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© The Author(s) 2019., Background: Attention deficit hyperactivity disorder (ADHD) is a childhood-onset disorder characterized by a persistent pattern of symptoms of developmentally inappropriate and impaired inattention and/or hyperactivity/impulsivity, with difficulties often continuing into adulthood. ADHD can come with other comorbid conditions. The aim of this study will be to quantify the prevalence and comorbidity of ADHD among children, adolescent, and adult population in Spain. Methods/design: We designed and registered a study protocol for an update and expansion of a systematic review and meta-analysis of pooled prevalence data. We will include cross-sectional observational studies reporting prevalence of ADHD in Spain and conducted in the general population, outpatient, and/or school settings. The primary outcome will be the prevalence of ADHD. Secondary outcomes will be the prevalence of any physical or mental comorbidity in association with ADHD. No limitations will be imposed on publication status, study conduct period, and language of dissemination. Comprehensive literature searches will be conducted in multiple electronic databases, including PubMed/MEDLINE, EMBASE, Scopus, Web of Science, PsycINFO, IME - Spanish Medical Index, and IBECS - Spanish Bibliographic Index of Health Sciences. We will also search Google Scholar, dissertation databases, and conference abstracts. Two team members will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. If feasible, we will conduct random effects meta-analysis. Prevalence estimates will be stratified according to gender, age, and geographical location. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., methodological quality, sample size, diagnostic criteria). Discussion: This systematic review and meta-analysis of observational data will provide an updated synthesis of the prevalence and comorbidity of ADHD in Spain. This study will also examine factors that may explain potential variations in prevalence data. The findings of this study will be published in a peer-reviewed journal. Systematic review registration: PROSPERO CRD42018106082., FC-L and RT-S are funded by CIBERSAM/Institute of Health Carlos III. MR is partially funded by the Spanish Health Services Research on Chronic Patients Network (REDISSEC)/Institute of Health Carlos III.

This systematic review and meta-analysis evaluates the association of anorexia nervosa with the cancer incidence and mortality among study populations with anorexia nervosa compared with the general population or those without anorexia nervosa., Key Points Question Are people with anorexia nervosa at a higher risk of developing or dying of cancer compared with those without anorexia and the general population? Findings In this systematic review and meta-analysis of 7 cohort studies including more than 42 000 participants with anorexia nervosa, there was no association of anorexia nervosa with overall cancer incidence or mortality. Anorexia nervosa was inversely associated with breast cancer incidence but positively associated with risk of developing lung and esophageal cancer. Meaning There was no association of anorexia nervosa with risk of cancer overall and few associations of anorexia nervosa with risk of site-specific cancer., Importance Anorexia nervosa is recognized as an important cause of morbidity in young people. However, the risk of cancer in people with anorexia nervosa remains uncertain. Objective To evaluate the association of anorexia nervosa with the risk of developing or dying of cancer. Data Sources MEDLINE, Scopus, Embase, and Web of Science from database inception to January 9, 2019. Study Selection Published observational studies in humans examining the risk of cancer in people with anorexia nervosa compared with the general population or those without anorexia nervosa. Studies needed to report incidence or mortality rate ratios (RRs). Data Extraction and Synthesis Screening, data extraction, and methodological quality assessment were performed by at least 2 researchers independently. A random-effects model was used to synthesize individual studies. Heterogeneity (I2) was assessed and 95% prediction intervals (PIs) were calculated. Main Outcomes and Measures All cancer incidence and cancer mortality associated with anorexia nervosa. Secondary outcomes were site-specific cancer incidence and mortality. Results Seven cohort studies published in 10 articles (42 602 participants with anorexia nervosa) were included. Anorexia nervosa was not associated with risk of developing any cancer (4 studies in women; RR, 0.97; 95% CI, 0.89-1.06; P = .53; I2, 0%; 95% PI, 0.80-1.18; moderate confidence). Anorexia nervosa was associated with decreased breast cancer incidence (5 studies in women; RR, 0.60; 95% CI, 0.50-0.80; P

Resumen Introduccion y objetivos Los anos de vida ajustados por discapacidad aunan en una medida consecuencias mortales y no mortales de las enfermedades. El objetivo fue cuantificar la carga de enfermedad de la cardiopatia isquemica en Espana en 2008 mediante el calculo de anos de vida ajustados por discapacidad. Metodos Anos perdidos por muerte prematura calculados a partir de defunciones por cardiopatia isquemica por edad y sexo del Instituto Nacional de Estadistica y tabla de vida del estudio de carga global de enfermedad 2010. Anos vividos con discapacidad calculados para el sindrome coronario agudo, la angina estable y la insuficiencia cardiaca isquemica, con datos del registro de altas hospitalarias y de estudios poblacionales, y pesos de discapacidad del estudio de carga global de enfermedad 2010. Se calcularon tasas brutas y estandarizadas por edad (poblacion estandar europea). Se realizaron analisis de sensibilidad univariantes. Resultados En 2008 se perdieron en Espana 539.570 anos de vida ajustados por discapacidad por cardiopatia isquemica (tasa bruta: 11,8/1.000; estandarizada: 8,6/1.000). El 96% correspondia a anos perdidos por muerte prematura y el 4% por discapacidad. De estos ultimos, el 83% por insuficiencia cardiaca, el 15% por angina estable y el 2% por sindrome coronario agudo. En el analisis de sensibilidad, el factor que mas modifico los resultados fue la ponderacion por edad. Conclusiones La cardiopatia isquemica sigue teniendo un gran impacto en la salud de la poblacion, principalmente por mortalidad prematura. Los resultados aportan una vision global de la situacion epidemiologica y pueden servir para evaluar intervenciones sobre las manifestaciones agudas y cronicas de la isquemia cardiaca.

