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Abstract Background The histopathological analysis of minor salivary gland biopsies, particularly through the quantification of the Focus Score (FS), is pivotal in the diagnostic workflow for Sjögren's Syndrome (SS). AI-based image recognition using deep learning models has demonstrated potential in enhancing diagnostic accuracy and efficiency in preclinical research. Objectives The primary aim of this investigation was to utilize an auto-machine learning (autoML) platform for the automated segmentation and quantification of FS on histopathological slides, aiming to augment diagnostic precision and speed in SS. Methods A cohort comprising 86 patients with sicca syndrome (37 diagnosed with SS based on the 2016 ACR/EULAR Classification Criteria and 49 non-SS) was selected for an in-depth histological examination. A repository of 172 slides (two per patient) was assembled, encompassing 74 slides meeting the classificatory thresholds for SS (FS ≥ 1, indicative of lymphocytic infiltration) and 98 slides showcasing normal salivary gland histology. The autoML platform utilized (Giotto, L2F, Lausanne Switzerland) employed a Convolutional Neural Network (CNN) architecture (ResNet-152) for the training and validation phases, using a dataset of 172 slides. Results The developed model exhibited a reliability score of 0.88, proficiently distinguishing SS cases, with a sensitivity of 89.47% (95% CI: 66.86% to 98.70%) and a specificity of 88.24% (95% CI: 63.56% to 98.54%). The model found histological slides of suboptimal quality (e.g., those compromised during fixation or staining processes) to be the most challenging for accurate classification. Conclusion AutoML platforms offer a rapid and flexible approach to developing machine learning models, even with smaller datasets, as demonstrated in this study for SS. These platforms hold significant potential for enhancing diagnostic precision and efficiency in both clinical and research settings. Multicentric studies with larger patient cohorts are essential for thorough evaluation and validation of this innovative diagnostic approach.

Abstract Salivary gland squamous cell carcinomas (SG-SCCs) constitute a rare type of head and neck cancer which is linked to poor prognosis. Due to their low frequency, the molecular mechanisms responsible for their aggressiveness are poorly understood. In this work we studied the role of the phosphatase DUSP1, a negative regulator of MAPK activity, in controlling SG-SCC progression. We generated DUSP1 KO clones in A253 human cells. These clones showed a reduced ability to grow in 2D, self-renew in ECM matrices and to form tumors in immunodeficient mice. This was caused by an overactivation of the stress and apoptosis kinase JNK1/2 in DUSP1 −/+ clones. Interestingly, RNAseq analysis revealed that the expression of SOX2, a well-known self-renewal gene was decreased at the mRNA and protein levels in DUSP1 −/+ cells. Unexpectedly, CRISPR-KO of SOX2 did not recapitulate DUSP1 −/+ phenotype, and SOX2-null cells had an enhanced ability to self-renew and to form tumors in mice. Gene expression analysis demonstrated that SOX2-null cells have a decreased squamous differentiation profile -losing TP63 expression- and an increased migratory phenotype, with an enhanced epithelial to mesenchymal transition signature. In summary, our data indicates that DUSP1 and SOX2 have opposite functions in SG-SCC, being DUSP1 necessary for tumor growth and SOX2 dispensable showing a tumor suppressor function. Our data suggest that the combined expression of SOX2 and DUSP1 could be a useful biomarker to predict progression in patients with SG-SCCs.

Mass tourism in Spain became one of the most prosperous economic sectors in the mid-twentieth century, collaborating in the process of convergence with Europe, using the seductive power of the media, especially the cinema. A quantitative and (to a lesser extent) qualitative analysis methodology was followed. After reviewing the academic literature, the records of the National Film Library were consulted, selecting 87 films of tourist content and of national production, during the period of operation of the Ministry of Information and Tourism (1951-1977). The results have made it possible to identify the tourist segments, the cinematographic genres, the type of tourists, national or foreign, as well as the heritage elements and the services present in the tourist product of the time, visualizing the scenarios where the plots of the films are developed. The cinematography allows showing the elements that constitute the economic tourism model of Franco’s Spain, focused on towns on the Mediterranean coast, especially on the Costa del Sol. The research translates the antecedents of tourism marketing, using cinema as a means of communication that recognizes the economic transformation of Spanish society and the new image of Spain to be projected abroad.

Abstract The World Health Organization (WHO) Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders was developed by WHO to address the worldwide challenges and gaps in provision of care and services for people with epilepsy and other neurological disorders and to ensure a comprehensive, coordinated response across sectors to the burden of neurologic diseases and to promote brain health across life-course. Headache disorders constitute the second most burdensome of all neurological diseases after stroke, but the first if young and midlife adults are taken into account. Despite the availability of a range of treatments, disability associated with headache disorders, and with migraine, remains very high. In addition, there are inequalities between high-income and low and middle income countries in access to medical care. In line with several brain health initiatives following the WHOiGAP resolution, herein we tailor the main pillars of the action plan to headache disorders: (1) raising policy prioritization and strengthen governance; (2) providing effective, timely and responsive diagnosis, treatment and care; (3) implementing strategies for promotion and prevention; (4) fostering research and innovation and strengthen information systems. Specific targets for future policy actions are proposed. The Global Action Plan triggered a revolution in neurology, not only by increasing public awareness of brain disorders and brain health but also by boosting the number of neurologists in training, raising research funding and making neurology a public health priority for policy makers. Reducing the burden of headache disorders will not only improve the quality of life and wellbeing of people with headache but also reduce the burden of neurological disorders increasing global brain health and, thus, global population health.

Abstract Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient’s features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder. Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.

Abstract The 2030 Agenda for Sustainable Development sets out, through 17 Sustainable Development Goals (SDGs), a path for the prosperity of people and the planet. SDG 3 in particular aims to ensure healthy lives and promote well-being for all at all ages and includes several targets to enhance health. This review presents a “headache-tailored” perspective on how to achieve SDG 3 by focusing on six specific actions: targeting chronic headaches; reducing the overuse of acute pain-relieving medications; promoting the education of healthcare professionals; granting access to medication in low- and middle-income countries (LMIC); implementing training and educational opportunities for healthcare professionals in low and middle income countries; building a global alliance against headache disorders. Addressing the burden of headache disorders directly impacts on populations’ health, as well as on the possibility to improve the productivity of people aged below 50, women in particular. Our analysis pointed out several elements, and included: moving forward from frequency-based parameters to define headache severity; recognizing and managing comorbid diseases and risk factors; implementing a disease management multi-modal management model that incorporates pharmacological and non-pharmacological treatments; early recognizing and managing the overuse of acute pain-relieving medications; promoting undergraduate, postgraduate, and continuing medical education of healthcare professionals with specific training on headache; and promoting a culture that favors the recognition of headaches as diseases with a neurobiological basis, where this is not yet recognized. Making headache care more sustainable is an achievable objective, which will require multi-stakeholder collaborations across all sectors of society, both health-related and not health-related. Robust investments will be needed; however, considering the high prevalence of headache disorders and the associated disability, these investments will surely improve multiple health outcomes and lift development and well-being globally.

