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When students solve problems on the Internet, they have to find a balance between quickly scanning large sections of information in web pages and deeply processing those that are relevant for the task. We studied how high school students articulate scanning and deeper processing of information while answering questions using a Wikipedia document, and how their reading comprehension skills and the question type interact with these processes. By analyzing retrospective think-aloud protocols and eye-tracking measures, we found that scanning of information led to poor hypertext comprehension, while deep processing of information produced better performance, especially in location questions. This relationship between scanning, deep processing, and performance was qualified by reading comprehension skills in an unexpected way: Scanning led to lower performance especially for good comprehenders, while the positive effect of deep processing was independent of reading comprehension skills. We discussed the results in light of our current knowledge of Internet problem solving. [ABSTRACT FROM AUTHOR]

Copyright of International Journal of Medicine & Science of Physical Activity & Sport / Revista Internacional de Medicina y Ciencias de la Actividad Física y del Deporte is the property of Revista Internacional de Medicina y Ciencias de la Actividad Fisica y del Deporte and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background and Objective : The aim of this study was to analyze sex differences in risk factors associated with hospital mortality in patients with Fournier gangrene (FG). Materials and Methods: A retrospective population-based study (2016-2021) included FG hospitalizations in Spain. To identify the risk factors, we used multivariable logistic regression and reported adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results : There were 3644 admissions for FG during the study period (82.5% men and 17.5% women). The mean hospitalization rate per 1000 admissions/year was 0.23 for men and 0.05 for women, and the mean hospitalization rate per 100,000 inhabitants/year was 2.7 for men and 0.4 in women. The most common comorbidities were hypertension (44.9%) and diabetes mellitus (35.6%). The main complications were sepsis (22.1%), 29.8% were admitted to the intensive care unit and 16.1% died. Mortality was higher in women (aOR 1.32, 95% CI 1.07-1.63). The main independent risk factors for mortality in the entire sample were older age, neoplasms, chronic kidney disease, heart failure, sepsis, acute kidney injury, and admission to the intensive care unit. In women, they were older age, leukemia, sepsis, acute kidney injury, and admission to the intensive care unit. Conclusions: The overall FG mortality rate was slightly higher in women than in men, people aged >64 years, people with chronic kidney disease, sepsis, and acute kidney injury, and admission to the intensive care unit. The independent factors associated with mortality in women were similar in both sexes.

Pseudococcus longispinus (Targioni-Tozzetti) (Hemiptera: Coccoidea: Pseudococcidae), a polyphagous and cosmopolitan pest native to Australia, is a highly damaging pest for numerous crops of economic importance. The sex pheromone of this species (2-(1,5,5-trimethylcyclopent-2-en-1-yl)ethyl acetate), currently used for pest monitoring purposes, was not attractive to males in field experiments conducted in Spanish persimmon orchards infested with this mealybug. The virgin and mated female volatile profiles of these P. longispinus populations were studied by the volatile collection of effluvia in Porapak-Q. The resulting extracts were analyzed by gas chromatography coupled to mass spectrometry (GC-MS), revealing a new compound specific to virgin females and different from the previously described sex pheromone. Based on GC-MS data and nuclear magnetic resonance experiments, we envisaged monoterpene 2-(1,5-dimethyl-4-methylenecyclopent-2-en-1-yl)ethyl acetate as the new sex pheromone candidate, which was synthesized and shown to be attractive in the field to P. longispinus males of the Spanish population.