Introduction and objectives The health indicator disability-adjusted life years combines the fatal and nonfatal consequences of a disease in a single measure. The aim of this study was to evaluate the burden of ischemic heart disease in 2008 in Spain by calculating disability-adjusted life years. Methods The years of life lost due to premature death were calculated using the ischemic heart disease deaths by age and sex recorded in the Spanish National Institute of Statistics and the life-table in the 2010 Global Burden of Disease study. The years lived with disability, calculated for acute coronary syndrome, stable angina, and ischemic heart failure, used hospital discharge data and information from population studies. Disability weights were taken from the 2010 Global Burden of Disease study. We calculated crude and age standardized rates (European Standard Population). Univariate sensitivity analyses were performed. Results In 2008, 539 570 disability-adjusted life years were lost due to ischemic heart disease in Spain (crude rate, 11.8/1000 population; standardized, 8.6/1000). Of the total years lost, 96% were due to premature death and 4% due to disability. Among the years lost due to disability, heart failure accounted for 83%, stable angina 15%, and acute coronary syndrome 2%. In the sensitivity analysis, weighting by age was the factor that changed the results to the greatest degree. Conclusions Ischemic heart disease continues to have a huge impact on the health of our population, mainly because of premature death. The results of this study provide an overall vision of the epidemiologic situation in Spain and could serve as the basis for evaluating interventions targeting the acute and chronic manifestations of cardiac ischemia.

Our objectives were to analyse the place of death, its temporal trend and associated sociodemographic factors among patients with amyotrophic lateral sclerosis (ALS) resident in the Autonomous Community of Madrid. This was a population based cross-sectional study of deaths from ALS (ICD-10 code G12.2) from 2003 to 2011, included in regional death statistics. The sociodemographic variables were age, gender, marital status, place of residence and socioeconomic level. Logistic regressions were performed to identify factors associated with death in hospital, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Joinpoint models were used to analyse annual trends for death in hospital. Of 1035 patients who died of ALS, 56.1% died in a hospital, 30.4% at home, 8.3% in a residential home and it was unknown for 5.1%. The percentage of deaths in hospital was lower in older and in single people than in married ones (55.0% and 61.9%, respectively; ORa 0.74, 95% CI 0.57-0.97). This percentage increased progressively as socioeconomic level fell (66.3% in Q5 compared to 49.6% in Q1, ORa 2.03, 95% CI 1.36-3.02). A significant increase in the percentage of deaths in hospital was observed. In conclusion, factors such as age, marital status or socioeconomic level play a part in the place of death of those with ALS.

Background and objective The aim of the present study was to determine the national burden of cerebrovascular diseases in the adult population of Spain. Patients and methods Cross-sectional, descriptive population-based study. We calculated the disability-adjusted life years (DALY) metric using country-specific data from national statistics and epidemiological studies to obtain representative outcomes for the Spanish population. DALYs were divided into years of life lost due to premature mortality (YLLs) and years of life lived with disability (YLDs). DALYs were estimated for the year 2008 by applying demographic structure by sex and age-groups, cause-specific mortality, morbidity data and new disability weights proposed in the recent Global Burden of Disease study. In the base case, neither YLLs nor YLDs were discounted or age-weighted. Uncertainty around DALYs was tested using sensitivity analyses. Results In Spain, cerebrovascular diseases generated 418,052 DALYs, comprising 337,000 (80.6%) YLLs and 81,052 (19.4%) YLDs. This accounts for 1,113 DALYs per 100,000 population (men: 1,197 and women: 1,033) and 3,912 per 100,000 in those over the age of 65 years (men: 4,427 and women: 2,033). Depending on the standard life table and choice of social values used for calculation, total DALYs varied by 15.3% and 59.9% below the main estimate. Conclusions Estimates provided here represent a comprehensive analysis of the burden of cerebrovascular diseases at a national level. Prevention and control programmes aimed at reducing the disease burden merit further priority in Spain.

BACKGROUND: Anorexia nervosa is characterized by a severe restriction of caloric intake, low body weight, fear of gaining weight or of becoming fat, and disturbance of body image. Pathogenesis of the disorder may include genetic predisposition, hormonal changes and a combination of environmental, psychosocial, and cultural factors. Cancer is the second leading cause of death worldwide. At present, no systematic reviews and meta-analyses have evaluated the risk of cancer in people with anorexia nervosa. The objective of this study will be to evaluate the association between anorexia nervosa and the risk of developing or dying from cancer. METHODS/DESIGN: This study protocol is part of a systematic collection and assessment of multiple systematic reviews and meta-analyses (umbrella review) evaluating the association of cancer and multiple central nervous system disorders. We designed a specific protocol for a new systematic review and meta-analysis of observational studies of anorexia nervosa with risk of developing or dying from any cancer. Data sources will be PubMed, Embase, Scopus, Web of Science, and manual screening of references. Observational studies (case-control and cohort) in humans that examined the association between anorexia nervosa and risk of developing or dying from cancer will be sought. The primary outcomes will be cancer incidence and cancer mortality in association with anorexia nervosa. Secondary outcomes will be site-specific cancer incidence and mortality, respectively. Screening of abstracts and full texts, and data abstraction will be performed by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. The quality of studies will be assessed by using the Ottawa-Newcastle scale by two team members independently. Random effects models will be conducted where appropriate. Subgroup and additional analyses will be conducted to explore the potential sources of heterogeneity. The World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for cancer outcomes. DISCUSSION: Findings from this systematic review will inform an ongoing umbrella review on cancer and central nervous system disorders. Our systematic review and meta-analysis of observational studies will establish the extent of the epidemiological evidence underlying the association between anorexia nervosa and cancer. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017067462. Specific funding from the Generalitat Valenciana (PROMETEOII/2015/021) and CIBERSAM/Institute of Health Carlos III was received for this work. The funders were not involved in the design of the protocol or decision to submit the protocol for publication, nor will they be involved in any aspect of the conduct of the review. BH is supported by a New Investigator Award from the Canadian Institutes of Health Research and the Drug Safety and Effectiveness Network. MR is partially funded by the Spanish Health Services Research on Chronic Patients Network (REDISSEC)/Institute of Health Carlos III. The views expressed in this article are the views of the authors and may not be understood or quoted as being made on behalf of, or reflecting the position of, the funder(s) or any institution. Sí