Abstract Background Migraine is a highly prevalent primary headache disorder and a leading cause of disability. Difficulties in access to care during diagnostic and therapeutic journey contribute to the disease burden. Several target-specific drugs have reached the market in the past four years and have modified the treatment paradigm in migraine. The aim of this study is to provide an updated snapshot of the pathways and hurdles to care for migraine in different European countries by directly asking patients. Methods In 2021 the European Migraine and Headache Alliance proposed a 39-item questionnaire that was administered online to an adult migraine population in European countries. Questions were focused on socio-demographic and migraine data, access to diagnosis and treatment, disease-related burden and the main channel for disease information. Results A total of 3169 questionnaires were returned from 10 European countries. Responders were predominantly females, age range 25–59 years, with a migraine history longer than 10 years in 82% of cases, and with at least 8 headache days per month in 57% of cases. Respondents reported limitations in social, working and personal life during both the ictal and interictal phase. The activities mostly impaired during the attacks were driving (55%), cooking or eating (42%), taking care of family/childcare (40%) and getting medicines at the pharmacy (40%). The most frequently reported unmet need was the long delay between the first visit and migraine diagnosis: 34% of respondents had to see ≥ 4 specialists before being correctly diagnosed, and between the diagnosis and treatment prescription: > 5 years in 40% of cases. The most relevant needs in terms of quality of life were the desire for a lower migraine frequency, an effective treatment and a greater involvement in society. Conclusions Data from the present survey point to the existence and persistence of multiple hurdles that result in significant limitations to access to care and to the patients’ social life. A close cooperation between decision makers, healthcare workers and patients is needed to overcome these barriers. Graphical Abstract

Abstract The stigma of migraine, despite an impressive body of data on the epidemiological of migraine and the associated disability, burden and cost of migraine to patients, has not been fully evaluated as an important factor in the chronicization of the disease and social isolation of the patient. In this commentary, we present three points of view. From the point of view of a European advocacy body active in the field of migraine medicine, actions to improve the perception of migraine within the community regarding the stigma for people with migraine are presented at the personal, relational and occupational levels. From the point of view of a clinician who is an expert on migraine, proposals are made for treatment and rehabilitation paths specifically dedicated to the reintegration of these individuals into social contexts.

Measurement(s) navigation data • temperature of air • atmospheric humidity • radar reflectivity • brightness temperature • cloud properties • radiation • atmospheric wind Technology Type(s) GPS navigation system • dropsondes • radar • microwave radiometer • particle count and size analyzer • imager • noseboom sensors Factor Type(s) temporal • location Sample Characteristic - Environment atmosphere Sample Characteristic - Location Arctic Ocean region

BackgroundThere is an unmet need for a better understanding and management of headache, particularly migraine, beyond specialist centers, which may be facilitated using digital technology. ObjectiveThe objective of this study was to identify where, when, and how people with headache and migraine describe their symptoms and the nonpharmaceutical and medicinal treatments used as indicated on social media. MethodsSocial media sources, including Twitter, web-based forums, blogs, YouTube, and review sites, were searched using a predefined search string related to headache and migraine. The real-time data from social media posts were collected retrospectively for a 1-year period from January 1, 2018, to December 31, 2018 (Japan), or a 2-year period from January 1, 2017, to December 31, 2018 (Germany and France). The data were analyzed after collection, using content analysis and audience profiling. ResultsA total of 3,509,828 social media posts related to headache and migraine were obtained from Japan in 1 year and 146,257 and 306,787 posts from Germany and France, respectively, in 2 years. Among social media sites, Twitter was the most used platform across these countries. Japanese sufferers used specific terminology, such as “tension headaches” or “cluster headaches” (36%), whereas French sufferers even mentioned specific migraine types, such as ocular (7%) and aura (2%). The most detailed posts on headache or migraine were from Germany. The French sufferers explicitly mentioned “headache or migraine attacks” in the “evening (41%) or morning (38%),” whereas Japanese mentioned “morning (48%) or night (27%)” and German sufferers mentioned “evening (22%) or night (41%).” The use of “generic terms” such as medicine, tablet, and pill were prevalent. The most discussed drugs were ibuprofen and naproxen combination (43%) in Japan; ibuprofen (29%) in Germany; and acetylsalicylic acid, paracetamol, and caffeine combination (75%) in France. The top 3 nonpharmaceutical treatments are hydration, caffeinated beverages, and relaxation methods. Of the sufferers, 44% were between 18 and 24 years of age. ConclusionsIn this digital era, social media listening studies present an opportunity to provide unguided, self-reported, sufferers’ perceptions in the real world. The generation of social media evidence requires appropriate methodology to translate data into scientific information and relevant medical insights. This social media listening study showed country-specific differences in headache and migraine symptoms experienced and in the times of the day and treatments used. Furthermore, this study highlighted the prevalence of social media usage by younger sufferers compared to that by older sufferers.

Abstract Background Haemophilia A (HA) has been associated with poor health-related quality of life and a large economic burden, accentuated by severity, arthropathy, and inhibitors. To meet global standards of care, the management of HA should align with the principles of care outlined by the World Federation of Haemophilia. The aims of the present study were to establish a set of proposals to improve HA management within the Spanish National Health System (SNHS) and to estimate the impact its hypothetical implementation would generate from a clinical, healthcare, economic, and social perspective. Methods A multidisciplinary group of experts agreed on a set of 15 proposals to improve HA management within the SNHS. Thereafter, a forecast-type Social Return on Investment analysis was carried out to estimate the impact of implementing this set of proposals within the SNHS over a one-year timeframe, in relation to the required investment. Results This study estimated that the implementation of the complete set of 15 proposals would require a total investment of 2.34 M€ and have a total impact of 14.60 M€. Accordingly, every euro invested in the complete set of 15 proposals would yield a social return of €6.23 (€3.37 in the worst-case scenario and €9.69 in the best-case scenario) of both tangible and intangible nature in similar proportions (45.71 and 54.29%, respectively). Conclusions These results can be used to inform policy and practice such that interventions that may potentially improve current public health challenges associated with the management of HA may be implemented.

Abstract Background There have been several calls for estimations of costs and consequences of headache interventions to inform European public-health policies. In a previous paper, in the absence of universally accepted methodology, we developed headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache. Here we apply this methodology and present the findings. Methods Data sources were published evidence and expert opinions, including those from an earlier economic evaluation framework using the WHO-CHOICE model. We used three headache-type-specific analytical models, for migraine, tension-type-headache (TTH) and medication-overuse-headache (MOH). We considered three European Region case studies, from Luxembourg, Russia and Spain to include a range of health-care systems, comparing current (suboptimal) care versus target care (structured services implemented, with provider-training and consumer-education). We made annual and 5-year cost estimates from health-care provider and societal perspectives (2020 figures, euros). We expressed effectiveness as healthy life years (HLYs) gained, and cost-effectiveness as incremental cost-effectiveness-ratios (ICERs; cost to be invested/HLY gained). We applied WHO thresholds for cost-effectiveness. Results The models demonstrated increased effectiveness, and cost-effectiveness (migraine) or cost saving (TTH, MOH) from the provider perspective over one and 5 years and consistently across the health-care systems and settings. From the societal perspective, we found structured headache services would be economically successful, not only delivering increased effectiveness but also cost saving across headache types and over time. The predicted magnitude of cost saving correlated positively with country wage levels. Lost productivity had a major impact on these estimates, but sensitivity analyses showed the intervention remained cost-effective across all models when we assumed that remedying disability would recover only 20% of lost productivity. Conclusions This is the first study to propose a health-care solution for headache, in the form of structured headache services, and evaluate it economically in multiple settings. Despite numerous challenges, we demonstrated that economic evaluation of headache services, in terms of outcomes and costs, is feasible as well as necessary. Furthermore, it is strongly supportive of the proposed intervention, while its framework is general enough to be easily adapted and implemented across Europe.

