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Background Cardio-vascular disease and depression are thought to be closely related, due to shared risk factors. The aim of the study was to determine the association between cardio-vascular risk (CVR) factors and depressive status in a population (55–75 years) with metabolic syndrome (MetS) from the PREDIMED-Plus trial. Methods and findings Participants were classified into three groups of CVR according to the Framingham-based REGICOR function: (1) low (LR), (2) medium (MR) or (3) high/very high (HR). The Beck Depression Inventory-II (BDI-II) was used to assess depressive symptoms at baseline and after 2 years. The association between CVR and depressive status at baseline (n = 6545), and their changes after 2 years (n = 4566) were evaluated through multivariable regression models (logistic and linear models). HR women showed higher odds of depressive status than LR [OR (95% CI) = 1.78 (1.26, 2.50)]. MR and HR participants with total cholesterol Conclusions Improving cardiovascular health could prevent the onset of depression in the elderly. Diabetes and total cholesterol in individuals at high CVR, may play a specific role in the precise response. International Standard Randomized Controlled Trial (ISRCTN89898870).

Purpose: To compare the effect of discontinuing bisphosphonate treatment on fracture risk in postmenopausal women at high versus low risk of fracture. Design: Retrospective, longitudinal and population-based cohort study. Setting: Barcelona City Primary Care. Catalan Health Institute. Participants: All women attended by primary care teams who in January 2014 had received bisphosphonate treatment for at least five years were included and followed for another five years. Intervention: Patients were classified according to their risk of new fractures, defined as those who had a history of osteoporotic fracture and/or who received treatment with an aromatase inhibitor, and the continuity or deprescription of the bisphosphonate treatment was analyzed over fiver year follow-up. Main measurements: The cumulative incidence of fractures and the incidence density were calculated and analyzed using logistic regression and Cox models. Results: We included 3680 women. There were no significant differences in fracture risk in high-risk women who discontinued versus continued bisphosphonate treatment (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.87–1.58 for total osteoporotic fractures). However, discontinuers at low risk had a lower incidence of fracture than continuers. This difference was significant for vertebral fractures (HR 0.64, 95% CI 0.47–0.88) and total fractures (HR 0.77, 95% CI 0.64–0.92). Conclusion: Our results suggest that deprescribing bisphosphonates in women who have already received five years of treatment does not increase fracture risk. In low-risk women, continuing this treatment might could even favor the appearance of new osteoporotic fractures. Resumen: Objetivo: Comparar el efecto de la desprescripción de bifosfonatos sobre el riesgo de fractura en mujeres posmenopáusicas con alto y bajo riesgo de fractura. Diseño: Estudio de cohortes retrospectivo, longitudinal y de base poblacional. Emplazamiento: Atención primaria Barcelona. Institut Català de la Salut. Participantes: Se incluyeron todas las mujeres atendidas por los equipos de atención primaria que a enero de 2014 habían recibido tratamiento con bifosfonatos durante al menos cinco años. Intervención: Se clasificó a las pacientes según su riesgo de nuevas fracturas, definido como presencia de antecedentes de fractura osteoporótica y/o tratamiento con un inhibidor de la aromatasa, y se analizó la continuidad o desprescripción del tratamiento con bifosfonatos a lo largo de cinco años de seguimiento. Mediciones principales: La incidencia acumulada de fracturas y la densidad de incidencia se calcularon y analizaron mediante regresión logística y modelos de Cox. Resultados: Se incluyeron 3.680 mujeres. No hubo diferencias significativas en el riesgo de fractura en mujeres de alto riesgo que desprescribieron el bisfosfonato comparado con aquellas que continuaron (hazard ratio [HR] 1,17, intervalo de confianza [IC] de 95% 0,87-1,58 para fracturas osteoporóticas totales). Sin embargo, los que discontinuaron con bajo riesgo tuvieron una menor incidencia de fractura que los que continuaron. Esta diferencia fue significativa para fracturas vertebrales (HR 0,64, IC 95% 0,47-0,88) y fracturas totales (HR 0,77, IC 95% 0,64-0,92). Conclusiones: Nuestros resultados sugieren que la desprescripción de bifosfonatos en mujeres que ya han recibido cinco años de tratamiento no aumenta el riesgo de fractura. En mujeres de bajo riesgo, la continuación de este tratamiento podría incluso favorecer la aparición de nuevas fracturas osteoporóticas.