[Background] The objective of this study will be to synthesize the epidemiological evidence and evaluate the validity of the associations between central nervous system disorders and the risk of developing or dying from cancer., [Methods/design] We will perform an umbrella review of systematic reviews and conduct updated meta-analyses of observational studies (cohort and case-control) investigating the association between central nervous system disorders and the risk of developing or dying from any cancer or specific types of cancer. Searches involving PubMed/MEDLINE, EMBASE, SCOPUS and Web of Science will be used to identify systematic reviews and meta-analyses of observational studies. In addition, online databases will be checked for observational studies published outside the time frames of previous reviews. Eligible central nervous system disorders will be Alzheimer’s disease, anorexia nervosa, amyotrophic lateral sclerosis, autism spectrum disorders, bipolar disorder, depression, Down’s syndrome, epilepsy, Huntington’s disease, multiple sclerosis, Parkinson’s disease and schizophrenia. The primary outcomes will be cancer incidence and cancer mortality in association with a central nervous system disorder. Secondary outcome measures will be site-specific cancer incidence and mortality, respectively. Two reviewers will independently screen references identified by the literature search, as well as potentially relevant full-text articles. Data will be abstracted, and study quality/risk of bias will be appraised by two reviewers independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. Random-effects meta-analyses of primary observational studies will be conducted where appropriate. Parameters for exploring statistical heterogeneity are pre-specified. The World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for cancer outcomes., [Discussion] Our study will establish the extent of the epidemiological evidence underlying the associations between central nervous system disorders and cancer and will provide a rigorous and updated synthesis of a range of important site-specific cancer outcomes., Specific funding from the Generalitat Valenciana (PROMETEOII/2015/021) and CIBERSAM/Institute of Health Carlos III was received for this work. BH is supported by a New Investigator Award from the Canadian Institutes of Health Research and the Drug Safety and Effectiveness Network. MJP is supported by an Australian National Health and Medical Research Council Early Career Fellowship (1088535). MR is partially funded by the Spanish Health Services Research on Chronic Patients Network (REDISSEC)/Institute of Health Carlos III.

Resumen Objetivo Se analiza la carga de enfermedad de los adolescentes y jovenes en Espana en el ano 2008. Material y metodos Estudio transversal de base poblacional. Se estiman los anos de vida ajustados por discapacidad (AVAD) por sexo y causa especifica en personas de 15-29 anos. Las fuentes de informacion fueron: 1) Defunciones por edad, sexo y causa; 2) Estimaciones de la poblacion a julio de 2008; y 3) Estimaciones del patron de discapacidad para paises europeos con baja mortalidad. Resultados En 2008, los adolescentes y jovenes perdieron 786.479 AVAD (414.346 en varones). Las enfermedades no transmisibles causaron 661.282 AVAD (84% respecto al total). Las principales causas especificas de carga de enfermedad fueron: depresion (16% de AVAD), abuso de alcohol (11%), migranas (9%), trastorno bipolar (7%), esquizofrenia (6%), accidentes de circulacion (5%) y adiccion a drogas (5%). Conclusiones La carga de enfermedad expresada en AVAD permite definir las perdidas de salud en adolescentes y jovenes. A estas edades, la promocion y proteccion de la salud son fundamentales, para prevenir la aparicion de enfermedades en el adulto.

Background and objective An important input to decision-making and health planning is a consistent and comparative description of the population health status. The purpose of this study was to describe the burden of disease in the Region of Valencia (Spain). Material and methods Disability-adjusted life years (DALYs) were calculated and divided into years of life lost (YLLs) and years lived with disability (YLDs). Using death registry data and Valencian population estimates in 2008, we calculated the number of deaths and YLLs. YLDs were based on age- and sex-specific data for countries of the EURO-A subregional level (which includes the Region of Valencia) from the Global Burden of Disease study. The results were stratified by age group, sex and underlying cause of death. The DALY values were used to rank the leading conditions of disease burden. Results In 2008, the total number of DALYs lost was about 551 thousands (53% in men). The main categories of DALYs lost were neuropsychiatric conditions (30%; 167 thousands), malignant tumors (15%; 85 thousands), cardiovascular diseases (13%; 72 thousands) and sense organ diseases (8%; 46 thousands). Depression (8% of DALYs; 47 thousands), dementias (8%; 42 thousands), ischaemic heart disease (5%; 27 thousands), hearing loss (4%; 22 thousands), stroke (4%; 20 thousands) and lung cancer (3%; 19 thousands) were the leading specific causes of disease burden. Conclusions We provide for the first time ever information on the burden of disease in the Valencian population. At this local level, the use of DALYs can help to monitor the population health status and guide the debates on rational priority-setting.

Summary Objective To provide a comprehensive and detailed overview of the burden of disease in Spain for 2008. Implications for public health policies are discussed. Study design Cross-sectional population-based study. Methods Disability-adjusted life years (DALYs) were calculated at country level using the methodology developed in the Global Burden of Disease study. DALYs were divided into years of life lost and years of life lived with disability. Results were obtained using Spanish mortality data for 2008 and morbidity data estimated previously by the World Health Organization for Euro-A. Results In 2008, DALYs lost due to all diseases and injuries were estimated at 5.1 million. Non-communicable diseases accounted for 89.2% of the total DALYs. The leading causes of DALYs were neurological and mental disorders (29.9%), malignant neoplasms (15.8%) and cardiovascular diseases (12.5%). The main specific causes included depression (5.5%), ischaemic heart disease (5.5%), lung cancer (5.3%) and alcohol abuse (4.7%) among males; and depression (11.7%), dementias (10.0%), hearing loss (4.2%) and cerebrovascular disease (3.5%) among females. Conclusions Measuring DALYs specifically for Spain represents a systematic analysis of population health losses, and also provides an important measure to track the outcomes of future health interventions.

