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Se revisan los métodos de series temporales en los estudios epidemiológicos sobre contaminación atmosférica, ilustrándolo mediante una regresión de Poisson autoregresiva, la cual ha sido utilizada en los proyectos APHEA y EMECAM. Se relacionan las variaciones en el número diario de muertos mayores de 70 años (todas las causas, CIE-9:001-799) en Barcelona, 1991-1995, con las variaciones en los niveles diarios promedio de contaminación por humos negros. Se utiliza una regresión de Poisson por cuanto la variable aleatoria dependiente sigue presumiblemente tal distribución de probabilidad. Como confusores se consideran variables meteorológicas (promedios diarios de temperatura y de humedad), comportamientos tendenciales, estacionales y efectos de calendario presentes en la mortalidad (todos ellos aproximados de forma determinista) así como cualquier otra variable que tenga un comportamiento que pueda relacionarse con la variable dependiente (ocurrencia de epidemias de gripe por ejemplo). La relación entre la mortalidad y las variables confusoras se modeliza de forma no lineal y se tienen en cuenta además los previsibles periodos de latencia (utilizando retardos de variables explicativa por ejemplo). Sin embargo, y debido a que el control no es perfecto, se opta por estimar un modelo de Poisson autoregresivo (introduciendo como variables explicativas diversos retardos de la mortalidad) corrigiendo la autocorrelación residual. La principal ventaja del método de análisis descrito es la de permitir un control de variables confusoras desde un punto determinista, con un software al alcance de todos los grupos que participan en el proyecto. Además, permite que el método se pueda aplicar de una formar protocolizada y estandarizada que facilite la comparación de resultados y permita la realización de un meta-análisis.

El objetivo del presente trabajo es mostrar el protocolo de análisis elaborado dentro del proyecto EMECAM, ilustrando su aplicación en el efecto de la contaminación en la mortalidad en Valencia ciudad. Se consideran como variables respuesta la mortalidad diaria para todas las causas, excepto las externas Las variables explicativas son las series diarias de diversos contaminantes (humos negros, SO2, NO2, CO, O3). Como posibles variables de confusión se consideran factores metereológicos, factores estructurales y casos semanales de gripe. Se construye un modelo de regresión Poisson para cada una de las cuatro series de mortalidad en dos fases. En la primera se construye un modelo basal con las posibles variables de confusión. En una segunda se incluyen las variables de contaminación o sus retardos, controlando la autocorrelación residual con la inclusión de retardos de mortalidad. El proceso de construcción del modelo basal sigue el siguiente proceso: 1º) Incluir los términos sinusoidales significativos hasta orden 6. 2º) Incluir los términos significativos de temperatura o temperatura al cuadrado con sus retardos hasta orden 15. 3º) Repetir el proceso con la humedad relativa.4º) Introducir los términos significativos de años del calendario, tendencia diaria y tendencia al cuadrado. 5º) Los días de la semana como variables "dummy" se incluyen siempre en el modelo. 6º) Incluir los días festivos, y de los retardos hasta 15 días de gripe aquellos que fueron significativos. Tras la reevaluación del modelo, se prueba cada uno de los contaminantes y sus retardos hasta orden 5. Se analiza el efecto por semestres incluyendo términos de interacción.

OBJECTIVE: To study the linkage between material deprivation and mortality from all causes, for men and women separately, in the capital cities of the provinces in Andalusia and Catalonia (Spain). METHODS: A small-area ecological study was devised using the census section as the unit for analysis. 188,983 Deaths occurring in the capital cities of the Andalusian provinces and 109,478 deaths recorded in the Catalan capital cities were examined. Principal components factorial analysis was used to devise a material deprivation index comprising the percentage of manual labourers, unemployment and illiteracy. A hierarchical Bayesian model was used to study the relationship between mortality and area deprivation. MAIN RESULTS: In most cities, results show an increased male mortality risk in the most deprived areas in relation to the least depressed. In Andalusia, the relative risks between the highest and lowest deprivation decile ranged from 1.24 (Malaga) to 1.40 (Granada), with 95% credibility intervals showing a significant excess risk. In Catalonia, relative risks ranged between 1.08 (Girona) and 1.50 (Tarragona). No evidence was found for an excess of female mortality in most deprived areas in either of the autonomous communities. CONCLUSIONS: Within cities, gender-related differences were revealed when deprivation was correlated geographically with mortality rates. These differences were found from an ecological perspective. Further research is needed in order to validate these results from an individual approach. The idea to be analysed is to identify those factors that explain these differences at an individual level. [ABSTRACT FROM AUTHOR]