Abstract Background Health economic evaluations support health-care decision-making by providing information on the costs and consequences of health interventions. No universally accepted methodology exists for modelling effectiveness and cost-effectiveness of interventions designed to close treatment gaps for headache disorders in countries of Europe (or elsewhere). Our aim here, within the European Brain Council’s Value-of-Treatment project, was to develop headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache. Methods We developed three headache-type-specific decision-analytical models using the WHO-CHOICE framework and adapted these for three European Region country settings (Luxembourg, Russia and Spain), diverse in geographical location, population size, income level and health-care systems and for which we had population-based data. Each model compared current (suboptimal) care vs target care (delivered in accordance with the structured headache services model). Epidemiological and economic data were drawn from studies conducted by the Global Campaign against Headache; data on efficacy of treatments were taken from published randomized controlled trials; assumptions on uptake of treatments, and those made for Healthy Life Year (HLY) calculations and target-care benefits, were agreed with experts. We made annual and 5-year cost estimates from health-care provider (main analyses) and societal (secondary analyses) perspectives (2020 figures, euros). Results The analytical models were successfully developed and applied to each country setting. Headache-related costs (including use of health-care resources and lost productivity) and health outcomes (HLYs) were mapped across populations. The same calculations were repeated for each alternative (current vs target care). Analyses of the differences in costs and health outcomes between alternatives and the incremental cost-effectiveness ratios are presented elsewhere. Conclusions This study presents the first headache-type-specific analytical models to evaluate effectiveness and cost-effectiveness of implementing structured headache services in countries in the European Region. The models are robust, and can assist policy makers in allocating health budgets between interventions to maximize the health of populations.

Abstract In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the “patient journey”) with perplexing obstacles. High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary. The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded. It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

Abstract Background New treatments are currently offering new opportunities and challenges in clinical management and research in the migraine field. There is the need of homogenous criteria to identify candidates for treatment escalation as well as of reliable criteria to identify refractoriness to treatment. To overcome those issues, the European Headache Federation (EHF) issued a Consensus document to propose criteria to approach difficult-to-treat migraine patients in a standardized way. The Consensus proposed well-defined criteria for resistant migraine (i.e., patients who do not respond to some treatment but who have residual therapeutic opportunities) and refractory migraine (i.e., patients who still have debilitating migraine despite maximal treatment efforts). The aim of this study was to better understand the perceived impact of resistant and refractory migraine and the attitude of physicians involved in migraine care toward those conditions. Methods We conducted a web-questionnaire-based cross-sectional international study involving physicians with interest in headache care. Results There were 277 questionnaires available for analysis. A relevant proportion of participants reported that patients with resistant and refractory migraine were frequently seen in their clinical practice (49.5% for resistant and 28.9% for refractory migraine); percentages were higher when considering only those working in specialized headache centers (75% and 46% respectively). However, many physicians reported low or moderate confidence in managing resistant (8.1% and 43.3%, respectively) and refractory (20.7% and 48.4%, respectively) migraine patients; confidence in treating resistant and refractory migraine patients was different according to the level of care and to the number of patients visited per week. Patients with resistant and refractory migraine were infrequently referred to more specialized centers (12% and 19%, respectively); also in this case, figures were different according to the level of care. Conclusions This report highlights the clinical relevance of difficult-to-treat migraine and the presence of unmet needs in this field. There is the need of more evidence regarding the management of those patients and clear guidance referring to the organization of care and available opportunities.

Kidney transplantation is the best option for end-stage chronic kidney disease. Transplant viability is conditioned by drugs’ nephrotoxicity, ischemia–reperfusion damage, or acute rejection. An approach to improve graft survival is the identification of post-transplant renal function prognostic biomarkers. Our objective was to study three early kidney damage biomarkers (N-acetyl-d-glucosaminidase, NAG; neutrophil gelatinase-associated lipocalin, NGAL; and kidney injury molecule-1, KIM-1) in the initial period after transplantation and to identify possible correlations with main complications. We analysed those biomarkers in urine samples from 70 kidney transplant patients. Samples were taken on days 1, 3, 5, and 7 after intervention, as well as on the day that renal function stabilised (based on serum creatinine). During the first week after transplant, renal function improved based on serum creatinine evolution. However, increasing levels of biomarkers at different times during that first week could indicate tubular damage or other renal pathology. A relationship was found between NGAL values in the first week after transplantation and delayed graft function. In addition, higher NAG and NGAL, and lower KIM-1 values predicted a longer renal function stabilisation time. Therefore, urinary NAG, NGAL, and KIM-1 could constitute a predictive tool for kidney transplant complications, contributing to improve graft survival rates.

Resumen Los quistes epidérmicos son lesiones frecuentes en la piel, sin embargo, su presencia dentro de las glándulas salivares es rara, como reflejan los pocos casos encontrados en la literatura. El origen es la implantación iatrogénica de tejido epitelial en la glándula y deben considerarse en el diagnóstico diferencial cuando un paciente presenta una tumoración en esta zona con un antecedente quirúrgico otológico previo. Presentamos el caso clínico de una mujer intervenida por lesión parotídea con diagnóstico anatomopatológico de quiste epidermoide intraparotídeo. Entre sus antecedentes personales, había sido intervenida de timpanoplastia ipsilateral en la infancia, considerando que fue esta la causa de la lesión. Destacamos la rareza de la presentación de la lesión, la consideración de los quistes epidérmicos como complicación de la cirugía otológica, aunque sea infrecuente, y su importancia en el diagnóstico diferencial de las lesiones tumorales de parótida.

El fet que l’aplicació del dret de la UE condueixi a pràctiques desiguals a tots els estats membres dóna lloc a debats acalorats en la literatura. La investigació tendeix a centrar-se en com les limitacions del procés legislatiu de la UE que contribueixen a una amenaçadora harmonització a la pràctica; tanmateix, sovint es passen per alt les restriccions del procés de transposició. Per salvar aquesta bretxa, aquí explorem els factors nacionals i supranacionals que poden amenaçar l’harmonització, mitjançant un enfocament jurídic i lingüístic que revela la superposició entre els significats jurídics i lingüístics del dret de la UE. En particular, basant-nos en les nocions de Robertson de “punts de vista horitzontals i verticals” (Robertson, 2012a), fem una anàlisi jurídica i lingüística horitzontal de l’article 3 (2) de les versions espanyola i anglesa de la Directiva 2004/38 / CE sobre llibertat de moviment i residència, i una anàlisi jurídica i lingüística vertical d’aquest article en les dues versions lingüístiques i la seva transposició a Espanya i al Regne Unit. Els nostres resultats suggereixen que, en el nostre estudi de cas, tant la legislació de la UE com els factors relacionats amb la transposició poden influir en els problemes d’harmonització de la UE a la pràctica; factors com ara ambigüitat o indeterminació estratègica de la UE, negociacions polítiques i decisions de redacció supranacionals i nacionals.