Objective: To review standard methods used to evaluate the efficiency of oncology interventions, comparing their main characteristics with those of the studies aimed for other conditions. Methods: We performed a systematic review and comparative analysis calculating odds ratios (OR). We searched the biomedical literature to assess economic evaluation studies on malignant neoplasms in Spain published between 1983 and 2008. Their characteristics were reviewed and summarised, including the following variables: journal and year of publication, intervention, type and design of study, perspective, type of costs, financing source, and decision-making recommendations. Results: Sixty-three studies were included. Main characteristics of the reports were: costeffectiveness analysis and therapeutic interventions (60.3%; n = 38). Seventeen studies (27.0%) used an observational design. Economic evaluations of malignant neoplasms showed the following associations (compared to those studies addressing other causes [n = 411]): cost minimisation analysis (OR: 1.73; 95% confidence interval [CI]: 0.91-3.27), diagnostic interventions (OR: 2.18; 95% CI: 1.07-4.43), decision analysis design (OR: 0.46; 95% CI: 0.24-0.87), societal perspective (OR: 0.20; 95% CI: 0.05-0.86) and for-profit source of financing (OR: 0.52; 95% CI: 0.30-0.93). Conclusions: Economic evaluations of interventions for malignant neoplasms are not common despite the gradual increase produced during recent years in Spain. Reports presented heterogeneity in the quality of the information regarding the methods and the data sources used. Further efficiency evaluations of oncology interventions are needed and methodological quality should be warranted.

ResumenObjetivoAnalizar la carga de enfermedad de las personas mayores en España en el año 2008.MétodosEstudio transversal de base poblacional. Se calcularon los años de vida ajustados por discapacidad (AVAD) en personas de 60 y más años de edad. Los AVAD resultan de sumar los años de vida perdidos (AVP) y los años vividos con discapacidad (AVD). Los datos se obtuvieron, para los AVP, del Registro de Mortalidad, y para los AVD por inferencia de las estimaciones de la subregión Euro-A (que incluye España).ResultadosLas personas mayores perdieron 2,1 millones de AVAD, destacando los tumores malignos (21,3%), las enfermedades neuropsiquiátricas (21,1%) y las cardiovasculares (20,4%). Las principales causas específicas fueron demencias, cardiopatía isquémica, enfermedad vascular cerebral, enfermedad pulmonar obstructiva crónica, cáncer de pulmón, pérdidas de audición y artrosis.ConclusionesLa carga de enfermedad permite replantear la importancia de los distintos problemas de salud en relación con el clásico análisis de mortalidad.AbstractObjectiveWe analyzed the burden of disease in the elderly population in Spain in 2008.MethodsA population-based cross-sectional study was performed to calculate the disability-adjusted life years (DALYs) of the Spanish population aged ≥ 60 years old. DALYs are the sum of the number of years of life lost (YLLs) and the number of years lived with disability (YLDs). Data sources included the national mortality register for YLLs, and inference of Euro-A subregion (including Spain) estimates for YLDs.ResultsIn the elderly population, DALYs lost due to all diseases were estimated at 2.1 million. The main causes of DALYs were malignancies (21.3%), neuropsychiatric disorders (21.1%) and cardiovascular diseases (20.4%). The main specific subcategories were dementias, ischemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lung cancer, hearing loss and osteoarthritis.ConclusionsBurden of disease analysis allows distinct health problems to be reassessed in relation to classical mortality analysis.

Fundamentos: La pandemia de gripe A (H1N1) supuso la puesta en marcha en la Comunidad de Madrid (CM) de nuevas estrategias de vigilancia epidemiologica que diesen respuesta a las necesidades de inmediatez y exhaustividad. Los objetivos de este estudio son describir las caracteristicas de los casos recogidos por este sistema asi como mostrar las posibilidades de desagregacion geografica de estos datos. Metodos: Estudio descriptivo transversal entre el 1 de mayo de 2009 y el 22 de mayo de 2010. Se recabaron diariamente todos los episodios registrados y declarados como gripe en las historias clinicas electronicas de Atencion Primaria del Sistema Sanitario Publico de la CM. Se analizaron los datos por fecha, edad, sexo y zonificacion sanitaria, desagregando hasta profesional sanitario. Resultados: Se registraron 165.492 episodios de gripe (53,8% en mujeres). El mayor numero de casos fue en el grupo de 25 a 49 anos (70.691) y el grupo de 5 a 14 anos alcanzo la mayor tasa de incidencia semanal (1.618,65 por 100.000 en la semana 43). La tasa total semanal maxima fue 458,47 por 100.000 (semana 44). Los pediatras tuvieron el maximo de casos atendidos y de tasas acumuladas (12 de ellos atendieron a mas del 20% de su cupo). Conclusiones: La vigilancia de la gripe pandemica (H1N1) 2009 mediante la captura automatica diaria de datos de las historias clinicas electronicas de Atencion Primaria fue una fuente de informacion de especial utilidad en el seguimiento de la evolucion de la pandemia y la toma de decisiones estrategicas.