FUNDAMENTOS: La mayoría de los estudios que muestran la existencia de una asociación a corto plazo entre contaminación atmosférica y morbimortalidad, analizan los efectos de los contaminantes `clásicos' cuya fuente es la combustión. Sin embargo, los cambios en las fuentes de emisión, fundamentalmente hacia el tráfico rodado, han modificado la contaminación atmosférica, haciendo más importante los componentes foto-químicos, como el ozono (O3) y el dióxido de nitrógeno (NO2). Barcelona es una ciudad situada en una zona templada y su contaminación atmosférica proviene principalmente de las emisiones de los vehículos. El principal objetivo de este artículo es el de analizar la relación entre los contaminantes foto-químicos, NO2 y O3, y la mortalidad por diferentes causas, en la ciudad de Barcelona desde 1991 hasta 1995, utilizando el protocolo de análisis elaborado dentro del proyecto EMECAM. MÉTODOS: Variaciones diarias del número de muertes por todas las causas, del número de muertes por todas las causas entre mayores de 70 años, del número de muertes por causas del aparato circulatorio y por causas respiratorias se relacionan con las variaciones diarias de los contaminantes foto-químicos, a través de modelos de Poisson autoregresivos, controlando confusores como la temperatura, la humedad relativa, la estructura temporal sistemática y la estructura autoregresiva. RESULTADOS: Excepto la relación entre O3 y mortalidad a causa de enfermedades respiratorias, las relaciones entre contaminantes foto-químicos y mortalidad por todas las causas consideradas resultaron estadísticamente significativas. Los riesgos relativos de morir ante incrementos de O3 fueron mayores que ante incrementos de NO2, casi el triple entre enfermedades del aparato circulatorio. Los riesgos relativos de morir por todas las causas son menores que por causas específicas y que para aquellos individuos mayores de 70 años. Los resultados del análisis por semestres son muy similares a los del global mostrando, en todo caso, riesgos relativos algo mayores en los meses cálidos (mayo a octubre). CONCLUSIONES: La contaminación fotoquímica, sobre todo la causada por O3, representa un riesgo para la salud. En el caso del NO2 podría ocurrir que no fuese más que un indicador de las partículas suspendidas o de otros contaminantes cuyo origen es el tráfico urbano. Podría existir cierta modificación entre semestres de los efectos del O3 sobre la mortalidad por causas del aparato circulatorio.

Objectives: Few panel studies have investigated how different types of mental health (MH) and socio-emotional wellbeing (SEW) outcomes have changed during the pandemic and if their burden has been equally distributed at the population-level. We aimed to examine temporal changes in these outcomes and their socio-ecological predictors using panel data., Study Design: Longitudinal population-based survey with overlapping panels., Methods: Analyses were carried out using four measurements of data from the Health and Social Survey (April 2020 to April 2021). Participants included Andalusian (Spanish) residents aged 16 years or older who participated in all four measurements (n = 1223). Seven dichotomous MH and SEW outcomes, as well as several socio-ecological predictors informed by a conceptual model, were examined in descriptive and multivariate analyses., Results: Unadjusted odds of regular/bad perceived mental health (vs. excellent/very good/good), low socio-emotional wellbeing (vs. regular), low happiness (vs. regular), and feeling anxious (vs. not feeling anxious) decreased significantly from the first to the second measurement; however, in the fourth, low socio-emotional wellbeing significantly increased while low optimism decreased. Considering varying coefficients, objectively measured COVID-19 status and self-reported severity levels of the infection were statistically significant. Health status, social support, and household financial difficulty predicted higher adjusted odds in most of the seven assessed outcomes., Conclusions: Significant temporal variations in MH and SEW outcomes, along with their predictors, were observed during the first year of the pandemic. Some of these outcomes worsened as the pandemic progressed, whereas others improved. Findings also suggest that some individuals such as those experiencing poor health, limited social support, and low socioeconomic status are disproportionately impacted., (© 2024. The Author(s).)

Air pollution stands as an environmental risk to child mental health, with proven relationships hitherto observed only in urban areas. Understanding the impact of pollution in rural settings is equally crucial. The novelty of this article lies in the study of the relationship between air pollution and behavioural and developmental disorders, attention deficit hyperactivity disorder (ADHD), anxiety, and eating disorders in children below 15 living in a rural area. The methodology combines spatio-temporal models, Bayesian inference and Compositional Data (CoDa), that make it possible to study areas with few pollution monitoring stations. Exposure to nitrogen dioxide (NO 2 ), ozone (O 3 ), and sulphur dioxide (SO 2 ) is related to behavioural and development disorders, anxiety is related to particulate matter (PM 10 ), O 3 and SO 2 , and overall pollution is associated to ADHD and eating disorders. To sum up, like their urban counterparts, rural children are also subject to mental health risks related to air pollution, and the combination of spatio-temporal models, Bayesian inference and CoDa make it possible to relate mental health problems to pollutant concentrations in rural settings with few monitoring stations. Certain limitations persist related to misclassification of exposure to air pollutants and to the covariables available in the data sources used., (© 2024. The Author(s).)