Resumen: Objetivo: Averiguar si una intervención mediante carta dirigida a usuarios de benzodiacepinas consigue disminuir su consumo. Método: Estudio antes-después sin grupo control realizado en atención primaria en mayo de 2016. A 1.582 pacientes que tomaban una única dosis diaria de una benzodiacepina como hipnótico durante más de 3 meses se les envió una carta personalizada de su médico de familia con información sobre los efectos desfavorables de dicho consumo y la recomendación para retirarlo, con una pauta de descenso escalonada (Benzocarta). Se evaluó el porcentaje de pacientes que cesaron el consumo de benzodiacepinas, el porcentaje que las disminuyeron y la diferencia en la dosis total dispensada (miligramos equivalentes de diazepam dispensados en 3 meses) entre el periodo preintervención y postintervención (a los 6 y 12 meses). Resultados: Se obtuvieron datos de dispensaciones de 1.561 pacientes (media de edad: 69,3 años; 74% mujeres). Al año de la intervención, el 22,0% (intervalo de confianza del 95% [IC95%]:19,9-24,0) habían abandonado el consumo de benzodiacepinas y el 18,8% (IC95%:16,9-20,8) lo habían disminuido. Se observó una reducción estadísticamente significativa de la dosis total dispensada (media de la diferencia: 89 mg; IC95%: 72,2-105,7). Conclusión: La Benzocarta se asocia a una disminución relevante en el consumo de hipnóticos. Es una intervención sencilla y factible que puede aplicarse en poblaciones amplias, e incluso de forma repetida en el tiempo. Se requieren estudios controlados para confirmar su eficacia. Abstract: Objective: To determine whether a letter-based intervention to patients taking benzodiazepines reduces their consumption. Method: A before-after study without control group performed in primary care in May 2016. 1582 patients who took a single daily dose of benzodiazepines as hypnotic for more than 3 months were sent a personalized letter from their family doctor. The letter contained information about the risks of long-term benzodiazepine consumption and the recommendation to discontinue them with a gradual drop protocol (Benzoletter). The percentage of patients who stopped or decreased the use of benzodiazepines, and the difference in the total dose dispensed (mg equivalents of diazepam dispensed in three months) between the pre- and post-intervention period (at 6 and 12 months) were evaluated. Results: Dispensing data from 1561 patients were collected (average age: 69.3 years; 74% women). Twelve months after the intervention, 22.0% (95% confidence interval [95%CI]: 19.9-24.0) discontinued benzodiazepine consumption and 18.8% (95%CI: 16.9-20.8) reduced their consumption. A statistically significant reduction was observed in the total dose dispensed (mean difference: 89 mg; 95%CI: 72.2-105.7). Conclusion: The Benzoletter is associated with a significant decrease in the consumption of hypnotics. It is a simple and feasible intervention that allows acting on large populations, and it could even be periodically repeated. Controlled studies are required to confirm its effectiveness.

Abstract Background Patients with cancer have been shown to have a higher risk of clinical severity and mortality compared to non-cancer patients with COVID-19. Patients with hematologic malignancies typically are known to have higher levels of immunosuppression and may develop more severe respiratory viral infections than patients with solid tumors. Data on COVID-19 in patients with hematologic malignancies are limited. Here we characterize disease severity and mortality and evaluate potential prognostic factors for mortality. Methods In this population-based registry study, we collected de-identified data on clinical characteristics, treatment and outcomes in adult patients with hematologic malignancies and confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection within the Madrid region of Spain. Our case series included all patients admitted to 22 regional health service hospitals and 5 private healthcare centers between February 28 and May 25, 2020. The primary study outcome was all-cause mortality. We assessed the association between mortality and potential prognostic factors using Cox regression analyses adjusted for age, sex, comorbidities, hematologic malignancy and recent active cancer therapy. Results Of 833 patients reported, 697 were included in the analyses. Median age was 72 years (IQR 60–79), 413 (60%) patients were male and 479 (69%) and 218 (31%) had lymphoid and myeloid malignancies, respectively. Clinical severity of COVID-19 was severe/critical in 429 (62%) patients. At data cutoff, 230 (33%) patients had died. Age ≥ 60 years (hazard ratios 3.17–10.1 vs 2 comorbidities (1.41 vs ≤ 2), acute myeloid leukemia (2.22 vs non-Hodgkin lymphoma) and active antineoplastic treatment with monoclonal antibodies (2·02) were associated with increased mortality; conventional chemotherapy showed borderline significance (1.50 vs no active therapy). Conversely, Ph-negative myeloproliferative neoplasms (0.33) and active treatment with hypomethylating agents (0.47) were associated with lower mortality. Overall, 574 (82%) patients received antiviral therapy. Mortality with severe/critical COVID-19 was higher with no therapy vs any antiviral combination therapy (2.20). Conclusions In this series of patients with hematologic malignancies and COVID-19, mortality was associated with higher age, more comorbidities, type of hematological malignancy and type of antineoplastic therapy. Further studies and long-term follow-up are required to validate these criteria for risk stratification.

Abstract Introduction Despite advances in the management of headache disorders, some patients with migraine do not experience adequate pain relief with acute and preventive treatments. It is the aim of the present document to provide a definition of those migraines which are difficult-to-treat, to create awareness of existence of this group of patients, to help Healthcare Authorities in understanding the implications, and to create a basis to develop a better pathophysiological understanding and to support further therapeutic advances. Main body Definitions were established with a consensus process using the Delphi method. Patients with migraine with or without aura or with chronic migraine can be defined as having resistant migraine and refractory migraine according to previous preventative failures. Resistant migraine is defined by having failed at least 3 classes of migraine preventatives and suffer from at least 8 debilitating headache days per month for at least 3 consecutive months without improvement; definition can be based on review of medical charts. Refractory migraine is defined by having failed all of the available preventatives and suffer from at least 8 debilitating headache days per month for at least 6 consecutive months. Drug failure may include lack of efficacy or lack of tolerability. Debilitating headache is defined as headache causing serious impairment to conduct activities of daily living despite the use of pain-relief drugs with established efficacy at the recommended dose and taken early during the attack; failure of at least two different triptans is required. Conclusions We hope, that the updated EHF definition will be able to solve the conflicts that have limited the use of definitions which have been put forward in the past. Only with a widely accepted definition, progresses in difficult-to-treat migraine can be achieved. This new definition has also the aim to increase the understanding of the impact of the migraine as a disease with all of its social, legal and healthcare implications. It is the hope of the EHF Expert Consensus Group that the proposed criteria will stimulate further clinical, scientific and social attention to patients who suffer from migraine which is difficult-to-treat.