Objetivo: Estimar la prevalencia de problemas de salud crónicos en inmigrantes y compararla con la de la población autóctona, utilizando la historia clínica electrónica (HCE) de atención primaria (AP). Métodos: Estudio descriptivo transversal con pacientes de 16 y más años incluidos en el sistema sanitario público de la Comunidad de Madrid. Se estimaron prevalencias ajustadas por edad para cada sexo y nacionalidad (agrupada en regiones) a partir de los episodios de atención registrados en la HCE de AP con alguna anotación en 2005 o 2006. Resultados: El 36,8% de la población inmigrante presentaba alguna enfermedad crónica (55,3% de autóctonos) tras ajustar por edad, con más frecuencia en mujeres y en población de origen africano y latinoamericano. Las enfermedades más prevalentes en los extranjeros fueron las alergias (tasa cruda: 10,2%), las lumbalgias (9,1%), problemas crónicos de piel (6,8%) y trastornos mentales (6,4%). Conclusiones: La prevalencia de enfermedades crónicas es menor en la población extranjera y varía según el sexo y la procedencia.Objective: To estimate the prevalence rates of chronic disorders in immigrants and to compare them with those in the native population, based on electronic clinical records in primary care (ECRPC). Methods: We performed a descriptive cross-sectional study in patients aged 16 and over included in the Madrid Regional Public Health System. Age-adjusted prevalence rates for each sex and region were estimated on the basis of medically examined cases registered in the ECRPC with any new data entry made in 2005 or 2006. Results: After age-adjustment, a total of 36.8% immigrants had some chronic health problem (vs. 55.3% natives). These disorders were more frequent among women and among the population from Africa and Latin America. The highest overall prevalence rates in the foreign population were allergy (10.2% crude rate), low-back pain (9.1%), chronic skin problems (6.8%) and mental disorders (6.4%). Conclusions: The prevalence rate of chronic disease is lower in the foreign population and differs according to sex and country of origin.

The search of suitable indicators for estimating the risk of road traffic injuries is nowadays a relevant topic. The objective of this study was to carry out a comparative description of mortality and inhospital morbidity by age and sex, using population rates and mobility exposure related indicators.Cross sectional study in the Community of Madrid, 2003-2005. Population rates and mortality and morbidity rates per billion of persons-kilometers travelled and per million of persons-hours travelled were estimated and compared by age and sex. The Minimum Basic Hospital Discharge Data Set, the 2004 Mobility House Survey of the Community of Madrid and the mortality register of the Statistic Institute of the Community of Madrid were used as information sources.7,413 hospital discharges and 1,046 deaths were identified. Morbidity and mortality population rates in men were 62.24 and 9.20 respectively, and in women 23.80 and 2.97 per 100,000 inhabitants, being the highest rates those for men aged 16-24 years (119.27 hospital discharges and 12.00 deaths per 100,000 inhabitants). Women of 65 years and older showed the highest mobility related rates: 649.78 hospital discharges and 96.72 deaths per 10(9) km, and 13.11 hospital discharges and 1.95 deaths per 10(6) travelled hours.Morbidity and mortality were higher in men for the three indicators. Rates referred to mobility exposure, faced to population rates, decrease mortality and morbidity due to road traffic injuries in men and young ages and increase both in advanced ages.

Fundamento y objetivo La carga de enfermedad (determinada mediante los anos de vida ajustados por discapacidad, AVAD) podria definir prioridades sanitarias. El objetivo de este estudio fue determinar las enfermedades que causan mayor carga de enfermedad en la poblacion infantojuvenil espanola. Material y metodo Calculo de los componentes de AVAD (anos de vida perdidos + anos vividos con discapacidad) por grupos de edad y sexo. Se emplearon como fuentes el registro de mortalidad nacional y las estimaciones de AVAD de la Organizacion Mundial de la Salud. Resultados La tasa total de AVAD fue de 46,57/1.000 habitantes, con una mayor proporcion en los menores de 1 ano de edad. La primera causa de AVAD son las enfermedades no transmisibles, seguidas de las transmisibles y perinatales, aunque en el segmento de edad entre 5 y 14 anos la segunda causa la constituyen los accidentes y lesiones, con una mayor proporcion de varones en estos pacientes. Conclusiones La carga de enfermedad determinada mediante AVAD es un buen indicador para definir la salud de la poblacion.

Background: The impact of palliative home care programs on in-patient admissions and deaths has not been appropriately established. Aim: The main objectives of this study have been to evaluate the frequency of in-patient hospital deaths and the use of hospital resources among cancer patients in two areas of the Madrid Region, as well as to assess differences between one area with and one without a palliative home care team (PHCT) in those variables. Design and setting: We conducted a population-based study comparing two adjacent metropolitan areas of approximately 200,000 inhabitants each in the Madrid Region, Spain, measuring in-patient deaths, emergency room admissions and in-patient days among cancer patients who died in 2005. Only one of the two areas had a fully established PHCT. Results: 524/549 cancer patients (95%) had an identified place of death: 74% died in hospital, 17% at home, 6% in an in-patient hospice and 3% in a nursing home. The frequency of hospital deaths was significantly lower among patients of the PHCT area (61% versus 77%, p < 0.001), as well as the number of patients using emergency and in-patient services (68% versus 79%, p = 0.004, and 66 versus 76%, p = 0.012, respectively). After adjusting for other factors, the risk of hospital death was lower among patients older than 80 (OR, 95% CI, 0.3, 0.1–0.5), higher among patients with hematological malignancies (OR 6.1, 2.0–18.9) and lower among patients of the PHCT area (OR 0.4, 0.2–0.6). Conclusions: Our findings suggest that a PHCT is associated with reduced in-patient deaths and overall hospitalization over the last two months of life.

OBJECTIVE: This article analyses the burden of disease in adolescents and young people in Spain in 2008. MATERIAL AND METHODS: A cross-sectional population-based study. We estimated disability-adjusted life years (DALYs) by sex and cause for subjects aged 15-29 years. Data sources were used: 1) National death records by age, sex and cause; 2) Population data (both in July 2008); and 3) Estimates of the disability pattern for European countries with very low mortality. RESULTS: In 2008, adolescents and young people lost 786,479 DALYs (414,346 in males). Non-communicable diseases generated 661,282 DALYs (84% of the total). The main specific causes of disease burden were: unipolar depression (16% of DALYs), alcohol use disorders (11%), migraine (9%), bipolar disorder (7%), schizophrenia (6%), road traffic accidents (5%) and drug addiction disorders (5%). CONCLUSIONS: The burden of disease expressed in DALYs can define the loss of health in adolescents and young people. At these ages, health promotion and protection are essential to prevent the onset of disease in adulthood. Language: es