Background: The reallocation of health care services during the coronavirus disease 2019 (COVID-19) pandemic disrupted the continuity of primary care. This study examines the repercussions of the COVID-19 pandemic on clinical indicators within the Catalan population, emphasising individuals with chronic conditions. It provides insights into mortality and transfer rates considering intersectional perspectives., Methods: We designed a retrospective, observational population-based cohort study based on routinely collected data from January 2015 to June 2021 for all individuals available in the Information System for Research in Primary Care (Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP)), the largest public primary care database in Catalonia, Spain. We included 6 301 095 individuals, constituting 81.6% of Catalonia's population in 2020. To perform a repeated measurements analysis of the indicators, we focussed on individuals who had one or more indicators in both the pre-pandemic (January 2015 to March 2020) and pandemic periods (March 2020 to June 2021), and those diagnosed with type 2 diabetes mellitus (T2D), high blood pressure, and heart failure. We selected key clinical indicators for analysis, including systolic and diastolic blood pressure, body mass index (BMI), cholesterol (total, high, and low-density lipoprotein), triglycerides, glycosylated haemoglobin, the Barthel index, and cardiovascular risk (Registre Gironí del cor (REGICOR) index)., Results: Mortality and transfer rates increased during the pandemic, contributing to a decline in the active population in the public health system. We also observed a reduction in pandemic period prevalence of patients with chronic conditions: -26.7% for heart failure, -15.1% for high blood pressure, and -14.6% for T2D. In both pre-pandemic and pandemic periods, 1 632 013 subjects had at least one clinical indicator record. Clinical indicators worsened in patients diagnosed with chronic conditions during the pandemic. Most indicators worsened, with differences between men and women (+9.4% vs +3.7% for the REGICOR index and -14.1% vs -16.6% for the Barthel index in men and in women, respectively), and to a similar extent (or greater in some cases) in individuals without these conditions., Conclusions: We used longitudinal data to assess the repercussions of the COVID-19 pandemic on population health while considering a wide range of clinical indicators and socioeconomic determinants. Our analysis shows a deterioration in clinical indicators during the pandemic, particularly in cardiometabolic factors, underscoring the importance of continuous primary care for individuals with chronic conditions., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Objectives: Socioeconomic inequalities have played a significant role in the unequal coverage of the COVID-19 vaccine. The objectives of this study were to (1) assess the socioeconomic inequalities in COVID-19 vaccination coverage in Catalonia, Spain; (2) analyse the spatial variation over time of these inequalities; and (3) assess variations in time and space in the effect of vaccination on inequalities in COVID-19 outcomes., Study Design: A mixed longitudinal ecological study design was used., Methods: Catalonia is divided in to 373 Basic Health Areas. Weekly data from these Basic Health Areas were obtained from the last week of December 2020 until the first week of March of 2022. A joint spatio-temporal model was used with the dependent variables of vaccination and COVID-19 outcomes, which were estimated using a Bayesian approach. The study controlled for observed confounders, unobserved heterogeneity, and spatial and temporal dependencies. The study allowed the effect of the explanatory variables on the dependent variables to vary in space and in time., Results: Areas with lower socioeconomic level were those with the lowest vaccination rates and the highest risk of COVID-19 outcomes. In general, individuals in areas that were located in the upper two quartiles of average net income per person and in the lower two quartiles of unemployment rate (i.e., the least economically disadvantaged) had a higher propensity to be vaccinated than those in the most economically disadvantaged areas. In the same sense, the greater the percentage of the population aged ≥65 years, the higher the propensity to be vaccinated, while areas located in the two upper quartiles of population density and areas with a high percentage of poor housing had a lower propensity to be vaccinated. Higher vaccination rates reduced the risk of COVID-19 outcomes, while COVID-19 outcomes did not influence the propensity to be vaccinated. The effects of the explanatory variables were not the same in all areas or between the different waves of the pandemic, and clusters of excess risk of low vaccination in the most disadvantaged areas were detected., Conclusions: COVID-19 vaccination inequalities in the most disadvantaged areas could be a result of structural barriers, such as the lack of access to information about the vaccination process, and/or logistical challenges, such as the lack of transportation, limited Internet access or difficulty in scheduling appointments. Public health strategies should be developed to mitigate these barriers and reduce vaccination inequalities., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Although many studies have assessed the socioeconomic inequalities caused by COVID-19 in several health outcomes, there are numerous issues that have been poorly addressed. For instance, have socioeconomic inequalities in mortality from COVID-19 increased? What impact has the pandemic had on inequalities in specific causes of mortality other than COVID-19? Are the inequalities in COVID-19 mortality different from other causes? In this paper we have attempted to answer these questions for the case of Spain., Methods: We used a mixed longitudinal ecological design in which we observed mortality from 2005 to 2020 in the 54 provinces into which Spain is divided. We considered mortality from all causes, not excluding, and excluding mortality from COVID-19; and cause-specific mortality. We were interested in analysing the trend of the outcome variables according to inequality, controlling for both observed and unobserved confounders., Results: Our main finding was that the increased risk of dying in 2020 was greater in the Spanish provinces with greater inequality. In addition, we have found that: (i) the pandemic has exacerbated socioeconomic inequalities in mortality, (ii) COVID-19 has led to gender differences in the variations in risk of dying (higher in the case of women) and (iii) only in cardiovascular diseases and Alzheimer did the increased risk of dying differ between the most and least unequal provinces. The increase in the risk of dying was different by gender (greater in women) for cardiovascular diseases and cancer., Conclusion: Our results can be used to help health authorities know where and in which population groups future pandemics will have the greatest impact and, therefore, be able to take appropriate measures to prevent such effects., (© 2023. The Author(s).)

Objective: To describe the clinical and demographic characteristics of patients with MND treated with riluzole by comparing two dosage forms (oral suspension and tablets), as well as the impact on survival in patients with and without dysphagia according to the form of dosage. Methods: Retrospective and prospective cohort of patients diagnosed with MND at the multidisciplinary functional unit of Motor Neuron Disease in our center in the period between 1 of January 2011 and 31 of December 2020 ( n  = 742). A descriptive analysis (univariate and bivariate) was carried out and survival curves were estimated. Results: During the follow-up period, 402 males (54.18%) and 340 females (45.82%) were diagnosed with MND. Of these patients, 632 (97.23%) were being treated with 100mg riluzole: 282 (54.55%) patients took this in tablet form and 235 (45.45%) oral suspension. Riluzole in tablet form is taken more frequently by men than women, in younger age ranges, and mostly without dysphagia (78.31%). Also, it is the predominant dosage form for classic spinal ALS and respiratory phenotypes. Dosages via oral suspension are taken by patients in the older age ranges (over 64.8 years), mostly with dysphagia (53.67%) and more frequently with bulbar phenotypes such as classic bulbar ALS and PBP. Because of this, patients using oral suspension (most of them with dysphagia) had a poorer survival rate (at 90% CI) than patients using tablets (most of them without dysphagia). Conclusions: The most appropriate dosage form should be given according to the patient's needs at each stage of the disease and, furthermore, oral suspension could improve adherence to treatment because it avoids having to change from one form (tablet) to the other (suspension) when swallowing disorders appear.