BackgroundDiabetes mellitus (DM) is one of the leading chronic diseases globally and one of the most common causes of death, morbidity, and poor quality of life. According to the WHO, DM is also one of the main risk factors for developing active tuberculosis (TB). Subjects with DM are at a higher risk of infections, in addition to frequent micro and macrovascular complications, and therefore sought to determine whether poor glycemic control is linked to a higher risk of developing TB.MethodsWe used a retrospective cohort of diabetic subjects to predict the incidence of TB. All DM patients were recruited from Ciutat Vella (the inner-city of Barcelona) from January 2007 until December 2016, with a follow-up period until December 2018 (≥2 years). Data were extracted from Barcelona's Primary Care medical record database - SIDIAP, and linked to the Barcelona TB Control Program. The incidence of TB and the impact of glycemic control were estimated using time-to-event curves analyzed by Cox proportional hazard regression. Hazard ratios (HRs) and 95% confidence intervals (CIs), unadjusted and adjusted by potential confounding variables, were also assessed, which included age, sex, diabetes duration, macrovascular and microvascular signs, BMI, smoking habit, alcohol consumption and geographical origin.ResultsOf 8,004 DM patients considered for the study (equating to 68,605 person-years of follow-up), 84 developed TB [incidence rate = 70 (95% CI: 52–93) per 100,000 person-years]. DM subjects with TB were younger (mean: 52.2 vs. 57.7 years old), had higher values of glycosylated hemoglobin (HbA1c) (7.66 vs. 7.41%) and total triglycerides (122 vs. 105 mg/dl), and had twice the frequency of diabetic nephropathy (2.08 vs. 1.18%). The calculated incidence rate increased with increasing HbA1c: 120.5 (95% CI 77.2–179.3) for HbA1c ≥ 7.5%, 143 (95% CI 88.3–218.1) for HbA1c ≥ 8% and 183.8 (95% CI 105–298) for HbA1c ≥ 9%. An increase in the risk of TB was also observed according to a poorer optimization of glycemic control: adjusted HR 1.80 (95% CI 0.60–5.42), 2.06 (95% CI 0.67–6.32), and 2.82 (95% CI 0.88–9.06), respectively.ConclusionDiabetic subjects with worse glycemic control show a trend toward a higher risk of developing TB.