Background Attention deficit hyperactivity disorder (ADHD) is a commonly diagnosed neuropsychiatric disorder in childhood, but the frequency of the condition is not well established in many countries. The aim of the present study was to quantify the overall prevalence of ADHD among children and adolescents in Spain by means of a systematic review and meta-analysis. Methods PubMed/MEDLINE, IME, IBECS and TESEO were comprehensively searched. Original reports were selected if they provided data on prevalence estimates of ADHD among people under 18 years old in Spain and were cross-sectional, observational epidemiological studies. Information from included studies was systematically extracted and evaluated. Overall pooled-prevalence estimates of ADHD were calculated using random-effects models. Sources of heterogeneity were explored by means sub-groups analyses and univariate meta-regressions. Results Fourteen epidemiological studies (13,026 subjects) were selected. The overall pooled-prevalence of ADHD was estimated at 6.8% [95% confidence interval (CI) 4.9 – 8.8%] representing 361,580 (95% CI 260,550 – 467,927) children and adolescents in the community. There was significant heterogeneity (P < 0.001), which was incompletely explained by subgroup analyses and meta-regressions. Conclusions Our findings suggest that the prevalence of ADHD among children and adolescents in Spain is consistent with previous studies conducted in other countries and regions. This study represents a first step in estimating the national burden of ADHD that will be essential to building evidence-based programs and services.

Background: Some immigrants and refugees might be more vulnerable than other groups to pandemic influenza because of pre-existing health and social disparities, migration history and living conditions. The objective of this study was to compare, between the immigrant and autochtonous population, the incidence and characteristics of influenza cases consulting in primary care (PC) and severe influenza cases. Methods: Descriptive cross-sectional study of influenza episodes registered in PC and severe influenza cases reported between 1 May 2009 and 22 May 2010, by gender and origin. Age-adjusted rates were calculated and the association between origin and chronic pathology, pregnancy, delay in admission to hospital and admission to intensive care units (ICU) was analyzed by logistic regression and generalized linear models. Results: The influenza rate in PC, adjusted by age, was lower for immigrant population (2396.3, 95% confidence interval (95% CI) 2362.5–2430.0 vs. 2795.9, 95% CI 2780.4–2811.5 per 100 000). The difference between severe influenza rates by origin was not statistically significant. Chronic conditions were less common in immigrant population. In severe influenza cases, pregnancy was more common in immigrant women, and the probability of admission to ICU was higher in men from Central and Eastern Europe (prevalence ratio (PR) 8.44, 95% CI 2.81–25.40) and North African women (PR 3.30, 95% CI 1.09–10.05). Conclusion: Differences in influenza rates were detected by origin. This information could be useful for new pandemic wave management purposes, in addition to targetting future investigations. Pandemic influenza preparedness and response plans should incorporate specific actions to improve immigrants’ access to health services and to decrease cultural barriers.

Background Measures of premature mortality have been used to guide debates on future health priorities and to monitor the population health status. Standard expected years of life lost (SEYLL) is one of the methods used to assess the time lost due to premature death. This article affords an overview of premature mortality in Spain for the year 2008. Methods A population-based study was conducted estimating SEYLL by sex and age groups. SEYLL, a key component of the disability-adjusted life years measure of disease burden, was calculated using Princeton West standard life tables with life expectancy at birth fixed at 80 years for males and 82.5 years for females. Population data and specific death records were obtained from the official registers of the National Institute of Statistics. All data were analysed and prepared in GesMor and Epidat software packages. Results The burden of premature mortality was estimated at 2.1 million SEYLL when age at death is taken into account. Males lost 60.9% and females lost 39.1% of total SEYLL. Malignant tumors (34.5%) and cardiovascular diseases (24.0%) were the leading categories in terms of SEYLL. Ischaemic heart disease (8.5%) and lung cancers (8.0%) were the most common specific causes of SEYLL followed by cerebrovascular diseases (5.9%), colorectal cancer (4.1%), road traffic accidents (3.5%), Alzheimer and other dementias (2.9%), chronic obstructive pulmonary disease (2.8%), breast cancer (2.8%) and suicides (2.6%). Conclusions In Spain, premature mortality was essentially due to chronic non-communicable diseases. Data provided in this study are relevant for a more balanced health agenda aimed at reducing the burden of premature mortality. This study also represents a first step in estimating the overall burden of disease in terms of premature death and disability.

We analyzed the burden of disease in the elderly population in Spain in 2008.A population-based cross-sectional study was performed to calculate the disability-adjusted life years (DALYs) of the Spanish population aged ≥ 60 years old. DALYs are the sum of the number of years of life lost (YLLs) and the number of years lived with disability (YLDs). Data sources included the national mortality register for YLLs, and inference of Euro-A subregion (including Spain) estimates for YLDs.In the elderly population, DALYs lost due to all diseases were estimated at 2.1 million. The main causes of DALYs were malignancies (21.3%), neuropsychiatric disorders (21.1%) and cardiovascular diseases (20.4%). The main specific subcategories were dementias, ischemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lung cancer, hearing loss and osteoarthritis.Burden of disease analysis allows distinct health problems to be reassessed in relation to classical mortality analysis.

Background The allocation of limited available healthcare resources demands an agreed rational allocation principle and the consequent priority setting. We assessed the association between economic evaluations of healthcare interventions published in Spain (1983-2008) and the disease burden in the population. Methods Electronic databases (e.g., PubMed/MEDLINE, SCOPUS, ISI Web of Knowledge, CRD, IME, IBECS) and reports from health technology assessment agencies were systematically reviewed. For each article, multiple variables were recorded such as: year and journal of publication, type of study, health intervention targetted, perspective of analysis, type of costs and sources of information, first author's affiliation, explicit recommendations aimed at decision-making, and the main disease cause to which the intervention was addressed. The following disease burden measures were calculated: years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs), and mortality by cause. Correlation and linear regression models were fitted. Results Four hundred and seventy-seven economic evaluations were identified. Cardiovascular diseases (15.7%), infectious diseases (15.3%), malignant neoplasms (13.2%), and neuropsychiatric diseases (9.6%) were the conditions most commonly addressed. Accidents and injuries, congenital anomalies, oral conditions, nutritional deficiencies and other neoplasms were the categories with a lowest number of studies (0.6% for each of them). For the main disease categories (n = 20), a correlation was seen with: mortality 0.67 (p = 0.001), DALYs 0.63 (p = 0.003), YLLs 0.54 (p = 0.014), and YLDs 0.51 (p = 0.018). By disease sub-categories (n = 51), the correlations were generally low and non statistically significant. Conclusions Examining discrepancies between economic evaluations in particular diseases and the overall burden of disease helps shed light on whether there are potentially over- and under-investigated areas. The approach taken could help policy-makers understand whether resources for economic evaluation are being allocated by using summary measures of population health.