Introduction: Empowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool for fostering patient empowerment and is mostly provided on an individual basis. Virtual communities of practice (VCoP) present a unique opportunity for online education in chronic condition self-management within a social context. This research aims to evaluate the effectiveness/cost-effectiveness of individualised, online self-management education compared with VCoP among middle-aged individuals living with multiple chronic conditions., Methods and Analysis: People aged 30-60, living with ≥2 chronic conditions and receiving care in primary care (PC) centres and outpatient hospital-based clinics in Madrid and Canary Islands will enrol in an 18-month parallel-design, blinded (intervention assessment and data analysts), pragmatic (adhering to the intention-to-treat principle), individually randomised trial. The trial will compare two 12-month web-based educational offers of identical content; one delivered individually (control) and the other with online social interaction (VCoP, intervention). Using repeated measures mixed linear models, with the patient as random effect and allocation groups and time per group as fixed effects, we will estimate between-arm differences in the change in Patient Activation Measure from baseline to 12 months (primary endpoint), including measurements at 6-month and 18-month follow-up. Other outcomes will include measures of depression and anxiety, treatment burden, quality of life. In addition to a process evaluation of the VCoP, we will conduct an economic evaluation estimating the relative cost-effectiveness of the VCoP from the perspectives of both the National Health System and the Community., Ethics and Dissemination: The trial was approved by Clinical Research Ethics Committees of Gregorio Marañón University Hospital in Madrid/Nuestra Señora Candelaria University Hospital in Santa Cruz de Tenerife. The results will be disseminated through workshops, policy briefs, peer-reviewed publications and local/international conferences., Trial Registration Number: NCT06046326., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Previous studies have documented a high rate of implantation success with the ACURATE neo2 valve, as well as a reduction in paravalvular leak (PVL) compared to its predecessor, the ACURATE neo. However, there are no studies that have reviewed and compared the long-term clinical and hemodynamic outcomes of these patients., Aims: This study aimed to evaluate the results of the ACURATE neo transcatheter aortic valve in a real-world context, and to compare the results of the outcomes of both generations of this device (ACURATE neo and ACURATE neo2), with a specific focus on procedural success, safety, and long-term effectiveness., Methods: A prospective study including all consecutive patients treated with the ACURATE neo device in seven hospitals was conducted (Clinical Trials Identification Number: NCT03846557). The primary endpoint consisted of a composite of adverse events, including mortality, aortic insufficiency, and other procedural complications. As the second-generation device (ACURATE neo2) replaced the ACURATE neo during the study period, hemodynamic and clinical results before admission, at 30 days, and at 1 year of follow-up were compared between the two generations., Results: A total of 296 patients underwent transcatheter aortic valve implantation with the ACURATE device, with 178 patients receiving the ACURATE neo and 118 patients receiving the ACURATE neo2. In the overall population, the absence of device success occurred in 14.5%. The primary reason for the absence of device success was the presence of para-valvular regurgitation ≥ 2. There were no instances of coronary occlusions, valve embolization, annulus rupture, or procedural deaths. ACURATE neo2 was associated with a significantly higher device success rate (91.7% vs. 82%, p = 0.04), primarily due to a significantly lower rate of para-valvular regurgitation, which remained significant at 1 year., Conclusion: The use of ACURATE neo and neo2 transcatheter aortic valves is associated with satisfactory clinical results and an extremely low rate of complications. The ACURATE neo2 enables a significantly higher device success rate, primarily attributed to a significant reduction in the rate of PVL., (© 2024 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Data from the sentinel surveillance system of severe acute respiratory infections in Spain were used to estimate the impact of administration of nirsevimab to children born from 1 April 2023 onwards., Methods: Estimated RSV hospitalisations in < 1-year-olds during weeks 40, 2023, to 8, 2024, were compared to the number that would be expected after accounting for the background change in RSV circulation in the 2023/24 season, compared to 2022/23., Results: We estimated 9364-9875 RSV hospitalisations less than expected, corresponding to a 74%-75% reduction., (© 2024 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Rheumatic and musculoskeletal diseases (RMDs) are chronic diseases that may alternate between asymptomatic periods and flares. These conditions require complex treatments and close monitoring by rheumatologists to mitigate their effects and improve the patient's quality of life. Often, delays in outpatient consultations or the patient's difficulties in keeping appointments make such close follow-up challenging. For this reason, it is very important to have open communication between patients and health professionals. In this context, implementing telemonitoring in the field of rheumatology has great potential, as it can facilitate the close monitoring of patients with RMDs. The use of these tools helps patients self-manage certain aspects of their disease. This could result in fewer visits to emergency departments and consultations, as well as enable better therapeutic compliance and identification of issues that would otherwise go unnoticed., Objective: The main objective of this study is to evaluate the implementation of a hybrid care model called the mixed attention model (MAM) in clinical practice and determine whether its implementation improves clinical outcomes compared to conventional follow-up., Methods: This is a multicenter prospective observational study involving 360 patients with rheumatoid arthritis (RA) and spondylarthritis (SpA) from 5 Spanish hospitals. The patients will be followed up by the MAM protocol, which is a care model that incorporates a digital tool consisting of a mobile app that patients can use at home and professionals can review asynchronously to detect incidents and follow patients' clinical evolution between face-to-face visits. Another group of patients, whose follow-up will be conducted in accordance with a traditional face-to-face care model, will be assessed as the control group. Sociodemographic characteristics, treatments, laboratory parameters, assessment of tender and swollen joints, visual analog scale for pain, and electronic patient-reported outcome (ePRO) reports will be collected for all participants. In the MAM group, these items will be self-assessed via both the mobile app and during face-to-face visits with the rheumatologist, who will do the same for patients included in the traditional care model. The patients will be able to report any incidence related to their disease or treatment through the mobile app., Results: Participant recruitment began in March 2024 and will continue until December 2024. The follow-up period will be extended by 12 months for all patients. Data collection and analysis are scheduled for completion in December 2025., Conclusions: This paper aims to provide a detailed description of the development and implementation of a digital solution, specifically an MAM. The goal is to achieve significant economic and psychosocial impact within our health care system by enhancing control over RMDs., Trial Registration: ClinicalTrials.gov NCT06273306; https://clinicaltrials.gov/ct2/show/NCT06273306., International Registered Report Identifier (irrid): PRR1-10.2196/55829., (©Marta Novella-Navarro, Jose M Iniesta-Chamorro, Diego Benavent, Javier Bachiller-Corral, Enrique Calvo-Aranda, Helena Borrell, Laura Berbel-Arcobé, Victoria Navarro-Compan, Xabier Michelena, Leticia Lojo-Oliveira, Jaime Arroyo-Palomo, Mariana Diaz-Almiron, Verónica García García, Irene Monjo-Henry, Claudia María Gómez González, Enrique J Gomez, Alejandro Balsa, Chamaida Plasencia-Rodríguez. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 22.04.2024.)

Healthcare workers are people who work in health activities, whether or not they have direct contact with citizens. Currently, around 1.3 million people (70% women) work in healthcare activities in Spain. This represents around 10% of the active population, having increased by 33% since 2008, especially the number of women, which has doubled. Healthcare organizations, especially hospitals, are extremely complex workplaces, with precarious working and employment conditions, especially in more hierarchical occupations, exposing healthcare workers to numerous occupational hazards, mainly from ergonomic and psychosocial conditions. These causes frequent musculoskeletal and mental disorders, highlighting burnout, which is estimated at 40% in some services such as intensive care units. This high morbidity is reflected in a high frequency of absences due to illness, around 9% after the pandemic. The pandemic, and its consequences in the last three years, has put extreme pressure on the health system and has clearly shown its deficiencies in relation to working and employment conditions. The hundreds of occupational health professionals, technicians and healthcare workers, who are part of the structures of health organizations, constitute very valuable resources to increase the resilience of the NHS. We recommend the strengthening in resources and institutionally of the occupational health services of health centers and the creation of an Observatory of working, employment and health conditions in the National Health Service, as an instrument for monitoring changes and proposing solutions., (Copyright © 2024 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Competing Interests: We declare no competing interests. This Comment would not have been possible without the contribution of many colleagues in the Andalusian health system. We thank the Hospital Universitario Puerta del Mar team and the Bahía de Cádiz–La Janda team, for their important work in the outbreak investigation and control. We also thank all of the members of the Andalusian Epidemiological Surveillance System who have participated in the outbreak surveillance and all of the health-care professionals who collaborated in the diagnosis and management of patients.