Introduction: The aim of this study was to study the effect of air pollution and noise has on the population in Madrid Community (MAR) in the period 2013-2018, and its economic impact., Methods: Time series study analysing emergency hospital admissions in the MAR due to all causes (ICD-10: A00-R99), respiratory causes (ICD-10: J00-J99) and circulatory causes (ICD-10: I00-I99) across the period 2013-2018. The main independent variables were mean daily PM 2.5 , PM 10 , NO 2 , 8-h ozone concentrations, and noise. We controlled for meteorological variables, Public Holidays, seasonality, and the trend and autoregressive nature of the series, and fitted generalised linear models with a Poisson regression link to ascertain the relative risks and attributable risks. In addition, we made an economic assessment of these hospitalisations., Results: The following associations were found: NO 2 with admissions due to natural (RR: 1.007, 95% CI: 1.004-1.011) and respiratory causes (RR: 1.012, 95% CI: 1.005-1.019); 8-h ozone with admissions due to natural (RR: 1.049, 95% CI: 1.014-1.046) and circulatory causes (RR: 1.088, 95% CI: 1.039-1.140); and diurnal noise (L Aeq7-23h ) with admissions due to natural (RR: 1.001, 95% CI: 1.001-1.002), respiratory (RR: 1.002, 95% CI: 1.001-1.003) and circulatory causes (RR: 1.003, 95% CI: 1.002-1.005). Every year, a total of 8246 (95% CI: 4580-11,905) natural-cause admissions are attributable to NO 2 , with an estimated cost of close on €120 million and 5685 (95% CI: 2533-8835) attributed to L Aeq7-23h with an estimated cost of close on €82 million., Conclusions: Nitrogen dioxide, ozone and noise are the main pollutants to which a large number of hospitalisations in the MAR are attributed, and are thus responsible for a marked deterioration in population health and high related economic impact., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The principal objective of this paper is to introduce an online interactive application that helps in real-time monitoring of the COVID-19 pandemic in Catalonia, Spain (PandemonCAT)., Methods: This application is designed as a collection of user-friendly dashboards using open-source R software supported by the Shiny package., Results: PandemonCAT reports accumulated weekly updates of COVID-19 dynamics in a geospatial interactive platform for individual basic health areas (ABSs) of Catalonia. It also shows on a georeferenced map the evolution of vaccination campaigns representing the share of population with either one or two shots of the vaccine, for populations of different age groups. In addition, the application reports information about environmental and socioeconomic variables and also provides an interactive interface to visualize monthly public mobility before, during, and after the lockdown phases. Finally, we report the smoothed standardized COVID-19 infected cases and mortality rates on maps of basic health areas ABSs and regions of Catalonia. These smoothed rates allow the user to explore geographic patterns in incidence and mortality rates. The visualization of the variables that could have some influence on the spatiotemporal dynamics of the pandemic is demonstrated., Conclusions: We believe the addition of these new dimensions, which is the key innovation of our project, will improve the current understanding of the spread and the impact of COVID-19 in the community. This application can be used as an open tool for consultation by the public of Catalonia and Spain in general. It could also have implications in facilitating the visualization of public health data, allowing timely interpretation due to the unpredictable nature of the pandemic.

Infant antibiotic use has been modestly associated with childhood overweight, while evidence on prenatal exposures remains less clear. A systematic review and meta-analysis were conducted to examine associations between maternal antibiotic exposure and subsequent risk of childhood overweight/obesity. Publications were retrieved from PubMed and Web of Science databases up to December 2019. A random effects model was used to summarize risk estimates, overall, and by period and frequency of exposure. Ten observational studies were included in the narrative synthesis. We did not observe a clear pattern of association between prenatal antibiotic use and childhood overweight/obesity. There were suggestive associations for repeated exposures (≥3 courses) and those taking place during the second trimester of gestation, which were also pointed out in our meta-analysis (relative risk, RR 2T  = 1.15 (95% CI 1.04; 1.28, I 2  = 18%), and RR 3courses  = 1.31 (95% CI 1.03; 1.67, I 2  = 65%), respectively). In most studies, however, confounding by underlying infections cannot be ruled out. Overall, current data do not conclusively support the hypothesis that prenatal exposure to antibiotics is a risk factor for childhood obesity/overweight. Further studies, controlling for underlying infections and exploring the association according to frequency, period (both prenatal and intrapartum) and type of antibiotic, are needed to clarify this association., (© 2021 World Obesity Federation.)

Introduction: Understanding the underlying factors that influence the approach to overweight and obesity in children is basic to best support families searching a solution to this important public health problem., Objective: To assess attitudes and feelings of paediatric staff in addressing overweight and childhood obesity to parents, exploring perceived barriers and facilitators, for an effective care., Participants and Method: Qualitative study by means of individual semi-structured questionnaires of paediatric staff (paediatricians and paediatrician nurses; n = 57; 68% female) of primary health care centres and hospitals in Mallorca. Thematic analysis was done., Results: Three themes emerged from the data: "Parents' attitude in childhood obesity" (sub-themes "The conscience of parents", "The parents ask for help"), "Paediatric staff and childhood obesity" (sub-themes "Approaching to the problem: The interview with parents", "Looking together for the solution"), and "System barriers" (sub-themes "Improving teamwork and health policy", "Family participation in addressing childhood obesity")., Conclusions: Paediatric staffs know how to treat childhood obesity, but demand training on motivation. Effectivity on therapy of childhood obesity will be obtained after parents/carers recognize the problem and establish a trustful relationship with paediatric staff. The health system is still a barrier to the activity of paediatric personnel., (Copyright © 2021 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Oropharyngeal dysphagia (OD) is highly prevalent (up to 80%) in patients with motor neuron disease (MND), influencing the prognosis of the disease. The clinical assessment of dysphagia is complex. There are assessment scales and screening questionnaires, but they have not been tested in patients with MND. In a sample of 46 patients with MND, the sensitivity and specificity of the EAT-10 and SwalQoL questionnaires, as well as the ALS-SS and FOIS scales, were tested and compared to the gold standard technique (videofluoroscopy, VFS). The patients were stratified using the DOSSc variable according to the video fluoroscopic examination with (n = 37) or without (n = 8) signs of dysphagia, and the results were compared with the scores obtained in the dysphagia questionnaires. None of the studied questionnaires was more sensitive than the others, but one stood out for its high specificity (= 1): the SwalQoL revised FS. The symptom frequency section of the SwalQoL questionnaire with some modifications, (SwalQoL revised FS) may be a useful tool in the clinical assessment of dysphagia because it's capable to detect the patients that really don't have dysphagia. The ALS-SS showed the greatest validity as a severity scale of dysphagia among the sample studied. A specific questionnaire for screening for dysphagia in MND needs to be developed. Until that time, the proposal is to use a combination of the existing questionnaires for other pathologies (EAT-10 and SwalQoL) and the specific scale for MND, the ALS-SS, to make an accurately clinical assessment of OD in MND patients before to perform a videofluoroscopy., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

