism infections reached 34% (HR: 0.66; 95% CI: 0.43-1.01; p=0.059). Although our findings suggest moderate benefits from the vaccination, the evidence of clinical effectiveness appears limited.

This study assessed the relationship between the reception of conventional inactivated influenza vaccine and winter mortality in a prospective cohort that included 11,240 Spanish community-dwelling elderly individuals followed from January 2002 to April 2005. Annual influenza vaccine status was a time-varying condition and primary outcome was all-cause death during study period. Multivariable Cox proportional-hazard models adjusted by age, sex and co-morbidity were used to evaluate vaccine effectiveness. Influenza vaccination was associated with a significant reduction of 23% in winter mortality risk during overall influenza periods. The attributable mortality risk in non-vaccinated people was 24 deaths per 100,000 persons-week within influenza periods, the prevented fraction for the population was 14%, and one death was prevented for every 239 annual vaccinations (ranging from 144 in Winter 2005 to 1748 in Winter 2002).

Background: The incidence of basal cell carcinoma (BCC) is increasing. Curettage and electrodesiccation (CE) are not recommended for BCC treatment at medium- and high-risk facial sites. Surgical excision has been proposed as the treatment of choice., Objective: We sought to evaluate the cumulative recurrence rate (RR) of primary BCC in facial areas of medium and high risk after CE., Methods: This nonrandomized, clinical trial enrolled 257 patients with primary BCC located in medium- and high-risk facial areas, and treated with 4 or 5 cycles of CE by a single operator from a section specializing in BCC CE in a tertiary teaching hospital in Oviedo, Spain. Exclusion criteria for study entry included: recurrent BCC, fibrosing BCC, ill-defined BCC, and BCC larger than 10 mm in diameter (high-risk facial sites) or larger than 15 mm in diameter (medium-risk sites); BCC smaller than 4 mm; and nonbiopsy-proven BCC. BCCs included in the study were from the nose, and paranasal and nasal-labial fold (n = 105); eyelids and canthi (n = 48); perioral areas (n = 12); ears (n = 11); forehead and temples (n = 48); periauricular areas (n = 14); and malar areas and cheeks (n = 19). The primary outcome was recurrence of carcinoma, which was clinically evaluated by at least two observers in consensus. Data were analyzed using both a life table method and Kaplan-Meier analysis. The statistical analysis included best- and worst-case scenarios (which means that all cases lost to follow-up were considered as recurrences)., Results: The 5-year cumulative non-RR in the best-case scenario was 98.80% (SE 0.70, 95% confidence interval 97.40%-100%); thus, a 5-year cumulative RR of 1.20% was found after CE in our medium- and high-risk BCCs of the face (best case). The 5-year cumulative non-RR in the worst-case scenario was 79.40% (95% confidence interval 78.90%-79.90%); thus, a 5-year cumulative RR of 20.60%., Limitations: Retrospective design with a relatively small number of patients lost to follow-up is a study limitation., Conclusion: High 5-year cure rates can be obtained after CE of primary, nonfibrosing BCCs of medium- and high-risk areas of the face performed in a specialized section.

An increase in the incidence of group C meningococcal disease was observed in the Murcia Region (Spain) during 1996-1997. In September 1997, a massive vaccination campaign was implemented among the population aged 18 months to 19 years. The aim of this study was to assess the seroconversion rate of children aged 18-59 months and the persistence of immune response 1 year after vaccination. A total of 296 children were included. Blood samples were obtained before vaccination and 1 month and 1 year after vaccination. Three point seven percent of the children had bactericidal antibody titres of >/=1:8 before vaccination. One month after vaccination seroconversion was 63.7%, with a growing trend related to age at vaccination (p<0.0001). The increase in antibody titres was shown to be quantitatively greater above the age of 36 months (p<0.0001). One year after vaccination only 4.3% of the children who initially seroconverted still had bactericidal activity. Seroconversion in children under 5 increases with age but antibodies decline rapidly in the year following vaccination.

Objective: Assessment of the perceived quality of care for inguinal hernia repair procedures., Design: A two-step descriptive study using specific questionnaires., Setting: A tertiary care University Hospital., Subjects: Random sample of patients diagnosed of inguinal hernia in 1996. Group A, patients seen at the outpatient clinic before admission; group B, patients seen for follow-up after the surgical procedure., Interventions: Two different questionnaires were used., Main Outcome Measures: validity of the questionnaire was evaluated using Cronbach's alpha value. Scores were measured using the z value., Results: Total number of patients was 194. Both groups were comparable. The questionnaire was able to explain 66.3% of the variance. The Cronbach's alpha value was 0.90. Scores recorded were significantly different (P < 0.01) regarding the health care workers' attitude and hospital commodities' variables (rated as better than expected). Differences in scores for information supplied, overall results of the surgical procedure and food variables were not statistically significant., Conclusions: (i) The study of several fields where the patient's expectations are higher or lower contributes to prioritizing efforts to improve quality in the Surgery Department. (ii) The differences seen strongly suggest the need for patient's satisfaction surveys to be specific by diagnosis/dimension and adapted to patients' expectations.