Background: With the emergence of SARS-CoV-2, influenza surveillance systems in Spain were transformed into a new syndromic sentinel surveillance system. The Acute Respiratory Infection Surveillance System (SiVIRA in Spanish) is based on a sentinel network for acute respiratory infection (ARI) surveillance in primary care and a network of sentinel hospitals for severe ARI (SARI) surveillance in hospitals., Methods: Using a test-negative design and data from SARI admissions notified to SiVIRA between January 1 and October 3, 2021, we estimated COVID-19 vaccine effectiveness (VE) against hospitalization, by age group, vaccine type, time since vaccination, and SARS-CoV-2 variant., Results: VE was 89% (95% CI: 83-93) against COVID-19 hospitalization overall in persons aged 20 years and older. VE was higher for mRNA vaccines, and lower for those aged 80 years and older, with a decrease in protection beyond 3 months of completing vaccination, and a further decrease after 5 months. We found no differences between periods with circulation of Alpha or Delta SARS-CoV-2 variants, although variant-specific VE was slightly higher against Alpha., Conclusions: The SiVIRA sentinel hospital surveillance network in Spain was able to describe clinical and epidemiological characteristics of SARI hospitalizations and provide estimates of COVID-19 VE in the population under surveillance. Our estimates add to evidence of high effectiveness of mRNA vaccines against severe COVID-19 and waning of protection with time since vaccination in those aged 80 or older. No substantial differences were observed between SARS-CoV-2 variants (Alpha vs. Delta)., (© 2022 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Purpose: To determine the clinical and economic impact of inhaled corticosteroid (ICS) withdrawal in Spanish patients with COPD receiving triple therapy (TT) with ICS, long-acting β 2 -agonist (LABA), and long-acting muscarinic antagonist (LAMA)., Patients and Methods: This was an observational, retrospective study of BIG-PAC database medical records. Patients aged ≥40 years receiving TT from 2016 to 2018 were followed for 1 year. Two cohorts were identified: patients continuing TT (ICS+LABA+LAMA), and patients receiving TT with ICS withdrawn (LABA+LAMA). Variables included medication, exacerbations (moderate and severe), pneumonia, mortality, health resource use (HRU), and cost per patient/year. Cohorts were compared using propensity score matching (PSM). Multivariate statistical analysis using analysis of covariance and Cox proportional risks was conducted., Results: Of 6541 patients included, 5740 (87.8%) continued TT and 801 (12.2%) had ICS withdrawn. Patients with ICS withdrawal were younger, had lower disease burden, higher ICS doses, and more exacerbations compared with those continuing ICS. PSM matched 795 patients in each cohort. Mean age was 68.5 years (SD: 11.2), 69.9% were male, and mean Charlson index was 2.0. Patients with ICS withdrawal had more total exacerbations in the 12 months following withdrawal compared with patients continuing TT (36.6% vs 31.4%; p=0.030). No significant differences were found for pneumonia (3.3% vs 3.6%; p=0.583) and mortality (9.9% vs 7.5%; p=0.092). Median time to first exacerbation was shorter in patients with ICS withdrawal compared with those continuing ICS (HR: 0.69, 95% CI: 0.57-0.83; p<0.001). Mean health cost per patient/year among patients with ICS withdrawal was higher than those continuing TT (€2993 vs €2130; p<0.001)., Conclusion: ICS withdrawal in patients with COPD receiving TT was associated with increased exacerbations, HRU, and costs compared with continuing TT, with health and economic impacts on patients and the Spanish National Healthcare System, respectively. Pneumonia and mortality rates were similar between groups., Competing Interests: VNG, LAV-A, ASI, RC, SS, and MG-P are employees of GlaxoSmithKline; LAV-A and ASI also hold stocks in GlaxoSmithKline. AS-M and AS-N are employees of Real Life Data. Real Life Data received payments from GlaxoSmithKline to perform the study, but not for manuscript development. CG received fees from GlaxoSmithKline for her involvement in the study, but not for manuscript development. The authors report no other conflicts of interest in this work., (© 2022 Neches García et al.)

We conducted a prospective, multicenter, specific pilot study on uncomplicated urinary tract infections (uUTI). One-hundred non-duplicated uropathogenic Escherichia coli (UPEC) from uUTI occurred in 2020 in women attending 15 primary care centers of a single health region of northern Spain were characterized using a clonal diagnosis approach. Among the high genetic diversity showed by 59 different phylogroup-clonotype combinations, 11 clones accounted for 46% of the isolates: B2-ST73 (CH24-30); B2-ST73 (CH24-103); B2-ST131 (CH40-30); B2-ST141 (CH52-5); B2-ST372 (CH103-9); B2-ST404 (CH14-27); B2-ST404 (CH14-807); B2-ST1193 (CH14-64); D-ST69 (CH35-27); D-ST349 (CH36-54), and F-ST59 (CH32-41). The screening of the UPEC status found that 69% of isolates carried ≥ 3 of chuA, fyuA, vat , and yfcV genes. Multidrug resistance to at least one antibiotic of ≥ 3 antimicrobial categories were exhibited by 30% of the isolates, with the highest rates of resistance against ampicillin/amoxicillin (48%), trimethoprim (35%), norfloxacin (28%), amoxicillin-clavulanic acid (26%), and trimethoprim-sulfamethoxazole (24%). None extended-spectrum beta-lactamase/carbapenemase producer was recovered. According to our results, fosfomycin and nitrofurantoin should be considered as empirical treatment of choice for uUTI by E. coli (resistance rates 4% and 2%, respectively). We uncover the high prevalence of the pandemic fluoroquinolone-resistant ST1193 clone (6%) in uUTI, which represents the first report in Spain in this pathology. The genomic analysis showed similar key traits than those ST1193 clones disseminated worldwide. Through the SNP comparison based on the core genome, the Spanish ST1193 clustered with isolates retrieved from the Enterobase, showing high genomic similarity than the global ST1193 described in the United States, Canada and Australia. IMPORTANCE Analyzing the clonal structure and antimicrobial resistance of E. coli isolates implicated in uncomplicated urinary tract infections, one of the most frequent visits managed in primary health care, is of interest for clinicians to detect changes in the dynamics of emerging uropathogenic clones associated with the spread of fluoroquinolone resistance. It can also provide consensus concerning optimal control and antibiotic prescribing.

In Spain, there is not a national strategy to promote shared decision making (SDM) in clinical practice, and it is still not a requisite for improving the quality of health services, in either the legal norms or professionals' educational curricula. However, several national strategies in specific health areas increasingly include the principles of person centred care (PCC) and SDM into their objectives, promoting patients' empowerment and activation. Furthermore, several institutions continue to develop Patient Decision Aids (PtDAs) and other resources to facilitate patients' involvement in their own care; training programs for professionals; links between PtDAs and clinical practice guidelines; as well as interventional studies assessing the impact of PCC and SDM interventions in clinical practice. Initiatives to involve patients in health research design and health technology assessment are also being developed. We describe an update of the current state of research, policy and implementation of SDM after five years of substantial advances in Spain. Many challenges remain regarding national and regional policies on PCC and SDM, implementation of SDM in real practice and educational curricula, development of quality indicators and evaluation procedures., (Copyright © 2022. Published by Elsevier GmbH.)

Coronavirus disease 2019 (COVID-19) infection in elderly patients is more aggressive and treatments have shown limited efficacy. Our objective is to describe the clinical course and to analyze the prognostic factors associated with a higher risk of mortality of a cohort of patients older than 80 years. In addition, we assess the efficacy of immunosuppressive treatments in this population. We analyzed the data from 163 patients older than 80 years admitted to our institution for COVID-19, during March and April 2020. A Lasso regression model and subsequent multivariate Cox regression were performed to select variables predictive of death. We evaluated the efficacy of immunomodulatory therapy in three cohorts using adjusted survival analysis. The mortality rate was 43%. The mean age was 85.2 years. The disease was considered severe in 76.1% of the cases. Lasso regression and multivariate Cox regression indicated that factors correlated with hospital mortality were: age (hazard ratio [HR] 1.12, 95% confidence interval [CI]: 1.03-1.22), alcohol consumption (HR 3.15, 95% CI: 1.27-7.84), CRP > 10 mg/dL (HR 2.67, 95% CI: 1.36-5.24), and oxygen support with Venturi Mask (HR 6.37, 95% CI: 2.18-18.62) or reservoir (HR 7.87, 95% CI: 3.37-18.38). Previous treatment with antiplatelets was the only protective factor (HR 0.47, 95% CI: 0.23-0.96). In the adjusted treatment efficacy analysis, we found benefit in the combined use of tocilizumab (TCZ) and corticosteroids (CS) (HR 0.09, 95% CI: 0.01-0.74) compared to standard treatment, with no benefit of CS alone (HR 0.95, 95% CI: 0.53-1.71). Hospitalized elderly patients suffer from a severe and often fatal form of COVID-19 disease. In this regard, several parameters might identify high-risk patients upon admission. Combined use of TCZ and CS could improve survival., (© 2021 Wiley Periodicals LLC.)