Resumen: Objetivo: Describir la incidencia y mortalidad de COVID-19, durante la primera ola, en la población de personas mayores de Barcelona, según sus niveles previos de fragilidad. Diseño: Estudio de cohortes retrospectivo. Emplazamiento y participantes: Población de 65 o más años asignada a los centros de Atención Primaria de Barcelona del Institut Català de la Salut, seguidos entre marzo y junio de 2020. Mediciones principales: Fragilidad calculada al inicio a partir de la historia clínica informatizada. Resultados durante el seguimiento: diagnóstico de COVID-19, posible o confirmado con PCR y mortalidad por todas las causas. Resultados: Se analizaron 251788 mayores de 64 años. Un 61,3% tenían algún nivel de fragilidad, 27,8% moderada o grave. La incidencia de COVID-19 fue de 3,13 casos por 100 habitantes (N = 7883) y la mortalidad por COVID-19 fue del 21,5% (N =1 691). Tanto la incidencia como la mortalidad por COVID-19 fueron superiores a mayor edad, en hombres, a mayor privación y a mayor nivel de fragilidad. Los individuos con fragilidad leve, moderada y grave tuvieron un hazard ratio ajustado de enfermedad por COVID-19 de 1,47, 2,08 y 3,50 respectivamente. Entre los sujetos con COVID-19, aquéllos con fragilidad leve, moderada y grave tuvieron un hazard ratio ajustado de mortalidad por COVID-19 de 1,44, 1,69 y 2,47 respectivamente. Conclusiones: Consideramos necesario el abordaje de la fragilidad también en situación de pandemia, dado que es una condición tratable y a su vez factor de riesgo de COVID-19 más grave, donde el papel de la Atención Primaria es primordial, por su accesibilidad y longitudinalidad. Abstract: Objetive To describe the incidence and mortality of the first wave of COVID-19 in the elderly population of Barcelona, according to their previous levels of frailty. Design: Retrospective cohort study. Setting and participants: Population aged 65 or over assigned to the Barcelona Primary Care centres of the Institut Català de la Salut, followed between March and June 2020. Main measurements: Frailty was calculated at baseline from the computerised medical records. Results during follow-up: diagnosis of COVID-19, possible or confirmed with PCR and all-cause mortality. Results: 251 788 patients over 64 years of age were analysed, 61.3% had some level of frailty, 27.8% moderate or severe. The incidence of COVID-19 was 3.13 cases per 100 inhabitants (N = 7883) and the mortality from COVID-19 was 21.5% (N = 1691). Both the incidence and mortality from COVID-19 were higher at older age, in men, at greater deprivation and at a higher level of frailty. Individuals with mild, moderate, and severe frailty had an adjusted Hazard Ratio (HR) for COVID-19 disease of 1.47, 2.08, and 3.50, respectively. Among subjects with COVID-19, those with mild, moderate, and severe frailty had an adjusted HR for COVID-19 mortality of 1.44, 1.69, and 2.47, respectively. Conclusions: We consider it necessary to address frailty also in a pandemic situation, since it is a treatable condition and in turn a more serious risk factor for COVID-19, where the role of primary care is essential, due to its accessibility and longitudinal character.

ObjectiveTo evaluate the effect of Non-alcoholic fatty liver disease (NAFLD) status in the impact of lifestyle over Health-related quality of life (HRQoL) in patients with metabolic syndrome (MetS).MethodsBaseline and 1 year follow up data from the PREDIMED-plus cohort (men and women, 55-75 years old with overweight/obesity and MetS) were studied. Adherence to an energy-restricted Mediterranean Diet (er-MeDiet) and Physical Activity (PA) were assessed with a validated screeners. Hepatic steatosis index (HSI) was implemented to evaluate NAFLD while the SF-36 questionnaire provided HRQoL evaluation. Statistical analyses were performed to evaluate the influence of baseline NAFLD on HRQoL as affected by lifestyle during 1 year of follow up.ResultsData from 5205 patients with mean age of 65 years and a 48% of female participants. Adjusted linear multivariate mixed regression models showed that patients with lower probability of NAFLD (HSI < 36 points) were more responsive to er-MeDiet (β 0.64 vs β 0.05 per er-MeDiet adherence point, p< 0.01) and PA (β 0.05 vs β 0.01 per MET-h/week, p = 0.001) than those with high probability for NAFLD in terms Physical SF-36 summary in the 1 year follow up. 10 points of er-MeDiet adherence and 50 MET-h/week were thresholds for a beneficial effect of lifestyle on HRQoL physical domain in patients with lower probability of NAFLD.ConclusionThe evaluation of NAFLD by the HSI index in patients with MetS might identify subjects with different prospective sensitivity to lifestyle changes in terms of physical HRQoL (http://www.isrctn.com/ISRCTN89898870).