Resumen: Antecedentes y objetivos: Apenas existen estudios que hayan investigado el papel que la inflexibilidad psicológica (IP) pudiera tener en el contexto de la IRC. El objetivo primario de este estudio fue analizar las propiedades psicométricas, la fiabilidad y la validez de la versión española del Acceptance and Action Questionnaire-II adaptada al contexto de pacientes en tratamiento de hemodiálisis. El objetivo secundario fue analizar la relación entre IP y parámetros relacionados con la adhesión al tratamiento y calidad de vida en este tipo de pacientes. Materiales y métodos: Estudio transversal prospectivo con pacientes en hemodiálisis (n = 186). Resultados: El índice de tejido graso (15,56 ± 5,72 vs. 18,99 ± 8,91; p = 0,033), los niveles de fósforo (3,92 ± 1,24 vs. 4,66 ± 1,38; p = 0,001) y la ganancia de peso interdiálisis (1,56 ± 0,69 vs. 1,89 ± 0,93; p = 0,016) fueron mayores en los pacientes con más puntuación en IP. Los niveles de fósforo (p = 0,013) explicaron de forma significativa la variabilidad de los niveles de IP, la cual también se mostró como un predictor significativo (p = 0,026) de la variabilidad de los niveles de fósforo. Conclusiones: La adaptación del cuestionario Acceptance and Action Questionnaire-II al contexto de hemodiálisis da lugar a una medida válida y fiable de la IP para este tipo de pacientes, y los resultados de este estudio parecen apoyar el papel de la IP con relación a parámetros de salud y calidad de vida en el ámbito de las enfermedades crónicas. Abstract: Background and objectives: Few studies have investigated the role psychological inflexibility (PI) could have in the context of chronic renal failure. The primary objective of this study was to analyse the psychometric features, the reliability and the validity of the Spanish version of the Acceptance and Action Questionnaire-II (AAQ-II) adapted to the context of patients undergoing haemodialysis (HD). The secondary objective was to assess the relationship between PI and parameters related to the adherence to treatment and quality of life in these types of patients. Materials and methods: Prospective cross-sectional study with patients on haemodialysis (n = 186). Results: The fat tissue index (15.56 ± 5.72 vs. 18.99 ± 8.91, P = .033), phosphorus levels (3.92 ± 1.24 vs. 4.66 ± 1.38; P = .001) and interdialytic weight gain (1.56 ± 0.69 vs. 1.89 ± 0.93, P = .016) were higher in patients with a higher PI score. Phosphorus levels (P = .013) significantly explained the variability of PI levels. PI was also shown as a significant predictor (P = .026) of the variability of phosphorus levels. Conclusions: The adaptation of the AAQ-II questionnaire to the HD context led to a valid and reliable measurement of PI in these types of patients and our results also seem to support the relationship between PI and health and quality of life parameters in patients with chronic conditions. Palabras clave: Inflexibilidad psicológica, Evitación experiencial, Aceptación, Hemodiálisis, Calidad de vida, Keywords: Psychological inflexibility, Experiential avoidance, Acceptance, Haemodialysis, Quality of life

Background and objectives: Few studies have investigated the role psychological inflexibility (PI) could have in the context of chronic renal failure. The primary objective of this study was to analyse the psychometric features, the reliability and the validity of the Spanish version of the Acceptance and Action Questionnaire-II (AAQ-II) adapted to the context of patients undergoing haemodialysis (HD). The secondary objective was to assess the relationship between PI and parameters related to the adherence to treatment and quality of life in these types of patients. Materials and methods: Prospective cross-sectional study with patients on haemodialysis (N = 186). Results: The fat tissue index (15.56 ± 5.72 vs. 18.99 ± 8.91, P = 0.033), phosphorus levels (3.92 ± 1.24 vs. 4.66 ± 1.38; P = 0.001) and interdialytic weight gain (1.56 ± 0.69 vs. 1.89 ± 0.93, P = 0.016) were higher in patients with a higher PI score. Phosphorus levels (P = 0.013) significantly explained the variability of PI levels. PI was also shown as a significant predictor (P = 0.026) of the variability of phosphorus levels. Conclusions: The adaptation of the AAQ-II questionnaire to the HD context led to a valid and reliable measurement of PI in these types of patients and our results also seem to support the relationship between PI and health and quality of life parameters in patients with chronic conditions. Resumen: Antecedentes y objetivos: Apenas existen estudios que hayan investigado el papel que la inflexibilidad psicológica (IP) pudiera tener en el contexto de la IRC. El objetivo primario de este estudio fue analizar las propiedades psicométricas, la fiabilidad y la validez de la versión española del Acceptance and Action Questionnaire – II (AAQ-II) adaptada al contexto de pacientes en tratamiento de hemodiálisis (HD). El objetivo secundario fue analizar la relación entre IP y parámetros relacionados con la adhesión al tratamiento y calidad de vida en este tipo de pacientes. Materiales y métodos: Estudio transversal prospectivo con pacientes en hemodiálisis (N = 186). Resultados: El índice de tejido graso (15,56 ± 5,72 vs. 18,99 ± 8,91; p = 0,033), los niveles de fósforo (3,92 ± 1,24 vs. 4,66 ± 1,38; p = 0,001) y la ganancia de peso interdiálisis (1,56 ± 0,69 vs. 1,89 ± 0,93; p = 0,016) fueron mayores en los pacientes con más puntuación en IP. Los niveles de fósforo (p = 0,013) explicaron de forma significativa la variabilidad de los niveles de IP, la cual también se mostró como un predictor significativo (p = 0,026) de la variabilidad de los niveles de fósforo. Conclusiones: La adaptación del cuestionario AAQ-II al contexto de HD da lugar a una medida válida y fiable de la IP para este tipo de pacientes y los resultados de este estudio parecen apoyar el papel de la IP con relación a parámetros de salud y calidad de vida en el ámbito de las patologías crónicas.

Abstract Background Multiple Sclerosis (MS) is a chronic inflammatory, demyelinating and neurodegenerative disease that in many cases produces disability, having a high impact in patients’ lives, reducing significantly their quality of life. The aim of this study was to agree on a set of proposals to improve the current management of MS within the Spanish National Health System (SNHS) and apply the Social Return on Investment (SROI) method to measure the potential social impact these proposals would create. Methods A Multidisciplinary Working Team of nine experts, with representation from the main stakeholders regarding MS, was set up to agree on a set of proposals to improve the management of MS. A forecast SROI analysis was carried out, with a one-year timeframe. Data sources included an expert consultation, a narrative literature review and a survey to 532 MS patients. We estimated the required investment of a hypothetical implementation, as well as the potential social value that it could create. We calculated outcomes in monetary units and we measured intangible outcomes through financial proxies. Results The proposed ideal approach revealed that there are still unmet needs related to MS that can be addressed within the SNHS. Investment would amount to 148 million € and social return to 272 million €, so each euro invested could yield almost €2 of social return. Conclusions This study could guide health interventions, resulting in money savings for the SNHS and increases in patients’ quality of life.

ABSTRACT: Territory brands are vehicles for transmitting the attributes that identify a geographical setting, they facilitate market positioning and can contribute to generating an opinion that determines the promotion strategies of a place. The investment decisions of both private companies and institutional bodies will be strengthened if residents and tourists’ perception is known, seeking to reconcile the interests of visitors and citizens with the aim of collaborating in the creation of the city’s tourism planning under the principles of sustainability, open innovation and co-creation of value. The methodology used for this research focuses on an empirical study, for which a sample of 780 individuals was designed so that the Malaga brand was subjected to analysis with criteria of innovative opportunity, applying constructs that were measured with existing and proven scales. The results allow us to identify that the Malaga brand is being built and managed on the basis of the cultural projection of the city and its image attributes. The ratings of tourists and residents will serve as a basis for improving the management of Malaga as a tourist destination by the institutions involved, taking into account the interest of open innovation. The conclusions of the research can be extrapolated to other geographical environments with similar levels of tourism development.