Ethnopharmacological Relevance: The documentation and protection of traditional knowledge face new challenges in the era of open science. Focusing on medicinal and food uses, we discuss two innovative initiatives in Spain to document, protect and return to the society traditional knowledge., Materials and Methods: The Spanish Inventory of Traditional Knowledge related to Biodiversity has compiled and published information on the traditional use and management of flora, fauna, fungi, geodiversity, and ecosystems. CONECT-e (www.conecte.es) is an online platform where citizens can document knowledge and uses of wild and domesticated species. We describe the extent of these initiatives in terms of participation and accomplishment, and discuss their complementarities and challenges., Results: The initiatives described have fostered the establishment of a common standard for organizing traditional knowledge in databases that facilitate knowledge documentation: 131,066 uses and 152,246 local names have been documented so far. Using open data and copyleft licenses, these initiatives also contribute to the maintenance of traditional knowledge in the commons domain, guaranteeing the free exchange and reproduction of knowledge. However, the extensive focus of these initiatives on data sharing does not necessarily guarantee knowledge holders' data sovereignty., Conclusion: To protect TEK in a context of open science more efforts should be done to operationalize traditional knowledge holders' rights to data sovereignty., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

pUO-STmRV1 is an IncC plasmid discovered in the Spanish clone of the emergent monophasic variant of Salmonella enterica serovar Typhimurium, which has probably contributed to its epidemiological success. The sequence of the entire plasmid determined herein revealed a largely degenerated backbone with accessory DNA incorporated at four different locations. The acquired DNA constitutes more than two-thirds of the pUO-STmRV1 genome and originates from plasmids of different incompatibility groups, including IncF (such as R100 and pSLT, the virulence plasmid specific of S. Typhimurium), IncN and IncI, from the integrative element GIsul2, or from yet unknown sources. In addition to pSLT virulence genes, the plasmid carries genes conferring resistance to widely-used antibiotics and heavy metals, together with a wealth of genetic elements involved in DNA mobility. The latter comprise class 1 integrons, transposons, pseudo-transposons, and insertion sequences, strikingly with 14 copies of IS26, which could have played a crucial role in the assembly of the complex plasmid. Typing of pUO-STmRV1 revealed backbone features characteristically associated with type 1 and type 2 IncC plasmids and could therefore be regarded as a hybrid plasmid. However, a rooted phylogenetic tree based on core genes indicates that it rather belongs to an ancient lineage which diverged at an early stage from the branch leading to most extant IncC plasmids detected so far. pUO-STmRV1 may have evolved at a time when uncontrolled use of antibiotics and biocides favored the accumulation of multiple resistance genes within an IncC backbone. The resulting plasmid thus allowed the Spanish clone to withstand a wide variety of adverse conditions, while simultaneously promoting its own propagation through vertical transmission.

Background: To estimate the prevalence of symptoms and signs related to a COVID-19 case series confirmed by polymerase chain reaction (PCR) for SARS-CoV-2. Risk factors and the associated use of health services will also be analysed., Methods: Observational, descriptive, retrospective case series study. The study was performed at two Primary Care Health Centres located in Madrid, Spain. The subjects studied were all PCR SARS-CoV-2 confirmed cases older than 18 years, diagnosed from the beginning of the community transmission (March 13) until April 15, 2020. We collected sociodemographic, clinical, health service utilization and clinical course variables during the following months. All data was gathered by their own attending physician, and electronic medical records were reviewed individually., Statistical Analysis: A descriptive analysis was carried out and a Poisson regression model was adjusted to study associated factors to Health Services use., Results: Out of the 499 patients studied from two health centres, 55.1% were women and mean age was 58.2 (17.3). 25.1% were healthcare professionals. The most frequent symptoms recorded related to COVID-19 were cough (77.9%; CI 95% 46.5-93.4), fever (77.7%; CI95% 46.5-93.4) and dyspnoea (54.1%, CI95% 46.6-61.4). 60.7% were admitted to hospital. 64.5% first established contact with their primary care provider before going to the hospital, with a mean number of 11.4 Healthcare Providers Encounters with primary care during all the follow-up period. The number of visit-encounters with primary care was associated with being male [IRR 1.072 (1.013, 1.134)], disease severity {from mild respiratory infection [IRR 1.404 (1.095, 1.801)], up to bilateral pneumonia [IRR 1.852 (1.437,2.386)]}, and the need of a work leave [IRR 1.326 (1.244, 1.413]., Conclusion: Symptoms and risk factors in our case series are similar to those in other studies. There was a high number of patients with atypical unilateral or bilateral pneumonia. Care for COVID has required a high use of healthcare resources such as clinical encounters and work leaves.