BackgroundTuberculosis is the leading cause of mortality from lung infectious disease worldwide in recent years, and its incidence has re-emerged in large cities in low-incidence countries due to migration and socioeconomic deprivation causes. Diabetes mellitus and tuberculosis are syndemic diseases, with diabetes being considered a risk factor for developing tuberculosis.ObjectiveTo investigate whether diabetic patients were at increased risk of tuberculosis living in an inner-district of a large city of northeastern Spain.MethodsObservational matched retrospective cohort study based on clinical records from the population of the lowest socioeconomic status in Barcelona (Ciutat Vella district). A cohort including patients with type 1 and type 2 diabetes mellitus in 2007 and new cases until 2016 (8004 subjects), matched 1:1 by sex and age with a non-diabetic cohort. Follow-up period was until December 31st 2018. We evaluated the risk of developing tuberculosis in diabetic patients compared to non-diabetic patients during the follow up period. We used time-to-event analysis to estimate the incidence of tuberculosis, and competing risks regression by clusters and conditional Cox regression models to calculate the hazard ratio (HR) and its 95% confidence intervals (CI).ResultsAmong the 16,008 included subjects, the median follow-up was 8.7 years. The mean age was 57.7 years; 61.2% men and 38.8% women in both groups. The incidence of tuberculosis was 69.9 per 100,000 person-years in diabetic patients, and 40.9 per 100,000 person-years in non-diabetic patients (HR = 1.90; CI: 1.18–3.07). After adjustment for the country of origin, chronic kidney disease, number of medical appointments, BMI, alcoholism and smoking, the risk remained higher in diabetic patients (1.66: CI 0.99–2.77). Additionally, subjects from Hindustan or with a history of alcohol abuse also showed a higher risk of developing tuberculosis (HR = 3.51; CI:1.87–6.57, and HR = 2.73; CI:1.22–6.12 respectively).ConclusionPeople with diabetes mellitus were at higher risk of developing tuberculosis in a large cohort recruited in an inner-city district with a high incidence for this outcome, and low socioeconomic conditions and high proportion of migrants. This risk was higher among Hindustan born and alcohol abusers.

Objectives: This study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF). Setting: Patients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain). Participants: Patients with Advanced HF. Design: Multicenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV. Main measurements: The primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months. Results: Mean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months.The most important risk factor over the whole period was presenting a body mass index lower than 20 kg/m2 (three months OR 3.06, 95% CI: 1.58–5.92; six months OR 4.42, 95% CI: 2.08–9.38; and 12 months OR 3.68, 95% CI: 1.76–7.69). Conclusions: We may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease. Resumen: Objetivos: Analizar los factores que contribuyen a la mortalidad de pacientes en las etapas finales de la insuficiencia cardiaca (IC). Ámbito: Centros de atención primaria del Institut Català de la Salut, Cataluña, España. Participantes: Pacientes con IC avanzada. Diseño: Estudio de cohortes multicéntrico. Incluyó 1.148 pacientes de IC seguidos durante un año tras el registro de estadio funcional NYHA IV. Mediciones principales: El resultado principal fue la mortalidad por todas las causas. Se realizaron modelos de regresión logística multivariada (1, 3, 6 y 12 meses). Resultados: Edad media 82 años (DE 9), las mujeres representaron el 61,7%. Un total de 135 (11,8%) y 397 (34,6%) pacientes murieron 3 meses y un año después de su inclusión. El sexo masculino, la edad y el índice de masa corporal (IMC)

Introduction Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic disease in the Spanish population. Typically, T2DM is associated with other chronic conditions. Intensive medication at the time of diagnosis has proven effective in reducing cardiovascular risk, improving glycaemic control and preventing T2DM complications. However, it has not yet been demonstrated that a comprehensive and intensive health education protocol at the time of diagnosis has the benefits described previously. Currently, there is great variability in the practices of primary care nurses regarding health education at the time of disease diagnosis.We aimed to evaluate the effectiveness of a systematic protocol with a comprehensive care programme in people with newly diagnosed T2DM with associated comorbidities.Methods and analysis A multicentre quasi-experimental design comparing a group of individuals taking part in the intervention (intervention group (IG)) with a similar group receiving standard diabetes care (comparison group (CG)) is planned. The intervention will take place during the 3 months after study enrolment. Data will be collected at baseline and at 3, 6 and 12 months. Ten primary care centres in Barcelona city will be selected for participation: 5 for the IG and 5 for the CG. The IG will include five structured individual visits postdiagnosis with the primary care nurse, during which aspects of diabetes education will be discussed with the patient and his/her family. The results will be measured in terms of health-related quality of life and the change in main outcomes (glycated haemoglobin and weight).Ethics and dissemination The study fully met the requirements of the Ethical Committee of Clinical Investigation of the IDIAP Jordi Gol (approval code: P13/118). Patients will be informed that their data are confidential, and they have the right to withdraw at any time without penalty. Dissemination will include publishing the findings in peer-reviewed journals and sharing our findings at scientific conferences.Trial registration number NCT03990857; Pre-results.