This manuscript describes the rationale and protocol of a real-world data (RWD) study entitled Health Care and Social Survey (ESSOC, Encuesta Sanitaria y Social). The study's objective is to determine the magnitude, characteristics, and evolution of the COVID-19 impact on overall health as well as the socioeconomic, psychosocial, behavioural, occupational, environmental, and clinical determinants of both the general and more vulnerable population. The study integrates observational data collected through a survey using a probabilistic, overlapping panel design, and data from clinical, epidemiological, demographic, and environmental registries. The data will be analysed using advanced statistical, sampling, and machine learning techniques. The study is based on several measurements obtained from three random samples of the Andalusian (Spain) population: general population aged 16 years and over, residents in disadvantaged areas, and people over the age of 55. Given the current characteristics of this pandemic and its future repercussions, this project will generate relevant information on a regular basis, commencing from the beginning of the State of Alarm. It will also establish institutional alliances of great social value, explore and apply powerful and novel methodologies, and produce large, integrated, high-quality and open-access databases. The information described here will be vital for health systems in order to design tailor-made interventions aimed at improving the health care, health, and quality of life of the populations most affected by the COVID-19 pandemic.

A systematic search of the literature was performed to compare the effects of interventions that targeted sedentary behaviours or physical activity (PA) or physical fitness on primary prevention of obesity in 6- to 12-year-old children. The search identified 146 reports that provided relevant data for meta-analysis. Point estimates in % body fat were higher for fitness interventions compared with PA interventions (standardized mean difference = -0.11%; 95% CI = -0.26 to 0.04, and -0.04%; 95% CI = -0.15 to 0.06, respectively). Including sedentary behaviour to a PA- or fitness-oriented intervention was not accompanied by an increase in intervention effectiveness, as the point estimates were slightly smaller compared with those for PA- or fitness-only interventions. Overall, the effects tended to be larger in girls than in boys, especially for PA + sedentary behaviour interventions. There was some evidence for inequality, as the effects on body mass index were seen when interventions were delivered in the general population (standardized mean difference = -0.05, 95% CI = -0.07 to -0.02), but not in groups of disadvantaged children (standardized mean difference = -0.01, 95% CI = -0.29 to 0.19). In conclusion, school-based PA interventions appear to be an effective strategy in the primary prevention of childhood obesity among 6- to 12-year-old children, but targeting sedentary behaviour in addition to PA or fitness does not increase the effectiveness of the intervention., (© 2021 World Obesity Federation.)

Background: While numerous studies have assessed the effects of environmental (meteorological variables and air pollutants) and socioeconomic variables on the spread of the COVID-19 pandemic, many of them, however, have significant methodological limitations and errors that could call their results into question. Our main objective in this paper is to assess the methodological limitations in studies that evaluated the effects of environmental and socioeconomic variables on the spread of COVID-19., Main Body: We carried out a systematic review by conducting searches in the online databases PubMed, Web of Science and Scopus up to December 31, 2020. We first excluded those studies that did not deal with SAR-CoV-2 or COVID-19, preprints, comments, opinion or purely narrative papers, reviews and systematic literature reviews. Among the eligible full-text articles, we then excluded articles that were purely descriptive and those that did not include any type of regression model. We evaluated the risk of bias in six domains: confounding bias, control for population, control of spatial and/or temporal dependence, control of non-linearities, measurement errors and statistical model. Of the 5631 abstracts initially identified, we were left with 132 studies on which to carry out the qualitative synthesis. Of the 132 eligible studies, we evaluated 63.64% of the studies as high risk of bias, 19.70% as moderate risk of bias and 16.67% as low risk of bias., Conclusions: All the studies we have reviewed, to a greater or lesser extent, have methodological limitations. These limitations prevent conclusions being drawn concerning the effects environmental (meteorological and air pollutants) and socioeconomic variables have had on COVID-19 outcomes. However, we dare to argue that the effects of these variables, if they exist, would be indirect, based on their relationship with social contact., Supplementary Information: The online version contains supplementary material available at 10.1186/s12302-021-00550-7., Competing Interests: Competing interestThe authors declare that they have no competing interests., (© The Author(s) 2021.)