Background: In recent decades, many self-report instruments have been developed to assess the extent to which patients want to be informed and involved in decisions about their health as part of the concept of person-centred care (PCC). The main objective of this research was to translate, adapt and validate the Patient-Practitioner Orientation Scale (PPOS) using a sample of primary care health-care professionals in Spain., Methods: Baseline analysis of PPOS scores for 321 primary care professionals (general practitioners and nurses) from 63 centres and 3 Spanish regions participating in a randomized controlled trial. We analysed missing values, distributions and descriptive statistics, item-to-scale correlations and internal consistency. Performed were confirmatory factor analysis (CFA) of the 2-factor model (sharing and caring dimensions), scale depuration and principal component analysis (PCA)., Results: Low inter-item correlations were observed, and the CFA 2-factor model only obtained a good fit to the data after excluding 8 items. Internal consistency of the 10-item PPOS was acceptable (0.77), but low for individual subscales (0.70 and 0.55). PCA results suggest a possible 3-factor structure. Participants showed a patient-oriented style (mean = 4.46, SD = 0.73), with higher scores for caring than sharing., Conclusion: Although the 2-factor model obtained empirical support, measurement indicators of the PPOS (caring dimension) could be improved. Spanish primary care health-care professionals overall show a patient-oriented attitude, although less marked in issues such as patients' need for and management of medical information., (© 2020 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Shiga toxin-producing E. coli (STEC) and enterotoxigenic E. coli (ETEC) are the main agents of swine colibacillosis, an infectious disease which implies important economic losses. We characterized here 186 diarrheagenic E. coli from Spanish industrial pig farms (2005-2017) to know which clones were involved in this syndrome, and the rates of antibiotic resistance. The PCR based on pathotype-associated virulence genes determined that 161 of 186 isolates (86.5 %) exhibited the ETEC pathotype, 10 (5.4 %) the STEC pathotype, and 15 (8.1 %) the hybrid ETEC/STEC pathotype. The majority of the isolates showed phylogroup A (85.5 %), clonotype CH11-24 (72 %) and belonged to the clonal complex (CC) 10, including two ETEC clones accounting for around 50 % of the 186 isolates: O157:HNM-A-ST10 (CH11-24), which exhibited mostly the fimbrial antigen F4ac; and O108:HNM-A-ST10 (CH11-24), which exhibited mainly F18. Other associations were O139:H1-E-ST1 (CH2-54) with the STEC pathotype, and both O141:H4-A-CC10 (CH11-24) and O138:HNM-E-ST42 (CH28-41) with ETEC/STEC. We found that 87.1 % of the isolates were multidrug-resistant, including 9% ESBL-producers, with the highest rates to nalidixic acid (82 %), colistin (77 %), ticarcillin (76 %) and ampicillin (76 %). Besides, more than 50 % of isolates showed non-susceptibility to gentamicin, tobramycin, doxycycline, ciprofloxacin, trimethoprim-sufamethoxazole and chloramphenicol. Additionally, 11 out of 17 ESBL-producing isolates were mcr-carriers. Results suggest that O108:HNM-A-ST10 (CH11-24) F18 is an emerging clone taking space left by other classical serogroups. Further follow-up studies on predominant clones in pig colibacillosis are essential for the update of vaccines, as alternative to the use of antibiotics., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Patients with generalised anxiety disorder (GAD) have concerns and needs about their health and the healthcare they receive. Patient decision aids (PtDAs) are tools that assist patients in making health decisions, when there is uncertainty about treatment choice, incorporating their personal preferences and values about the available treatment options. PtDAs can improve shared decision-making and lead to better treatment outcomes. The aim of this study is to evaluate the effectiveness of a web-based PtDA for patients with GAD in primary care (PC)., Methods and Analysis: The general study design is comprised of two stages: (1) development of a web-based PtDA for patients with GAD, derived from an evidence-based Clinical Practice Guideline and (2) assessment of the effectiveness of the PtDA in a randomised controlled trial (RCT) design, in PC centres in Tenerife (Spain). This RCT will be carried out with 124 patients with GAD, comparing the PtDA to a fact sheet with general information on mental health. Patients will review the PtDA in one session accompanied by a researcher. Post-intervention measures will be administered immediately after the intervention and at 3-month follow-up. The primary outcome will be decisional conflict. Secondary outcomes will include knowledge about GAD and its treatment, treatment preference, concordance between treatment preference and choice, and decision quality (knowledge ≥60% and concordant decision)., Ethics and Dissemination: The project received ethics approval from the local committee at Nuestra Señora de la Candelaria (HUNSC) University Hospital in Santa Cruz de Tenerife (code: CHUNSC&#95;2019&#95;58). Informed consent will be obtained from each participant before randomisation. Results from the trial will be submitted for publication in international peer-reviewed scientific journals and will be disseminated through workshops and local and international conferences., Trial Registration Number: NCT04364958., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Describe the characteristics of the therapeutic positioning reports (TPRs) published in Spain in the period 2013-2019., Design and Data Source: Systematic review of all TPRs published in the website of the Spanish Agency of Medicines and Health Products (AEMPS)., Selection of Studies: All TPRs published since May 2013, until March 2019 DATA EXTRACTION: The main variables collected were the therapeutic groups assessed, the number of TPRs, the time of elaboration, the existence of restrictions versus the authorized indications and the information on the efficiency of medicines., Results: During the period under review, 214 TPRs were carried out, with an average production time of 8.8 months, almost three times the objective of 3-month initially set. 57% of the TPRs established restrictions of use with respect to the approved indications. 26% of TPRs referred to the existence of economic data, although none included details on the efficiency. 10% of TPRs were updated., Conclusions: For TPRs to meet their objective of improving the efficiency of the assessment process and the consistency in the decisions on price, reimbursement and financing of medicines by the SNS, the deadlines established for publication must be met, incorporating systematically information on the efficiency of the drugs and including periodic updates with the new information generated., (Copyright © 2020 The Author(s). Publicado por Elsevier España, S.L.U. All rights reserved.)