The relationship between alcohol consumption and stroke is uncertain. Heavy alcohol consumption has been associated with an increased risk of stroke, while light drinking appears to be protective. However, the evidence is not uniform. We sought to examine the relationship between alcohol consumption and stroke, according to stroke type. We performed a population-based case-control study from September 1990 to December 1991. The study comprised 467 incident cases of stroke and 477 controls aged between 40 and 85. Case was defined following WHO criteria and control was randomly selected from the study base population. Alcohol exposure was obtained by medical interview. We found that consumption of less than 30 g/day of alcohol was protective against all stroke types combined, the multivariated adjusted odds ratio (OR) was 0.58 (95% confidence interval [CI], 0.41-0.83). Moderate alcohol drinking is also protective against all cerebral infarction combined (OR = 0.53; 95% CI, 0.35-0.80) and cortical infarction (OR = 0.40; 95% CI, 0.18-0.86). Drinking up to 30 g/day of alcohol has a borderline protective effect on deep cerebral infarction (OR = 0.40; 95% CI, 0.16-1.02) and has no effect on intracerebral hemorrhage (OR = 0.88; 95% CI, 0.44-1.74). Heavy alcohol drinking, over 140 g/day, is a risk factor for all stroke types combined (OR = 3.2; 95% CI, 1.1-9.7), all cerebral infarction combined (OR = 5.0; 95% CI, 1.5-16.3), small deep cerebral infarction (OR = 9.7; 95% CI, 2.6-36.7), intracerebral hemorrhage (OR = 6.2; 95% CI, 1.3-24.0), and is marginally associated with superficial cerebral infarction (OR = 4.6; 95% CI, 1.0-20.6). The relationship between alcohol and stroke depends on the alcohol dose and the pathology of the disease. Atherosclerosis of the large and medium cerebral arteries is found mainly in superficial cerebral infarction, and this type of stroke shows a J-shaped relationship with alcohol similar to that found in coronary heart disease, suggesting that they are similar diseases. On the other hand, arteriosclerosis of the penetrating arteries has been found in deep cerebral infarction and intracerebral hemorrhage, while atherosclerosis is not prominent. This may explain why alcohol does not have a protective effect on cerebral hemorrhage whereas heavy drinking is a strong risk factor in these two types of stroke.

Background: Family history of stroke has been considered as a risk factor for stroke, but this relationship is controversial. Some, but not all, studies have found an independent association between family history of stroke and stroke. This study examines the relationship between family history of stroke and all stroke types combined, cerebral infarction and intraparenchymatous haemorrhage., Methods: This is an incidence type, population-based case-control study. Cases were defined following WHO criteria and controls were randomly selected from the study-base population. Family history of stroke was obtained by medical interview. A total of 470 cases and 477 controls, aged 40-85 years, form the subjects of the study., Results: Family history of stroke in a first-degree relative is an independent risk factor for all stroke types combined, multivariate adjusted odds ratio (OR) 1.74, 95% confidence interval (CI) 1.24-2.44, for cerebral infarction, OR = 1.79 (95% CI 1.25-2.56), but not for intraparenchymatous haemorrhage, OR = 1.71 (95% CI 0.91-3.17). Risk of all stroke types combined was independently associated with a positive history of father with stroke OR = 1.93 (1.19-3.54) with a positive history of sibling with stroke, OR = 1.67 (95% CI 1.03-2.71) and a borderline significant association with a positive history of mother with stroke OR = 1.45 (95% CI 0.92-2.29). Cerebral infarction was independently associated with a positive history of father with stroke OR = 2.05 (95% CI 1.17-3.59), a positive history of sibling, OR = 1.69 (95% CI 1.01-2.84) and a borderline significant association with a positive history of mother with stroke OR = 1.58 (95% CI 0.97-2.56). Intracerebral haemorrhage was not significantly associated with a positive history of father with stroke OR = 1.39 (0.55-3.58) with a positive history of sibling, OR = 1.83 (95% CI 0.77-4.40), or with a positive history of mother with stroke OR = 1.36 (95% CI 0.59-3.09)., Conclusions: Family history of stroke is found in this study to be an independent risk factor for all stroke types combined and for cerebral infarction. Genetic factors may be involved, but it cannot be ruled out that the observed relationship is confounded by other risk factors, especially family aggregation of life-styles.

The prevalence of hepatitis A antibodies in the adult population of the Murcia Region (southeast of Spain) was estimated using an anonymous unlinked serosurvey in a population-based sample of 2,203 adults. The overall anti-HAV prevalence was 76.5%. The prevalence increased with age and was higher in individuals living in towns with less than 10,000 inhabitants.

We conducted an unlinked seroprevalence survey in a community-based sample of 2,203 adults to estimate the prevalence of hepatitis B and C virus markers in the general adult population of the Murcia region (Spain). The influence of age, sex and place of residence on the seroprevalence of hepatitis was investigated. The overall prevalence was 10.2% for anti-HBc antibodies, 0.9% for HBsAg, and 1% for anti-HCV. There was a trend of increasing prevalence with age for anti-HBc and anti-HCV regardless of sex and urban or rural residence. The prevalence of hepatitis B and C markers was higher in individuals living in urban areas, although there was no significant association. The results indicate that the Murcia region may be considered an area of low-intermediate endemicity for hepatitis B virus infection. This is one of the first reports assessing the prevalence rate for hepatitis C markers for a general population in Europe.