Background: The risk of infection and death by COVID-19 could be associated with a heterogeneous distribution at a small area level of environmental, socioeconomic and demographic factors. Our objective was to investigate, at a small area level, whether long-term exposure to air pollutants increased the risk of COVID-19 incidence and death in Catalonia, Spain, controlling for socioeconomic and demographic factors., Methods: We used a mixed longitudinal ecological design with the study population consisting of small areas in Catalonia for the period February 25 to May 16, 2020. We estimated Generalized Linear Mixed models in which we controlled for a wide range of observed and unobserved confounders as well as spatial and temporal dependence., Results: We have found that long-term exposure to nitrogen dioxide (NO 2 ) and, to a lesser extent, to coarse particles (PM 10 ) have been independent predictors of the spatial spread of COVID-19. For every 1 μm/m 3 above the mean the risk of a positive test case increased by 2.7% (95% credibility interval, ICr: 0.8%, 4.7%) for NO 2 and 3.0% (95% ICr: -1.4%,7.44%) for PM 10 . Regions with levels of NO 2 exposure in the third and fourth quartile had 28.8% and 35.7% greater risk of a death, respectively, than regions located in the first two quartiles., Conclusion: Although it is possible that there are biological mechanisms that explain, at least partially, the association between long-term exposure to air pollutants and COVID-19, we hypothesize that the spatial spread of COVID-19 in Catalonia is attributed to the different ease with which some people, the hosts of the virus, have infected others. That facility depends on the heterogeneous distribution at a small area level of variables such as population density, poor housing and the mobility of its residents, for which exposure to pollutants has been a surrogate., (Copyright © 2020 Elsevier Inc. All rights reserved.)

After the cases of COVID-19 skyrocketed, showing that it was no longer possible to contain the spread of the disease, the governments of many countries launched mitigation strategies, trying to slow the spread of the epidemic and flatten its curve. The Spanish Government adopted physical distancing measures on March 14; 13 days after the epidemic outbreak started its exponential growth. Our objective in this paper was to evaluate ex-ante (before the flattening of the curve) the effectiveness of the measures adopted by the Spanish Government to mitigate the COVID-19 epidemic. Our hypothesis was that the behavior of the epidemic curve is very similar in all countries. We employed a time series design, using information from January 17 to April 5, 2020 on the new daily COVID-19 cases from Spain, China and Italy. We specified two generalized linear mixed models (GLMM) with variable response from the Gaussian family (i.e. linear mixed models): one to explain the shape of the epidemic curve of accumulated cases and the other to estimate the effect of the intervention. Just one day after implementing the measures, the variation rate of accumulated cases decreased daily, on average, by 3.059 percentage points, (95% credibility interval: -5.371, -0.879). This reduction will be greater as time passes. The reduction in the variation rate of the accumulated cases, on the last day for which we have data, has reached 5.11 percentage points. The measures taken by the Spanish Government on March 14, 2020 to mitigate the epidemic curve of COVID-19 managed to flatten the curve and although they have not (yet) managed to enter the decrease phase, they are on the way to do so., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The optimal schedule for self-monitoring home BP (SMHBP) readings is enormously important in the diagnosis of different phenotypes related to hypertension. The aim of this study was to determine the prognostic capacity of a 3-day SMHBP schedule when using or suppressing the first-day measurements in compiling the results., Methods: A total of 767 newly diagnosed, nontreated patients with no history of cardiovascular disease (CVD) were followed for 6.2 years. As a baseline, office BP measurements were taken for all the patients who then went on to follow a 3-day SMHBP schedule, taking 2 readings in the morning and 2 in the evening. The prognostic calculation was performed with CVD variables. The prognostic capacity of the 3-day schedule was evaluated with and without the first-day readings (12 and 8 readings)., Results: A total of 223 normotensive subjects (NT), 271 subjects with sustained hypertension (SHT), and 184 white-coat hypertensive subjects (WCH) were followed. The distribution of 98 (14.4%) nonfatal CV events during the follow-up was as follows: WCH 21 (11.4%), NT 9 (4.0%), and SHT 68 (25.1%). No statistically significant differences were observed in the risk of CV events (OR) for the 2 groups of hypertensives, irrespective of the schedule of readings used (SHT with vs. without first-day readings: 8.81 (4.28-18.15) vs. 8.61 (4.15-17.85) and WCH with vs. without first-day readings: 2.71(1.13-6.47) vs. 3.40 (1.49-7.78))., Conclusions: Our findings show that first-day readings do not need to be discarded in order to calculate the final value of an SMHBP schedule., (© American Journal of Hypertension, Ltd 2019. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Purpose: To describe the distribution of Type 2 DM retinal lesions and determine whether it is symmetrical between the two eyes, is random or follows a certain pattern., Methods: Cross-sectional study of Type 2 DM patients who had been referred for an outpatients' ophthalmology visit for diabetic retinopathy screening in primary health care. Retinal photographic images were taken using central projection non-mydriatic retinography. The lesions under study were microaneurysms/haemorrhages, and hard and soft exudates. The lesions were placed numerically along the x- and y-axes obtained, with the fovea as the origin., Results: From among the 94 patients included in the study, 4770 lesions were identified. The retinal lesions were not distributed randomly, but rather followed a determined pattern. The left eye exhibited more microaneurysms/haemorrhages and hard exudates of a greater density in the central retina than was found in the right eye. Furthermore, more cells containing lesions were found in the upper temporal quadrants, (especially in the left eye), and tended to be more central in the left eye than in the right, while the hard exudates were more central than the microaneurysms/haemorrhages., Conclusion: The distribution of DR lesions is neither homogeneous nor random but rather follows a determined pattern for both microaneurysms/haemorrhages and hard exudates. This distribution means that the areas of the retina most vulnerable to metabolic alteration can be identified. The results may be useful for automated DR detection algorithms and for determining the underlying vascular and non-vascular physiopathological mechanisms that can explain these differences., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To study the strength of the evidence on efficacy, safety and acceptability of cholinesterase inhibitors (ChEI) and memantine for Alzheimer's disease (AD); and to determine the number of redundant post-authorisation trials., Methods: A cumulative meta-analysis with a trial sequential analysis (TSA) was performed. Primary outcomes were cognitive function assessed with ADAS-cog or SIB scales, discontinuation due to adverse events (AE) and discontinuation for any reason. The redundancy of post-authorisation clinical trials was studied by determining the novel aspects of each study on patient, intervention, comparator and trial outcome characteristics. Two criteria of futile trial (lenient and strict) were used., Results: A total of 63 randomised clinical trials (RCTs) (16,576 patients) were included. It was conclusive that neither ChEI nor memantine achieved clinically significant improvement in cognitive function. In relation to safety, there was sufficient evidence to conclude that donepezil caused a clinically relevant increase on dropouts due to AE whereas the evidence was inconclusive for the remaining interventions. Regarding acceptability, it was conclusive that no ChEI improved treatment discontinuation while it was uncertain for memantine. The proportion of redundant trials was 5.6% with the lenient criteria and 42.6% with the strict one., Conclusions: The evidence is conclusive that ChEI and memantine do not achieve clinically significant symptomatic improvement in AD while the acceptability of ChEI is unsatisfactory. Although evidence on the safety of pharmacological interventions for AD and acceptability of memantine is inconclusive, no further RCTs are needed as their efficacy is not clinically relevant. Redundant trials were identified but their number depends on the criteria of futility used.