For the first time, this study evaluates consumer exposure via poultry meat to Enterobacteriaceae with capacity to develop severe extraintestinal infections by either bacterial virulence and/or antibiotic resistance traits. The characterization of 256 isolates and the assessment of five parameters, showed that 96 of 100 poultry meat samples from supermarkets of northwest Spain posed ≥ one potential risk: i) 96% carried Enterobacteriaceae resistant to antimicrobials of categories A (64% to monobactams) or B (95% to cephalosporins 3rd and 4rd- generation, quinolones and/or polymixins) of the new categorization of EMA. ii) More than one extended-spectrum-β-lactamase (ESBL)-producing Enterobacteriaceae species were recovered from 28% of poultry meat. iii) High-risk lineages of E. coli, including multidrug-resistant ST131-H22, were present in 62% of samples. iv) E. coli recovered from 25% of samples conformed the ExPEC status. v) E. coli from 17% of samples satisfied the UPEC status. Of note, the recovery from different samples of two E. coli CC10-A (CH11-54) carrying mcr-1.1-bearing IncX4 plasmids, and four E. coli CC10-A (eae-beta1) of the hybrid pathotype aEPEC/ExPEC. (ESBL)-producing K. pneumoniae were isolated from 27% of samples. In summary, poultry meat microbiota is a source of genetically diverse Enterobacteriaceae, resistant to relevant antimicrobials and potentially pathogenic for consumers., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Virtual Communities of Practice (VCoP) or knowledge-sharing virtual communities offer ubiquitous access to information and exchange possibilities for people in similar situations, which might be especially valuable for the self-management of patients with chronic diseases. In view of the scarce evidence on the clinical and economic impact of these interventions on chronic conditions, we aim to evaluate the effectiveness and cost-effectiveness of a VCoP in the improvement of the activation and other patient empowerment measures in patients with ischaemic heart disease (IHD)., Methods and Analysis: A pragmatic randomised controlled trial will be performed in Catalonia, Madrid and Canary Islands, Spain. Two hundred and fifty patients with a recent diagnosis of IHD attending the participating centres will be selected and randomised to the intervention or control group. The intervention group will be offered participation for 12 months in a VCoP based on a gamified web 2.0 platform where there is interaction with other patients and a multidisciplinary professional team. Intervention and control groups will receive usual care. The primary outcome will be measured with the Patient Activation Measure questionnaire at baseline, 6, 12 and 18 months. Secondary outcomes will include: clinical variables; knowledge (Questionnaire of Cardiovascular Risk Factors), attitudes (Self-efficacy Managing Chronic Disease Scale), adherence to the Mediterranean diet (Mediterranean Diet Questionnaire), level of physical activity (International Physical Activity Questionnaire), depression (Patient Health Questionnaire), anxiety (Hospital Anxiety Scale-A), medication adherence (Adherence to Refill Medication Scale), quality of life (EQ-5D-5L) and health resources use. Data will be collected from self-reported questionnaires and electronic medical records., Ethics and Dissemination: The trial was approved by Clinical Research Ethics Committee of Gregorio Marañón University Hospital in Madrid, Nuestra Señora de Candelaria University Hospital in Santa Cruz de Tenerife and IDIAP Jordi Gol in Barcelona. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local/international conferences., Trial Registration Number: ClinicalTrials.gov Registry (NCT03959631). Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Osteoarthritis (OA) is a health condition sensitive to patient's preferences and values regarding the benefits and risks of the different treatment options. In this sense, patient decision aids (PtDA) can play an important role in helping patients to incorporate their values, needs, and preferences into the decision-making process, thus improving person-centered care. Previous research has focused almost exclusively on knee OA, and therefore, the aim of this study is to develop and evaluate the effectiveness of a PtDA for patients with hip OA., Methods: The general design consists of two phases: (1) design a web-based PtDA for patients with hip OA, following the recommended procedures: systematic review of safety/effectiveness of treatments, and an iterative process of development with the help of an Advisory Committee composed of health professionals and patients, and (2) to evaluate the impact of the PtDA on hip OA patients' decision-making process related with their treatment. For that aim, a multicenter randomized controlled trial will be carried out with 124 patients with hip OA in Tenerife (Spain) comparing intervention or usual care., Discussion: PtDAs have been recommended as a useful and effective resource for improving PCC in many health conditions. The intervention is intended to empower patients by fostering their active participation during the decision-making process about their treatment and by ensuring they make informed decisions congruent with their values and preferences. This study will contribute to the scientific knowledge about effectiveness of PtDAs in hip OA, in order to improve the quality of health care offered to these patients., Trial Registration: ClinicalTrials.gov NCT04241978 . Registered on 24 January 2020.

Background: Dilated cardiomyopathy is associated with increased risk of major cardiovascular events. Late gadolinium enhancement (LGE) cardiac magnetic resonance imaging is a unique tissue-based marker that, in single-center studies, suggests strong prognostic value. We retrospectively studied associations between LGE presence and adverse cardiovascular events in patients with dilated cardiomyopathy in a multicenter setting as part of an emerging global consortium (MINICOR [Multi-Modal International Cardiovascular Outcomes Registry])., Methods: Consecutive patients with dilated cardiomyopathy referred for cardiac magnetic resonance (2000-2017) at 12 institutions in 4 countries were studied. Using multivariable Cox proportional hazard and semiparametric Fine and Gray models, we evaluated the association between LGE and the composite primary end point of all-cause mortality, heart transplantation, or left ventricular assist device implant and a secondary arrhythmic end point of sudden cardiac death or appropriate implantable cardioverter-defibrillator shock., Results: We studied 1672 patients, mean age 56±14 years (29% female), left ventricular ejection fraction 33±11%, and 25% having New York Heart Association class III to IV; 650 patients (39%) had LGE. During 2.3 years (interquartile range, 1.0-4.3) follow-up, 160 patients experienced the primary end point, and 88 experienced the arrhythmic end point. In multivariable analyses, LGE was associated with 1.5-fold (hazard ratio, 1.45 [95% CI, 1.03-2.04]) risk of the primary end point and 1.8-fold (hazard ratio, 1.82 [95% CI, 1.20-3.06]) risk of the arrhythmic end point. Primary end point risk was increased in patients with multiple LGE patterns, although arrhythmic risk was higher among patients receiving primary prevention implantable cardioverter-defibrillator and widening QRS., Conclusions: In this large multinational study of patients with dilated cardiomyopathy, the presence of LGE showed strong prognostic value for identification of high-risk patients. Randomized controlled trials evaluating LGE-based care management strategies are warranted.

The present study was carried out to evaluate the prevalence of sequence type 131 (ST131) among 188 extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) collected in 2015 in Lucus Augusti University hospital (Lugo, Spain) and AP-HP Beaujon hospital (Clichy, France) with regard to other STs and to characterize, the types of ESBL produced, serotypes, virulence factor (VF)-encoding genes and the ST131 clades and subclades. ST131 was detected in 33 (39.1%) and 46 (47.9%) of the isolates in Lucus Augusti and Beaujon, respectively. The 109 remaining isolates displayed 57 other STs, the following STs being displayed by at least three isolates: ST10 (8 isolates), ST23 (3), ST38 (4), ST58 (3), ST88 (5), ST95 (4), ST167 (3), ST354 (5), ST361 (3), ST410 (6), ST648 (4), ST744 (3), and ST1615 (6). ST354, ST410, and ST1615 were significantly ( P < 0.05) more frequent in Lucus Augusti (5.4%, 6.5%, and 6.5%) than in Beaujon (0% for the three STs). The new globally emerging clone ST1193 among extraintestinal clinical ESBL-EC was identified in one isolate from France and one from Spain. CTX-M-15 was the commonest ESBL detected in the two hospitals (44.6% in Lucus Augusti and 50.0% in Beaujon). CTX-M-14 was significantly ( P = 0.0003) more frequent in Lucus Augusti (31.5%) than in Beaujon (10.4%), whereas CTX-M-1 (20.8 vs. 7.6%; P = 0.008) and CTX-M-27 (15.6 vs. 6.5%; P = 0.0389) were more frequent in Beaujon than in Lucus Augusti. The ST131 isolates showed a higher virulence score (mean 13.367) compared with the non-ST131 isolates (mean 7.661) ( P < 0.001). Among the 79 ST131 isolates, most of them (52; 65.8%) belonged to subclade C2 (also known as subclone H 30Rx) followed by those belonging to subclade C1 (cluster C1-M27: 16 isolates, 20.3%; cluster non-C1-M27: 6 isolates, 7.6%) and clade A (4 isolates; 5.1%). The C2 subclade isolates showed a higher VF-encoding gene score (mean 14.250) compared with the C1-M27 cluster isolates (mean 10.875) ( P < 0.001). In conclusion, this study highlights the epidemiological differences between the ESBL-EC isolated from two hospitals of France and Spain obtain in 2015 and reports, for the first time, the presence of clone ST1193 in Spain., (Copyright © 2020 Flament-Simon, García, Duprilot, Mayer, Alonso, García-Meniño, Blanco, Blanco, Nicolas-Chanoine and Blanco.)