Pandemic influenza (H1N1) 2009 led to implementation in the Madrid Region of new strategies of epidemiology surveillance in order to give response to the need of immediacy and exhaustiveness.Descriptive cross-sectional study between May 1th 2009 and May 22th 2010. All disease episodes registered and reported as influenza disease were collected every day from electronic clinical records in primary care of Madrid Regional Public Health System. Data were analyzed by date, age, sex and health zoning, disaggregating into health professionals.165.492 influenza episodes were registered (53,8% in women). The main number of cases was in the 25-49 years group (70.691), and the 5-14 years group reached the maximum weekly incidence rate (1.618,65/100.000 in the week 43). The highest weekly total incidence rate was 458,47/100.000 (week 44). Pediatricians reached the maximum of cases visited and of cumulated rates (12 pediatricians visited more than 20% of their total assigned population).Surveillance of pandemic influenza (H1N1) 2009 by automatic daily data collection from electronic clinical records in primary care has meant a specially useful information source for monitoring the development of pandemic influenza and for the strategic decision making.

The accumulation of chronic conditions in a same patient is increasingly more frequent for which is becoming a problem of public health. The objectives of this study are to describe the prevalence of comorbidity in the population, its epidemiological characteristics and its influence in the utilization of health services from the Regional Health Survey of Madrid (ERSM2007) and to compare two indicators of comorbidity.Cross-sectional study. The ERSM2007 was analyzed (n=12.190 over 15 years old). Two indicators were developed: the presence of 2 or more chronic conditions (PC) and the existence of 2 or more affected clinical categories according to a definition of comorbidited patient (PP). Other variables analyzed were: sex, age, social class, education, body mass index, physical activity, alcohol and tobacco consumption, and the utilization of health services. A descriptive analysis was carried out, bivariate and multivariate by means of logistic regression with odds ratios (OR) and confidence intervals of 95%.The prevalence of comorbidity measured with PC was 23.7% in men and 37.3% in women and with PP was 5.4% and 8.2% respectively. Comorbidity increased with age, with low educational level (OR=2.0; 1.4-2.8, in women without or with primary studies regarding university degree), with obesity (OR=2.6; 1.9-3.3, in obese women with regard to normal weighted women), and with the previous alcohol and tobacco consumption. The highest association was observed between PP and hospitalization (OR=4.1; 3.0-5.5 in men and OR=3.3; 2.6-4.3 in women).The prevalence of comorbidity was higher in women, in older people, with smaller level of studies or in more disadvantaged social classes. Comorbidity was associated with the obesity and with consumption of tobacco or alcohol. The utilization of the healthcare services enlarged with the comorbidity. These indicators can be complementary, because of their differential association with each healthcare level.

Background Chronic health problems are the main cause of disease, disability and death in developed countries, and their prevalence is increasing. Objective To estimate the prevalence of selected chronic illnesses based on electronic clinical records in primary care (ECRPC) and to assess its usefulness for epidemiological research, by comparing ECRPC data against those reported by a contemporary health survey. Design Descriptive cross-sectional study. Setting All primary care medical consultations in the Madrid Regional Public Health System (PHS). Subjects A total of 23 535 182 ECRPC-registered episodes of illness, generated by PHS patients over 15 years of age seeking medical care during 2005-06. Main outcome measures Prevalences of chronic diseases estimated on the basis of medically examined cases registered in ECRPC and morbidity as reported by a contemporary health survey covering the same geographic area. Results A total of 52.5% of the adult population had some chronic health problem. The highest overall prevalences were hypertension (14.8%), mental disorders (12.0%) and allergy (11.6%). Prevalences were generally highest among women, elderly and the native population. Depending on the specific disease, ECRPC-based prevalences were similar to (e.g. diabetes), higher (e.g. chronic skin problems) or lower (e.g. asthma and dyslipidaemia) than those reported by surveys, with certain age- and sex-related variations. Conclusions Prevalences estimated from ECRPC and survey data present variations depending on the disease, age and sex. Both data sources provide complementary information about chronic disease prevalence. ECRPC have the advantage of generating an ongoing standardized register and entailing no additional effort for health professionals.

The Carlos III Health Institute (Instituto de Salud Carlos III - Spain) allocates funding to health research support in the Spanish National Health System (NHS). This study aimed to analyse the correlation of health research fund allocations in the NHS and the burden of disease in Spanish population.Cross-sectional study. Burden of disease measures were calculated: disability-adjusted life-years (DALYs), years of life lost (YLLs) and mortality by cause. A correlation analysis (Spearman s Rho) was applied to test the association between these measures and 2006/2007 health research funding.Using disease categories (n=21), the correlation between funding and disease-burden measures is: DALY (r=0.72; p0.001), mortality (r=0.60; p=0.004) and YLL (r=0.56; p=0.008). By disease-specific subcategories (n=52): DALY (r=0.55; p0.001), mortality (r=0.54; p0.001) and YLL (r=0.55; p0.001). Malignant neoplasms, neuropsychiatric conditions, cardiovascular diseases and infectious and parasitic diseases receive the greater health research funding support. However, the higher funds allocated per DALY lost ratios were for blood and endocrine disorders, infectious and parasitic diseases and congenital anomalies.Our analysis suggests that NHS research funding is positive moderately high-associated with the burden of disease in Spain, although there exists certain diseases categories that are over or under-funded in relation to their burden generated. In health planning, burden of disease studies contributes with useful information for setting health research priorities.