Introduction: Global warming is resulting in an increase in temperatures which is set to become more marked by the end of the century and depends on the accelerating pace of greenhouse gas emissions into the atmosphere. Yet even in this scenario, so-called "cold waves" will continue to be generated and have an impact on health., Objectives: This study sought to analyse the impact of cold waves on daily mortality at a provincial level in Spain over the 2021-2050 and 2051-2100 time horizons under RCP4.5 and RCP 8.5 emission scenarios, on the basis of two hypotheses: (1) that the cold-wave definition temperature (T threshold ) would not vary over time; and, (2) that there would be a variation in T threshold ., Material and Methods: The results of a retrospective study undertaken for Spain as a whole across the period 2000-2009 enabled us to ascertain the cold-wave definition temperature at a provincial level and its impact on health, measured by reference to population attributable risk (PAR). The minimum daily temperatures projected for each provincial capital considering the above time horizons and emission scenarios were provided by the State Meteorological Agency. On the basis of the T threshold definition values and minimum daily temperatures projected for each province, we calculated the expected impact of low temperatures on mortality under the above two hypotheses. Keeping the PAR values constant, it was assumed that the mortality rate would vary in accordance with the available data., Results: If T threshold remained constant over the above time horizons under both emission scenarios, there would be no cold-related mortality. If T threshold were assumed to vary over time, however, then cold-related mortality would not disappear: it would instead remain practically constant over time and give rise to an estimated overall figure of around 250 deaths per year, equivalent to close on a quarter of Spain's current annual cold-related mortality and entailing a cost of approximately €1000 million per year., Conclusion: Given that cold waves are not going to disappear and that their impact on mortality is far from negligible and is likely to remain so, public health prevention measures must be implemented to minimise these effects as far as possible., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Our objective of this study was to determine if rate of estimated glomerular filtration rate (eGFR) decline and its intensity was associated with cardiovascular risk and death in patients with hypertension whose baseline eGFR was higher than 60 ml/minute/1.73 m2., Methods: This study comprised 2,516 patients with hypertension who had had at least 2 serum creatinine measurements over a 4-year period. An eGFR reduction of ≥10% per year has been deemed as high eGFR and a reduction in eGFR of less than 10% per year as a low decline. The end points were coronary artery disease, stroke, transitory ischemic accident, peripheral arterial disease, heart failure, atrial fibrillation, and death from any cause. Cox regression analyses adjusted for potentially confounding factors were conducted., Results: A total of 2,354 patients with low rate of eGFR decline and 149 with high rate of eGFR decline were analyzed. The adjusted model shows that a -10% rate of eGFR decline per year is associated with a higher risk of the primary end point (HR 1.9; 95% CI 1.1-3.5; P = 0.02) and arteriosclerotic vascular disease (HR 2.2; 95% CI 1.2-4.2; P < 0.001) in all hypertensive groups. The variables associated to high/low rate of eGFR decline in the logistic regression model were serum creatinine (OR 3.35; P < 0.001), gender, women (OR 15.3; P < 0.001), tobacco user (OR 1.9; P < 0.002), and pulse pressure (OR 0.99; P < 0.05)., Conclusions: A rate of eGFR decline equal to or higher than -10% per year is a marker of cardiovascular risk for patients with arterial hypertension without chronic kidney disease at baseline. It may be useful to consider intensifying the global risk approach for these patients., (© American Journal of Hypertension, Ltd 2019. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Our main objective was to evaluate the fundamental biases detected in studies assessing the effects the Great Recession had on health for the case of Spain. As secondary objectives we presented methods to control these biases and to discuss the results of the studies in question if they had controlled for them., Methods: We carried out a systematic review of the literature published up to June 2018. We evaluated the biases that could have happened in all the eligible studies., Results: From the review, we finally selected 53 studies. Of the studies we reviewed, 60.38% or 32 out of 53, were evaluated as having a high risk of bias. The main biases our review revealed were problems with evaluation, time bias, lack of control of unobserved confounding, and non-exogeneity when defining the onset of the Great Recession., Conclusions: The results from the studies that controlled the biases were quite consistent. Summing up, the studies reviewed found that the Great Recession increased the risk of declaring poor self-rated health and the deterioration of mental health. Both the mortality rate and the suicide rate may well have increased after the Great Recession, probably after a three- to four-year delay.