The most appropriate physiological signals to develop simplified as well as accurate screening tests for obstructive sleep apnoea (OSA) remain unknown. This study aimed at assessing whether joint analysis of at-home oximetry and airflow recordings by means of machine-learning algorithms leads to a significant diagnostic performance increase compared to single-channel approaches. Consecutive patients showing moderate-to-high clinical suspicion of OSA were involved. The apnoea-hypopnoea index (AHI) from unsupervised polysomnography was the gold standard. Oximetry and airflow from at-home polysomnography were parameterised by means of 38 time, frequency, and non-linear variables. Complementarity between both signals was exhaustively inspected via automated feature selection. Regression support vector machines were used to estimate the AHI from single-channel and dual-channel approaches. A total of 239 patients successfully completed at-home polysomnography. The optimum joint model reached 0.93 (95%CI 0.90-0.95) intra-class correlation coefficient between estimated and actual AHI. Overall performance of the dual-channel approach (kappa: 0.71; 4-class accuracy: 81.3%) significantly outperformed individual oximetry (kappa: 0.61; 4-class accuracy: 75.0%) and airflow (kappa: 0.42; 4-class accuracy: 61.5%). According to our findings, oximetry alone was able to reach notably high accuracy, particularly to confirm severe cases of the disease. Nevertheless, oximetry and airflow showed high complementarity leading to a remarkable performance increase compared to single-channel approaches. Consequently, their joint analysis via machine learning enables accurate abbreviated screening of OSA at home.

Objective: Osteoarthritis of the lower limb (OALL) worsens health-related quality of life (HRQL), but this impact has not been quantified with standardized measures. We intend to evaluate the impact of OALL on HRQL through measures based on individual preferences in comparison to the general population., Methods: A cross-sectional study was designed. A total of 6234 subjects aged 50 years or older without OALL were selected from the Spanish general population (National Health Survey 2011-12). An opportunistic sample of patients aged 50 years or older diagnosed with hip (n = 331) or knee osteoarthritis (n = 393), using the American Rheumatism Association criteria, was recruited from six hospitals and 21 primary care centers in Vizcaya, Madrid and Tenerife between January and December 2015. HRQL was measured with the EQ-5D-5L, and the results were transformed into utility scores. Sociodemographic variables (age, sex, social group, cohabitation), number of chronic diseases, and body mass index were considered. The clinical stage of OALL was collected using the Western Ontario and McMaster Universities Osteoarthritis Index and the Oxford hip score and Oxford knee score. Generalized linear models were constructed using the utility index as the dependent variable., Results: HRQL expressed by OALL patients was significantly worse than this of the general population. After adjustment for sociodemographic and clinical characteristics, the mean utility loss was -0.347 (95% CI: -0.390, -0.303) for osteoarthritis of the hip and -0.295 (95% CI: -0.336, -0.255) for osteoarthritis of the knee. OALL patients who were treated at a hospital had an additional utility loss of -0.112 (95% CI: -0.158, -0.065)., Conclusion: OALL has a great impact on HRQL. People with OALL perceive a utility loss of approximately 0.3 points compared to the general population without osteoarthritis, which is very high in relation to the utility loss reported for other chronic diseases and for arthritis in general., Competing Interests: The authors have declared that no competing interests exist.

Background: Parathyroid failure after total thyroidectomy is the commonest adverse event amongst both children and adults. The phenomenon of late recovery of parathyroid function, especially in young patients with persistent hypoparathyroidism, is not well understood. This study investigated differences in rates of parathyroid recovery in children and adults and factors influencing this., Methods: A joint dual-centre database of patients who underwent a total thyroidectomy between 1998 and 2018 was searched for patients with persistent hypoparathyroidism, defined as dependence on oral calcium and vitamin D supplementation at 6 months. Demographic, surgical, pathological, and biochemical data were collected and analysed. Parathyroid Glands Remaining in Situ (PGRIS) score was calculated., Results: Out of 960 patients who had total thyroidectomy, 94 (9.8%) had persistent hypoparathyroidism at 6 months, 23 (24.5%) children with a median [range] age 10 [0-17], and 71 (75.5%) adults aged 55 [25-82] years, respectively. Both groups were comparable regarding sex, indication, extent of surgery, and PGRIS score. After a median follow-up of 20 months, the parathyroid recovery rate was identical for children and adults (11 [47.8%] vs. 34 [47.9%]; p = 0.92). Sex, extent, and indication for surgery had no effect on recovery (all p > 0.05). PGRIS score = 4 (HR = 0.48) and serum calcium >2.25 mmol/L (HR = 0.24) at 1 month were associated with a decreased risk of persistent hypoparathyroidism on multivariate analysis (p < 0.05)., Conclusion: Almost half of patients recovered from persistent hypoparathyroidism after 6 months; therefore, the term persistent instead of permanent hypoparathyroidism should be used. Recovery rates of parathyroid function in children and adults were similar. Regardless of age, predictive factors for recovery were PGRIS score = 4 and a serum calcium >2.25 mmol/L at 1 month., (© 2021 S. Karger AG, Basel.)

Background: The objective of this study was to obtain utilities by means of EQ-5D-5L for different health states in patients with knee osteoarthritis (KOA) or hip osteoarthritis (HOA) in Spain, and to compare these values with those used in foreign studies with the aim of discussing their transferability for their use in economic evaluations conducted in Spain., Methods: Primary study: Observational prospective study of KOA or HOA patients in Spain. Sociodemographic and clinical characteristics were collected to characterize the sample. Utilities were elicited using the EQ-5D-5L questionnaire. ANOVA and bivariable analyses were conducted to identify differences between health states., Literature Review: Using the bibliographic databases NSH EED and CEA Registry, we conducted searches of model-based cost utilities analyses of technologies in KOA or HOA patients. Health states and utilities were extracted and compared with values obtained from the Spanish sample., Results: Three hundred ninety-seven subjects with KOA and 361 subjects with HOA were included, with average utilities of 0.544 and 0.520, respectively. In both samples, differences were found in utilities according to level of pain, stiffness and physical function (WOMAC) and severity of symptoms (Oxford scales), so that the worst the symptoms, the lower the utilities. The utilities after surgery were higher than before surgery. Due to limitations from our study related to sample size and observational design, it was not possible to estimate utilities for approximately half the health states included in the published models because they were directly related to specific technologies. For almost 100% of health states of the selected studies we obtained very different utilities from those reported in the literature., Conclusions: To our knowledge this is the first article with detailed utilities estimated using the EQ-5D-5L in Spain for KOA and HOA patients. In both populations, utilities are lower for worse health states in terms of level of pain, stiffness and physical function according to WOMAC, and according to the Oxford scales. Most utilities obtained from the Spanish sample are lower than those reported in the international literature. Further studies estimating utilities from local populations are required to avoid the use of foreign sources in economic evaluations.