To estimate the prevalence rates of chronic disorders in immigrants and to compare them with those in the native population, based on electronic clinical records in primary care (ECRPC).We performed a descriptive cross-sectional study in patients aged 16 and over included in the Madrid Regional Public Health System. Age-adjusted prevalence rates for each sex and region were estimated on the basis of medically examined cases registered in the ECRPC with any new data entry made in 2005 or 2006.After age-adjustment, a total of 36.8% immigrants had some chronic health problem (vs. 55.3% natives). These disorders were more frequent among women and among the population from Africa and Latin America. The highest overall prevalence rates in the foreign population were allergy (10.2% crude rate), low-back pain (9.1%), chronic skin problems (6.8%) and mental disorders (6.4%).The prevalence rate of chronic disease is lower in the foreign population and differs according to sex and country of origin.

Background Burden of disease is a joint measure of mortality and morbidity which makes it easier to compare health problems in which these two components enjoy different degrees of relative importance. The objective of this study is ascertaining the burden of disease due to cancer in Spain via the calculation of disability-adjusted life years (DALYs). Methods DALYs are the sum of years of life lost due to premature mortality and years lost due to disability. World Health Organization methodology and the following sources of data were used: the Mortality Register and Princeton Model Life Table for Years of life lost due to premature mortality and population, incidence estimates (Spanish tumour registries and fitting of generalized linear mixed models), duration (from data of survival in Spain from the EUROCARE-3 study and fitting of Weibull distribution function) and disability (weights published in the literature) for Years lost due to disability. Results There were 828,997 DALYs due to cancer (20.5 DALYs/1,000 population), 61% in men. Of the total, 51% corresponded to lung, colorectal, breast, stomach and prostate cancers. Mortality (84% of DALYs) predominated over disability. Subjects aged under 20 years accounted for 1.6% and those aged over 70 years accounted for 30.1% of DALYs. Conclusion Lung, colorectal and breast cancers are responsible for the highest number of DALYs in Spain. Even if the burden of disease due to cancer is predominantly caused by mortality, some cancers have a significant weight of disability. Information on 2000 burden of disease due to cancer can be useful to assess how it has evolved over time and the impact of medical advances on it in terms of mortality and disability.

BACKGROUND: The Carlos III Health Institute (Instituto de Salud Carlos III - Spain) allocates funding to health research support in the Spanish National Health System (NHS). This study aimed to analyse the correlation of health research fund allocations in the NHS and the burden of disease in Spanish population. METHODS: Cross-sectional study. Burden of disease measures were calculated: disability-adjusted life-years (DALYs), years of life lost (YLLs) and mortality by cause. A correlation analysis (Spearman s Rho) was applied to test the association between these measures and 2006/2007 health research funding. RESULTS: Using disease categories (n=21), the correlation between funding and disease-burden measures is: DALY (r=0.72; p

Fundamentos: La acumulación de patologías crónicas en un mismo paciente es cada vez más frecuente, por lo que se está convirtiendo en un problema de salud pública. Los objetivos de este estudio son describir la prevalencia de pluripatología en la población, sus características epidemiológicas y su influencia en la utilización de servicios sanitarios a partir de la Encuesta Regional de Salud de Madrid (ERSM2007) y comparar dos indicadores de pluripatología. Métodos: Estudio descriptivo transversal. Se analizó la ERSM2007 (n=12.190 mayores de 15 años). Se elaboraron dos indicadores: la presencia de 2 o más Problemas Crónicos (PC) y la existencia de 2 o más categorías clínicas afectadas según una definición de Paciente Pluripatológico (PP). Otras variables analizadas fueron: sexo, edad, clase social, nivel de estudios, índice de masa corporal, actividad física, consumos de alcohol y de tabaco, y la utilización de servicios sanitarios. Se realizó un análisis descriptivo, bivariado y multivariado mediante regresión logística con el cálculo de odds ratios (OR) e intervalos de confianza del 95%. Resultados: La prevalencia de pluripatología medida con PC fue 23,7% en hombres y 37,3% en mujeres y con PP fue 5,4% y 8,0% respectivamente. La pluripatología aumentó con la edad, con el bajo nivel educativo (OR=2,0; 1,4-2,8, en mujeres sin estudios o primarios respecto a universitarios), con la obesidad (OR=2,6; 1,9-3,3, en obesas respecto a mujeres de peso normal), y con el consumo previo de alcohol y de tabaco. La mayor asociación se observó con PP y el ingreso hospitalario (OR=4,1 ; 3,0-5,5 en hombres y OR=3,3 ; 2,6-4,3 en mujeres). Conclusiones: La prevalencia de pluripatología fue mayor en mujeres, en personas de mayor edad, con menor nivel de estudios o en clases sociales más desfavorecidas. Se asoció con la obesidad, con consumos previos de tabaco o alcohol. La utilización de los servicios sanitarios aumentó con la pluripatología. Estos indicadores pueden ser complementarios, por su diferente asociación con cada nivel asistencial.

Ferran Catala-Lopez * y Ricard Genova-Maleras d a Centro Superior de Investigacion en Salud Publica (CSISP), Red de Investigacion en Servicios de Salud en Enfermedades Cronicas (REDISSEC), Conselleria de Sanitat, Generalitat Valenciana, Valencia, Espana b Fundacion Instituto de Investigacion en Servicios de Salud, Valencia, Espana Division de Farmacoepidemiologia y Farmacovigilancia, Agencia Espanola de Medicamentos y Productos Sanitarios (AEMPS), Madrid, Espana d Servicio de Informes de Salud y Estudios, Subdireccion de Promocion de la Salud y Prevencion, Consejeria de Sanidad, Comunidad de Madrid, Madrid, Espana www .e lsev ier .es /m ed i c in ac l in ic a