Background: In recent years, a number of studies have been conducted with the aim of analysing the impact that high temperatures will have on mortality over different time horizons under different climate scenarios. Very few of these studies take into account the fact that the threshold temperature used to define a heat wave will vary over time, and there are practically none which calculate this threshold temperature for each geographical area on the assumption that there will be variations at a country level., Objective: To analyse the impact that high temperatures will have on mortality across the periods 2021-2050 and 2051-2100 under a high-emission climate scenario (RCP8.5), in a case: (a) where adaptation processes are not taken into account; and (b) where complete adaptation processes are taken into account., Material and Methods: Based on heat-wave definition temperature (T threshold ) values previously calculated for the reference period, 2000-2009, for each Spanish provincial capital, and their impact on daily mortality as measured by population attributable risk (PAR), the impact of high temperatures on mortality will be calculated for the above-mentioned future periods. Two hypotheses will be considered, namely: (a) that T threshold does not vary over time (scenario without adaptation to heat); and, (b) that T threshold does vary over time, with the percentile to which said T threshold corresponds being assumed to remain constant (complete adaptation to heat). The temperature data were sourced from projections generated by Coupled Model Intercomparison Project (CMIP5) climate models adapted to each region's local characteristics by the State Meteorological Agency (Agencia Estatal de Meteorología/AEMET). Population-growth projections were obtained from the National Statistics Institute (Instituto Nacional de Estadística/INE). In addition, an economic estimate of the resulting impact will be drawn up., Results: The mean value of maximum daily temperatures will rise, in relation to those of the reference period (2000-2009), by 1.6⁰C across the period 2021-2050 and by 3.3⁰C across the period 2051-2100. In a case where there is no heat-adaptation process, overall annual mortality attributable to high temperatures in Spain would amount to 1414 deaths/year (95% CI: 1089-1771) in the period 2021-2050, rising to 12,896 deaths/year (95% CI: 9852-15,976) in the period 2051-2100. In a case where there is a heat-adaptation process, annual mortality would be 651 deaths/year (95% CI: 500-807) in the period 2021-2050, and 931 deaths per year (95% CI: 770-1081) in the period 2051-2100. These results display a high degree of heterogeneity. The savings between a situation that does envisage and one that does not envisage an adaptive process is €49,100 million/year over the 2051-2100 time horizon., Conclusion: A non-linear increase in maximum daily temperatures was observed, which varies widely from some regions to others, with an increase in mean values for Spain as a whole that is not linear over time. The high degree of heterogeneity found in heat-related mortality by region and the great differences observed on considering an adaptive versus a non-adaptive process render it necessary for adaptation plans to be implemented at a regional level., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Proton Pump Inhibitors (PPIs) have been associated with chronic kidney disease (CKD). Our objective was to quantify the association between PPI use and incident CKD in a population-based cohort., Methods and Findings: We used a population-based retrospective cohort, including people aged 15 years or over, between January 1, 2005 and December 31, 2012. PPI use was measured in a follow-up session by recording prescriptions. Incident CKD was defined as an estimated glomerular filtration rate < 60 ml/ min/1.73 m2 and/or urinary albumin level to creatinine level ≥ 30 mg/g, in two or more determinations over a period of at least 3 months of the follow-up. Proton Pump Inhibitor use was associated with incident CKD in analysis adjusted for different clinical variables (Hazard Ratio (HR) 1.18; 95% CI 1.04-1.51) in individuals who used PPI in the basal visit (HR 1.37; 95% CI 1.25-1.50) and in those who started to use PPI during the follow-up. High doses of PPI increased the risk of incident CKD (HR 1.92; 95%CI 1.00-6.19) for any type of exposure to PPIs (HR 2.40; 95%CI 1.65-3.46) and for individuals who used high doses throughout the follow-up. This risk of incident CKD increased after three months' exposure to PPIs, (HR1.78; 95% CI 1.39-2.25) between the third and sixth months and (HR 1.30; 95%CI 1.07-1.72) after the sixth month., Conclusions: PPI use is associated with a higher risk of incident CKD. This association is greater for high doses and becomes apparent after three months' exposure., Competing Interests: The authors have declared that no competing interests exist.

Background: Glomerular hyperfiltration is well recognized as an early renal alteration in subjects with diabetes mellitus. However, what is not well-known is whether hyperfiltration also occurs in the early stages of hyperglycaemia, for instance in prediabetes. Identifying subjects with glomerular hyperfiltration from among those with prediabetes might be helpful to implement preventive and therapeutic strategies. This study aimed to investigate the association of prediabetes with glomerular hyperfiltration and its associated variables., Methods: A representative sample of 9238 people aged ≥ 30 years and whose entire clinical and laboratory data were available, were included in this study. Hyperfiltration was defined as an estimated glomerular filtration rate (eGFR) above the age- and gender-specific 95th percentile. The eGFR was assessed using the Chronic Kidney Disease Epidemiology Collaboration equation., Results: After adjustment for age, gender, body mass index, systolic blood pressure and diastolic blood pressure, cholesterol, log (triglycerides), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, serum uric acid, smoking status, hypertension, and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, fasting plasma glucose (FPG) was found to be independently positively associated with eGFR. The hazard ratios (95% confidence interval) for hyperfiltration were 1.61 (1.28-2.03) and 2.30 (1.89-2.79) for prediabetes and diabetes, respectively, when compared with participants with normoglycemia., Conclusion: Prediabetes was associated with glomerular hyperfiltration. Longitudinal studies are needed to investigate whether hyperfiltration in prediabetes is associated with a later decline in eGFR.