Background: SARS-CoV-2 vaccines are an invaluable resource against COVID-19. Current vaccine shortage makes it necessary to prioritize distribution to the most appropriate segments of the population. Methods: This is a prospective cohort study of 63 health care workers (HCWs) from a General Hospital. We compared antibody responses to two doses of BNT162b2 mRNA COVID-19 vaccine between HCWs with previous SARS-CoV-2 infection (experienced HCWs) and HCWs without previous infection (naïve HCWs). Findings: Seven days after the first vaccine dose, HCWs with previous infection experienced a 126-fold increase in antibody levels (p50 AU). After the second dose, no significant increase in antibody levels was found in experienced HCWs, whereas in naïve HCWs, levels increased by 16-fold (p

This research analyzes the traffic of goods through the ports managed by the Port Authorities of the Spanish port system from the beginning of democracy in Spain to the end of the 21st century; a period that shows the effects on maritime transport as a result of the political changes that have taken place and the new regulations that have been applied, highlighting the 1992 Port Law, which would facilitate the transition from the port as an integrated center for international trade to the port as a logistics platform. We have used primary sources from the Spanish State Port’s archives and have consulted statistical yearbooks, commercial reports and the yearbooks of the National Statistics Institute (INE). This research allows us, through the data of the traffic of goods by presentation and the GVA at market prices, to quantify the transformation of the group of state-owned ports and their impact on the Spanish economy. Until now, speculation has focused on the share of freight traffic and its value at this time of transition in the Spanish economy, as well as the actual contribution it made to inflation in the period under study.

La necesidad de investigar los factores que influyen en el proceso de toma de decisiones en una traducción es recurrente en la literatura. En esta investigación abordamos uno de esos factores, la ideología presente en los textos, centrándonos en un estudio enmarcado en la traducción jurídica con­trahegemónica. En este artículo demostramos que el análisis contrastivo crítico planteado puede ser una herramienta de reflexión útil para revelar la ideología que subyace al uso del léxico en los textos de esta especialidad, tanto del texto origen como de los textos paralelos consultados en búsqueda de equivalentes para la traducción. Centrándonos en el caso de los textos administrativos, abordamos un estudio de caso en el marco de un encargo de traducción real, y realizamos un análisis contrastivo crítico de dos solicitudes de extranjería análogas en España (texto origen) y en el Reino Unido (texto paralelo), empleando el modelo tridimensional de análisis crítico del discurso de Fairclough. Los re­sultados obtenidos muestran que, en nuestro estudio de caso, los datos provistos por el análisis no solo favorecen la reflexión sobre cómo el poder y la dominación se reproducen en los textos analizados, sino también sobre cómo la elección de ciertas unidades léxicas en la traducción puede contribuir a la legitimación de la ideología dominante que subyace a ellas.

In this paper a pre-translation framework developed for public service translation is presented. The framework was developed from a sociological standpoint “whereby translation practice can be viewed in relation to people and institutions involved in it or affected by it” (Taibi & Ozolins, 2016, pp. 63-64) with the aim to provide contextualization and understanding that precedes the actual translation stage. After outlining the framework, its usefulness in obtaining key pre-translation information is showcased through an application form in the Spanish immigration context, i.e. an authentic public service text. Lastly, the paper shows how the information gathered based on the framework will assist in proposing an effective English translation of this application form in the future

Uno de los primeros contactos que un migrante tiene con la sociedad de acogida es a través de su Administración, dada la necesidad de que adquiera la documentación administrativa necesaria para acreditar su residencia. En estos procedimientos administrativos los ciudadanos se encuentran ante una doble dificultad: las barreras lingüísticas existentes y la complejidad del proceso jurídico-administrativo al que se enfrentan. En este contexto, la tecnología puede jugar un papel fundamental para facilitar la comprensión del procedimiento a través de distintos recursos digitales, no obstante, su traducción será primordial si se pretende responder a las necesidades de una población inmigrante lingüística y culturalmente heterogénea. En esa línea, en esta investigación pretendemos explorar cómo se proporcionan los servicios de traducción en España y en el Reino Unido en un procedimiento de extranjería en concreto, el proceso de obtención de la tarjeta de residencia de familiar de ciudadano de la Unión Europea en España y en el Reino Unido, así como examinar el importante papel que los recursos digitales pueden jugar en ambos países en este contexto migratorio.

Introducción: La promoción de la salud en el trabajo integra las iniciativas en salud y seguridad en ámbito ocupacional, con mejoras personales, incremento de productividad y menores riesgos y gastos sociales, especialmente en migraña, como enfermedad neurológica con prevalencia estimada en el 11% de la población. El objetivo de este trabajo fue conocer las condiciones preventivas de los trabajadores con migraña y las opciones de gestión preventiva en sus empresas. Método: Estudio observacional transversal realizado en 3.342 pacientes de España, Italia, Francia, Portugal, Irlanda, Reino Unido, Alemania y otros países de la UE mediante encuesta anónima en la web de la European Migraine & Headache Alliance (EMHA-web), entre septiembre de 2018 y enero de 2019. Resultados: Estrés laboral y uso de PVD son los riesgos más referidos por los trabajadores con migraña. El 43.71% de trabajadores desconoce el tipo de Servicio de Prevención de su empresa, 49.06% no dispone de servicio médico; el 67.67% no ha tenido impedimentos de acceso laboral por migraña, ni despido o no renovación del contrato, pero el 42,14% tuvo algún conflicto por pérdida de productividad; el 26,54% desconoce el concepto de especial sensibilidad o no lo ha solicitado por migraña; un 55,42% no se ha sentido comprendido ni apoyado por su empresa en sus limitaciones por migraña, pero sí por los compañeros. Conclusión: Se observa una deficiente información preventiva y escaso uso de las opciones de gestión adaptativa en las empresas para personas con migraña.

The pandemic caused by the coronavirus continues to test barriers around the world. In this sense, the tourism industry has become the sector most affected by the crisis with more than 900 million euros in losses. Recovery will require a great effort, especially in countries where the sector accounts for a large share of the economy and employment. This study analyzes the perceptions and proposals of the residents of the autonomous community of Andalusia. A total of 658 surveys were conducted during the closure. A quantitative and qualitative thematic analysis was carried out using SPSS and NVivo Pro programs. The findings provide significant insights into the economic recovery of society after the pandemic. The Andalusians have opted for local tourism so that the residents become the consumers of the tourist products of their territory. The deployment of new technologies and marketing campaigns should provide the basic strategies for structural changes and innovations. The residents demand a united Europe and disagree with the statements of some political leaders. The conclusions have practical and theoretical implications for tourist destinations.