Objective: To evaluate the impact of computerized clinical practice guidelines on the management, diagnosis, treatment, control, and follow-up of the main cardiovascular risk factors: hypertension, hypercholesterolaemia, and type 2 diabetes mellitus. Design: Pre-post controlled study. Setting: Catalonia, autonomous community located in north-eastern Spain. Participants: Individuals aged 35–74 years assigned to general practitioners of the Catalan Health Institute. Intervention: The intervention group consisted of individuals whose general practitioners had accessed the computerized clinical practice guidelines at least twice a day, while the control group consisted of individuals whose general practitioner had never accessed the computerized clinical practice guidelines platform. Main outcomes: The Chi-squared test was used to detect significant differences in the follow-up, control, and treatment variables for all three disorders (hypertension, hypercholesterolaemia, and type 2 diabetes mellitus) between individuals assigned to users and non-users of the computerized clinical practice guidelines, respectively. Results: A total of 189,067 patients were included in this study, with a mean age of 56 years (standard deviation 12), and 55.5% of whom were women. Significant differences were observed in hypertension management, treatment and control; type 2 diabetes mellitus management, treatment and diagnoses, and the management and control of hypercholesterolaemia in both sexes. Conclusions: Computerized clinical practice guidelines are an effective tool for the control and follow-up of patients diagnosed with hypertension, type 2 diabetes mellitus, and hypercholesterolaemia. The usefulness of computerized clinical practice guidelines to diagnose and adequately treat individuals with these disorders remains unclear.

Objetivo: Analizar el coste-efectividad de la aplicación de algoritmos diagnósticos en pacientes con sospecha de un primer episodio de trombosis venosa profunda (TVP) en la atención primaria, en comparación con la derivación sistemática a centros especializados. Diseño: Estudio observacional, transversal y analítico. Emplazamiento: Pacientes seleccionados en urgencias hospitalarias derivados desde la atención primaria para completar estudio y diagnóstico. Participantes: Se reclutó a 138 candidatos con clínica compatible con un primer episodio de TVP; 22 fueron excluidos (sin informe de derivación, clínica de más de 30 días, anticoagulados y TVP previa), incluyéndose finalmente a 116 pacientes, un 61% mujeres, de 71 años edad media. Mediciones principales: Variables de las escalas de probabilidad clínica de Wells y Oudega, dímero-D (portátil y hospitalario), ecografía-Doppler y costes directos generados por los 3 circuitos analizados: derivación sistemática de todos los pacientes, derivación según escala de Oudega o de Wells. Resultados: En el 18,9% se confirmó el diagnóstico de TVP. Las 2 escalas de probabilidad clínica presentaron una sensibilidad del 100% (IC del 95%: 85,1-100) y una especificidad alrededor del 40%. Con la aplicación de las escalas, se hubiesen podido evitar con total seguridad un tercio de las derivaciones a urgencias hospitalarias (p < 0,001) y se hubieran podido disminuir los costes del proceso diagnóstico en 8.620 € según Oudega y 9.741 € según Wells, por cada 100 pacientes atendidos. Conclusiones: La aplicación de algoritmos diagnósticos en las sospechas de TVP permitiría al médico de atención primaria una orientación más resolutiva y coste-efectiva del proceso diagnóstico.