Abstract Background Migraine is associated with many debilitating symptoms that affect daily functioning. My Migraine Voice is a large global cross-sectional study aimed at understanding the full burden and impact of migraine directly from patients suffering from ≥4 monthly migraine days (MMDs) with a history of prophylactic treatment failure. Methods This study was conducted worldwide (31 countries across North and South Americas, Europe, the Middle East and Northern Africa, and the Asia-Pacific region) using an online survey administered to adults with migraine who reported ≥4 MMDs in the 3 months preceding survey administration, with pre-specified criteria of 90% having used preventive migraine treatment (80% with history of ≥1 treatment failure). Prophylactic treatment failure was defined as a reported change in preventive medication by individuals with migraine for any reason, at least once. Results In total, 11,266 individuals participated in the survey. Seventy-four percent of the participants reported spending time in darkness/isolation due to migraine (average: 19 h/month). While 85% of all respondents reported negative aspects of living with migraine (feeling helpless, depressed, not understood), sleeping difficulties (83%), and fear of the next attack (55%), 57% shared ≥1 positive aspect (learning to cope, becoming a stronger person). Forty-nine percent reported feeling limited in daily activities throughout all migraine phases. Migraine impact on professional, private, or social domains was reported by 87% of respondents (51% in all domains). In the previous 12 months, 38% of respondents had visited the emergency department (average: 3.3 visits), whereas 23% stayed in hospital overnight (average: 3.2 nights) due to migraine. Conclusions The burden of migraine is substantial among this cohort of individuals with at least 4 migraine days per month and for whom at least 1 preventive migraine treatment had failed. Interestingly, respondents reported some positive aspects in their migraine journey; the greater resilience and strength brought on by coping with migraine suggests that if future treatments could address existing unmet needs, these individuals with migraine will be able to maximize their contribution to society.

Resumen: Los términos «comunidad» y «salud comunitaria» cada vez son más utilizados en diferentes ámbitos. Entendemos que es importante explorar las diversas cuestiones que se relacionan con ellos para analizar mejor cuál puede ser nuestro papel como profesionales y avanzar en esta línea. En este diálogo abordamos las relaciones de lo comunitario con diferentes elementos, como por ejemplo el territorio, que provoca el encuentro entre diferentes grupos y colectivos al mismo tiempo que potencia dinámicas identitarias que pueden llegar a ser excluyentes. En este sentido, las prácticas en torno a la identificación y la construcción de lo común, como punto de encuentro abierto e integrador, pueden ser un medio interesante para abordar esta cuestión. Las relaciones que se establecen con el resto de los miembros de la comunidad son también importantes y se señala el peligro de reproducir estas relaciones jerárquicas que limiten el recorrido de las prácticas comunitarias. Así, se propone establecer un diálogo con las personas y los grupos que conforman la comunidad, que se atreva a renombrar colectivamente la realidad común que se vive y se quiere transformar. Por último, reflexionamos sobre los roles profesionales, así como sobre las implicaciones sociopolíticas de los diferentes enfoques de la salud comunitaria que conviven en la actualidad. Abstract: Terms such as community or community health are used more and more frequently and in multiple contexts. As healthcare workers, we acknowledge the need to reflect upon these concepts in order to shed light on the different meanings we bestow on community health. This dialogue approaches the notion of the community examining its relationships with other notions; for example, we examine how the notion of territory could trigger both communitarian networks and exclusionary practices. On the other hand, the practices that identify and help in building what is “communal” are perceived as more inclusive and as a starting point to think about what communities mean. Far from a naive vision of the community as a non-hierarchical structure, this dialogue exposes the risks of reproducing inequalities within the communities we work with. Therefore, we propose maintaining an active dialogue within the communities to collectively rename the real experienced conditions that need to be transformed. Finally, this dialogue reflects upon the professional roles arising from the different approaches to community health and the sociopolitical implications that this diversity entails. Palabras clave: Comunidad, Redes comunitarias, Salud comunitaria, Desarrollo comunitario, Keywords: Community, Community networks, Community health, Community development

Abstract Background The implementation of evidence-based clinical practice guidelines (CPG) can improve patients care. To date, the impact of implementation strategies has not been evaluated in our context. This study is aimed to evaluate the effectiveness of a multifaceted tailored intervention targeting clinician education for the implementation of three cardiovascular risk-related CPGs (type 2 diabetes, hypertension and dyslipidemia) in primary care at the Basque Health Service compared with usual implementation. Methods We conducted a cluster randomized controlled trial in two urban districts with 43 primary care units (PCU). Data from all patients diagnosed with diabetes, hypertension and all those eligible for coronary risk (CR) assessment were included. In the control group, guidelines were introduced in the usual way (by email, intranet and clinical meetings). In the intervention group, the implementation also included a specific website and workshops. Primary endpoints were annual HbA1c testing (diabetes), annual general laboratory testing (hypertension) and annual CR assessment (dyslipidemia). Secondary endpoints were process, prescription and clinical endpoints related with guideline recommendations. Analysis was performed at a PCU level weighted by cluster size. Results Significant differences between groups were observed in primary outcomes in the dyslipidemia CPG: increased CR assessment for both women and men (weighted mean difference, WMD, 13.58 and 12.91%). No significant differences were observed in diabetes and hypertension CPGs primary outcomes. Regarding secondary endpoints, annual CR assessment was significantly higher in both diabetic and hypertensive patients in the intervention group (WMD 28.16 and 27.55%). Rates of CR assessment before starting new statin treatments also increased (WMD 23.09%), resulting in a lower rate of statin prescribing in low risk women. Diuretic prescribing was higher in the intervention group (WMD 20.59%). Clinical outcomes (HbA1c and blood pressure control) did not differ between groups. Conclusions The multifaceted implementation proved to be effective to increase the CR assessment and to improve prescription, but ineffective to improve diabetes and hypertension related outcomes. In order to obtain real improvements when cardiovascular issues are tackled, perhaps other or additional interventions need to be implemented besides education of professionals. Trial registration Current Controlled Trials, ISRCTN 88876909 (retrospectively registered on January 13, 2009)

El proyecto de recuperación del teatro romano de Cartagena ha contemplado la integración de los restos en el tejido urbano así como su adecuada conservación y exposición con fines didácticos y culturales. Además, la considerable riqueza de las piezas halladas durante las sucesivas campañas de excavación en el teatro ha ofrecido la oportunidad de dotar a la ciudad de un nuevo espacio museístico, el Museo del Teatro Romano, que no sólo sirve de adecuado marco expositivo, sino que, en la brillante concepción del arquitecto Rafael Moneo, conduce a los visitantes desde la plaza del Ayuntamiento hasta el interior del monumento.

Abstract Background Shared decision-making is a cornerstone of patient-centred care. The 9-item Shared Decision-Making Questionnaire (SDM-Q-9) is a brief self-assessment tool for measuring patients’ perceived level of involvement in decision-making related to their own treatment and care. Information related to the psychometric properties of the SDM-Q-9 for multiple sclerosis (MS) patients is limited. The objective of this study was to assess the performance of the items composing the SDM-Q-9 and its dimensional structure in patients with relapsing-remitting MS. Methods A non-interventional, cross-sectional study in adult patients with relapsing-remitting MS was conducted in 17 MS units throughout Spain. A nonparametric item response theory (IRT) analysis was used to assess the latent construct and dimensional structure underlying the observed responses. A parametric IRT model, General Partial Credit Model, was fitted to obtain estimates of the relationship between the latent construct and item characteristics. The unidimensionality of the SDM-Q-9 instrument was assessed by confirmatory factor analysis. Results A total of 221 patients were studied (mean age = 42.1 ± 9.9 years, 68.3% female). Median Expanded Disability Status Scale score was 2.5 ± 1.5. Most patients reported taking part in each step of the decision-making process. Internal reliability of the instrument was high (Cronbach’s α = 0.91) and the overall scale scalability score was 0.57, indicative of a strong scale. All items, except for the item 1, showed scalability indices higher than 0.30. Four items (items 6 through to 9) conveyed more than half of the SDM-Q-9 overall information (67.3%). The SDM-Q-9 was a good fit for a unidimensional latent structure (comparative fit index = 0.98, root-mean-square error of approximation = 0.07). All freely estimated parameters were statistically significant (P 0.40) with the exception of item 1 which presented the lowest loading (0.26). Items 6 through to 8 were the most relevant items for shared decision-making. Conclusions The SDM-Q-9 presents appropriate psychometric properties and is therefore useful for assessing different aspects of shared decision-making in patients with multiple sclerosis.

Este trabajo se enmarca en el contexto de una investigación más extensa circunscrita en la Estrategia Europea de Educación para el Desarrollo. La pretensión del proyecto ha sido promover un cambio de actitud hacia el desarrollo sostenible en sentido amplio que favorezca la mejora de la calidad y la eficacia de las acciones de Educación para el Desarrollo en el ámbito rural, generando un modelo participativo de educación que comprenda las causas que generan desigualdad y transmita valores más solidarios y cooperativos. Los datos recogidos, mediante cuestionario, nos permiten retratar el tipo de prácticas educativas realizadas en centros de enseñanza obligatoria de ámbito rural ubicados en diferentes regiones pertenecientes a los siete países europeos implicados en el proyecto, analizando la presencia y características de este tipo de acciones así como la inclusión de las mismas en el currículo educativo. Tras el análisis–diagnóstico realizado, el grupo de trabajo ha elaborado una agenda con propuestas de acción en torno a la institucionalización de la Educación para el Desarrollo, la formación de profesorado, los proyectos de innovación transversales e interdisciplinares y el desarrollo de un modelo teórico que justifique esas acciones.

Introduction: El traumatismo craneoencefálico (TCE) en ancianos supone un alto impacto asistencial y económico en los servicios de urgencias. En el Hospital Universitario Basurto (HUB) origina aproximadamente el 15% de las consultas quirúrgico-traumatológicas. La caída es la principal causa y la medicación/polifarmacia uno de los principales factores de riesgo modificable. Policy context and objective: En un estudio desarrollado en Urgencias del HUB sobre 859 pacientes atendidos por TCE durante un año, 90% fueron causados por caídas. El 72% estaban polimedicados, 82% tomaba algún medicamento crónico asociado a riesgo de caídas (benzodiacepinas, opioides…) y 62% alguno incluido en criterios STOPP. Casi 60% tomaba anticoagulantes/antiagregantes, lo que aumenta la morbilidad, prolongando la estancia hospitalaria. Simultáneamente, en los Centros de Atención Primaria (AP) de la Organización Sanitaria Integrada Bilbao-Basurto se desplegó, el “Programa para la Valoración Integral del mayor polimedicado (BiE-Kronikoak)” que contempla la revisión de la medicación en ancianos polimedicados, la valoración de factores de fragilidad y otros predictores de discapacidad y morbimortalidad. La confluencia de ambas circunstancias proporcionó una oportunidad para la integración asistencial. El objetivo del presente trabajo es diseñar e implantar un programa de coordinación para garantizar la continuidad asistencial a la población diana, que implica una cita prioritaria desde Urgencias en consulta de AP para revisar la medicación y realizar los cambios oportunos para prevenir/minimizar el riesgo de caídas y reingresos. Targeted population: Pacientes >75 años polimedicados (> 5 medicamentos crónicos) que acuden a urgencias del HUB por haber sufrido un TCE tras caída. Se excluyen pacientes residenciados. Highlights: Presentamos un proyecto multidisciplinar de integración que implica médicos, farmacéuticos y enfermería de urgencias y AP, apoyado por los mandos de la organización, que garantiza la continuidad asistencial. El funcionamiento del circuito se pilotó durante 3 meses resultando que, de 153 pacientes susceptibles de derivación desde Urgencias a la consulta de AP, solo 33 fueron citados y de ellos el 20% fueron atendidos. Esto permitió identificar sus puntos débiles y rediseñarlo. Los resultados de esta revisión serán presentados en el Congreso. Comments on transferability: El envejecimiento de la población y la polimedicación son realidades que afectan a todas las organizaciones sanitarias de los países desarrollados. Las caídas son causa frecuente de discapacidad y muerte en los ancianos. A menudo los medicamentos juegan un papel importante. La experiencia con los ancianos atendidos por TCE podría extrapolarse a otros motivos de ingreso tras caída (fracturas de cadera, etc), en los que una intervención coordinada sobre los factores de riesgo sería igualmente importante. Conclusions(key findings, discussion, lessons learned): La coordinación entre el Servicio de Urgencias hospitalario y AP facilita el cuidado integral de los ancianos polimedicados con riesgo de caídas. El buen funcionamiento del programa exige un líder, motivación constante de los participantes, implicación de los mandos y apoyo informático que simplifique las tareas. El diseño inicial del circuito presenta puntos débiles que hacen que un número importante de pacientes susceptibles de intervención no sean citados en AP, lo que ha obligado a un nuevo planteamiento, cuya efectividad se está evaluando actualmente.

Background and Objectives: Bariatric surgery remains the gold standard treatment for morbidly obese patients. Roux-en-y gastric bypass and laparoscopic sleeve gastrectomy are the most frequently performed surgeries worldwide. Obesity has also been related to gastroesophageal reflux disease (GERD). The management of a preoperative diagnosis of GERD, with/without hiatal hernia before bariatric surgery, is mandatory. Endoscopy can show abnormal findings that might influence the final type of surgery. The aim of this article is to discuss and review the evidence related to the endoscopic findings after bariatric surgery. Materials and Methods: A systematic review of the literature has been conducted, including all recent articles related to endoscopic findings after bariatric surgery. Our review of the literature has included 140 articles, of which, after final review, only eight were included. The polled articles included discussion of the endoscopy findings after roux-en-y gastric bypass and laparoscopic sleeve gastrectomy. Results: We found that the specific care of bariatric patients might include an endoscopic diagnosis when GERD symptoms are present. Conclusions: Recent evidence has shown that endoscopic follow-up after laparoscopic sleeve gastrectomy could be advisable, due to the pathological findings in endoscopic procedures in asymptomatic patients.

The certification of Malaga and Ronda wine route, within the model of certified wine routes in Spain, has given a new boost to wine tourism in Malaga. The study focuses on La Axarquía, located on the Eastern Costa del Sol in Southern Spain, which has been a reference point in the wine business since ancient times and has its own identity. This research aims at elaborating a diagnosis of the territory related to the possibilities offered by the area, from the perspective of the heritage resources and services provided by the winemakers outlining two efficient enotourism itineraries that enhance the value of the territory’s resources. The methodology used starts with the study of the territory in order to profile the existing resources, a task that was complemented by the analysis of the documentary sources required in order to understand the peculiarities of the territory. From there, a process of interviews was carried out between April and November 2019 with 100% of the winemakers and around 70% of the territory’s agents. The results of the research are specified in a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, which has allowed evaluating the possibilities of the enotourist development in La Axarquía, which is complemented with a proposal of two possible itineraries that will promote such development of the rural territory. The conclusions convey the possibilities of the territory of a tourist segment which puts its resources to good use and moves forward the deseasonalization and destructuring of tourism in Malaga, especially on the Eastern Costa del Sol, according to criteria of efficiency and profitability with wine as a reference, although it could be applied to other gastronomic and cultural resources linked to the tourist sector in other geographical areas.