Fundamento: En la últimas décadas la mortalidad por enfermedades cardiovasculares ha mostrado una tendencia decreciente en los países desarrollados, confirmada asimismo en España. No obstante siguen siendo la principal causa de mortalidad El objetivo de este trabajo es estudiar la asociación entre las enfermedades cardiovasculares y diversos factores de riesgo cardiovascular modificables en relación a su agrupación (clustering). Métodos: Estudio descriptivo transversal realizado en un centro de salud urbano, que incluyó a 2.248 personas de 15 o más años, seleccionadas por muestreo aleatorio simple del archivo de historias clínicas. Se calculó en forma de odds ratio (OR) el riesgo de tener alguna enfermedad cardiovascular (cardiopatía isquémica, enfermedad cerebrovascular o arteriopatia periférica de extremidades inferiores) en relación al clustering de los factores de riesgo tabaquismo, hipertensión arterial, hipercolesterolemia, hipertrigliceridemia y diabetes mellitus, ajustado por edad, sexo y factores de riesgo. Resultados: Las personas estudiadas tenían 224 enfermedades cardiovasculares. En el tabaquismo la OR como factor de riesgo aislado fue de 1,5 (IC95%: 1,0-2,2) y de 1,6 (IC95%: 0,9-2,5) con el clustering con los otros 4 factores de riesgo; con la hipertensión arterial de 2,1 (IC95%: 1,5-2,9) y de 1,7 (IC95%: 1,1-2,6), respectivamente; con la hipercolesterolemia de 1,7 (IC95%: 1,2-2,4) y de 1,6 (IC95%: 1,1- 2,4), respectivamente; con la diabetes de 2,5 (IC95%: 1,7-3,5) y 2,0 (IC95%: 1,3-3,0), respectivamente y con la hipertrigliceridemia de 1,8 (IC95%: 1,2-2,8) y 1,3 (IC95%: 0,8-2,1), respectivamente. Las OR se comportaron de manera similar al estratificar por cada enfermedad cardiovascular, aunque las OR más elevadas (entre 2,4 y 3,1) correspondieron al clustering de diabetes mellitus y tabaquismo. Conclusiones: El riesgo de tener enfermedades cardiovasculares sigue siendo elevado con el clustering de factores de riesgo cardiovascular, aunque se observan diferencias entre ellos.

Fundamento: No se dispone de estudios que hayan comparado SCORE, REGICOR y Framingham. El objetivo de este trabajo es estudiar cómo clasifican el riesgo cardiovascular las funciones REGICOR y SCORE, su correlación y concordancia respecto a Framingham (1998) y si presentan diferencias respecto a los factores de riesgo cardiovascular en los casos de riesgo alto. Métodos: Estudio descriptivo transversal realizado en atención primaria. Se incluyó a 851 personas entre 35-74 años, libres de enfermedades cardiovasculares y seleccionadas por muestreo aleatorio simple. Se estudió la proporción de pacientes de riesgo alto con Framingham (³20% a 10 años), SCORE (³5% a 10 años) y REGICOR con puntos de corte ³20%, ³15%, ³10% y ³5% a 10 años, ya que con REGICOR ³20% apenas hay casos con riesgo alto. Se comparó la correlación (r de Pearson) y concordancia (coeficiente Kappa) de las personas de riesgo alto de REGICOR y SCORE respecto a Framingham. Resultados: Presentaron riesgo alto 23,3% con Framingham, 15,2% con SCORE y un 1,4%, 5,8%, 17,6% y 57,0% con REGICOR con los puntos de corte descritos, respectivamente. REGICOR tuvo una correlación de 0,99 y SCORE de 0,78. REGICOR ³10% tuvo mejor concordancia (Kappa 0,83) que SCORE (Kappa 0,61). Al comparar los factores de riesgo cardiovascular de los casos con riesgo alto (³20% Framingham, ³5% SCORE y ³10% REGICOR), el segundo presentó mayor prevalencia de diabetes y menor de hipercolesterolemia (p