Introduction: The aim of the present study was to examine the diagnostic accuracy of screening tests in detecting cases requiring psychological intervention among patients referred for thoracic surgery., Methods: Emotional distress was evaluated in 105 patients referred for thoracic surgery by means of a diagnostic psychological interview (criterion variable). The screening ability of the following methods was analyzed: the physician's opinion (Yes/No), Hospital Anxiety and Depression Scale (HADS), single-item interview: «Are you depressed?» (Depression Question, ADEP) (1-5) and the single-item interview: «Are you anxious?» (Anxiety Question, ANXQ) (1-5)., Results: According to the clinical interview, 34% of the patients were clinical cases requiring psychological intervention. The total HADS (cut-off point of 10) showed a sensitivity=0.89, specificity=0.75 and AUC=0.883; the ADEP scale (>1) showed a sensitivity=0.79, specificity=0.74 and AUC=0.795; the ANXQ scale (>1) showed a sensitivity=0.78, specificity=0.41 and AUC=0.690; and the physician's opinion showed a sensitivity=0.47 and specificity=0.86., Conclusions: A high percentage of patients referred for thoracic surgery required psychological intervention. The best instrument to identify those patients requiring psychological care, taking a psychological interview as the criterion variable, was the total HADS score. This test is brief, simple and well accepted by patients; it is easy to implement within a thoracic surgery service and has a good diagnostic accuracy., (Copyright © 2019 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Acute flaccid paralysis (AFP) surveillance is key for global polio eradication. It allows detecting poliovirus (PV) reintroductions from endemic countries. This study describes AFP surveillance in Spain from 1998 to 2015. During this time, 678 AFP cases were reported to the Spanish National Surveillance Network. The mean notification rate was 0.58 AFP cases/100,000 population under 15 years old (range: 0.45/100,000-0.78/100,000). Two periods (P) are described: P1 (1998-2006) with the AFP notification rate ranging from 0.66/100,000 to 0.78/100,000, peaking in 2001 (0.84/100,000); and P2 (2007-2015) when the AFP rate ranged from 0.43/100,000 to 0.57/100,000, with the lowest rate in 2009 (0.31/100,000). No poliomyelitis cases were caused by wild PV infections, although two Sabin-like PVs and one imported vaccine-derived PV-2 were detected. Overall, 23 (3.4%) cases met the hot case definition. Most cases were clinically diagnosed with Guillain-Barré syndrome (76.9%; 504/655). The adequate stool collection rate ranged from 33.3% (7/21) to 72.5% (29/40). The annual proportion of AFP cases with non-polio enterovirus findings varied widely across the study period. AFP surveillance with laboratory testing for non-polio enteroviruses must be maintained and enhanced both to monitor polio eradication and to establish sensitive surveillance for prompt detection of other enteroviruses causing serious symptoms.

To determine the prevalence and diversity of Borrelia burgdorferi sensu lato (s.l.) in an endemic Nature Reserve (Sierra del Sueve) in North-Western Spain, and the risk of human exposure to infected ticks in Asturias, 1013 questing ticks and 70 small mammals were collected between 2012 and 2014. A retrospective descriptive analysis was also carried out on human Lyme borreliosis (LB) cases reported to the local hospital (Cabueñes). Samples were screened for B. burgdorferi s.l. presence by a nested PCR assay, and genospecies were confirmed by sequencing. B. burgdorferi s.l. was detected in 1.4% (12/845) of I. ricinus questing nymphs, 9.1% (2/33) of questing adults, and 12.9% (9/70) of small mammals, as well as in the other tick species. PCR positive samples of 17 questing tick and 6 small mammals were sequenced. Four genospecies were identified: B. afzelii, B. garinii, B. lusitaniae, and B. valaisiana. Phylogenetic analyses based on the flaB gene showed the heterogeneity of B. afzelii in this area. The detection of B. burgdorferi s.l. among questing ticks and small mammals in the study area, as well as the abundance of ticks and of large wild and domestic mammals, indicate a high risk of infection by B. burgdorferi s.l. in the area. Reporting of LB cases to the local hospital support this, and shows the need of thorough monitoring of B. burgdorferi infection in ticks and hosts in the area. More investigations are needed to assess the role of different wildlife species and the risk of transmission to humans., (Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.)

In this study, the incidence and genetic bases of nitrofurantoin resistance were established for clinical isolates of two successful clones of Salmonella enterica serovar Typhimurium, the pandemic "DT 104" and the pUO-StVR2 clone. A total of 61 "DT 104" and 40 pUO-StVR2 isolates recovered from clinical samples during 2008-2014 and assigned to different phage types, were tested for nitrofurantoin susceptibility. As previously shown for older isolates, all newly tested pUO-StVR2 isolates were highly resistant to nitrofurantoin (minimal inhibitory concentration [MIC] of 128 μg/ml), while 42.6%, 24.6%, and 32.8% of the "DT 104" isolates were susceptible, showed intermediate resistance or were highly resistant, with MICs of 8, 64, and 128 μg/ml, respectively. The genetic bases of nitrofurantoin resistance were established by PCR amplification and sequencing of the nfsA and nfsB genes encoding oxygen-insensitive nitroreductases. pUO-StVR2 isolates shared identical alterations in both nfsA (IS1 inserted into the coding region) and nfsB (in frame duplication of two codons). "DT 104" isolates with intermediate or high resistance had a missense mutation affecting the start codon of nfsA, while a single resistant isolate carried an additional frameshift mutation affecting nfsB. Complementation studies, performed with wild-type nfsA and nfsB, cloned independently and together into low and high copy-number vectors, confirmed NfsA and NfsB as responsible for nitrofurantoin toxicity. The same alterations persisted along time in isolates of each clone belonging to different phage types. Accordingly, changes leading to nitrofurantoin resistance have probably occurred before phage type diversification.

Background: Osteoarthritis is the most prevalent joint disease and a common cause of joint pain, functional loss, and disability. Conventional treatments demonstrate only modest clinical benefits without lesion reversal. Autologous mesenchymal stromal cell (MSC) treatments have shown feasibility, safety, and strong indications for clinical efficacy. We performed a randomized, active control trial to assess the feasibility and safety of treating osteoarthritis with allogeneic MSCs, and we obtain information regarding the efficacy of this treatment., Methods: We randomized 30 patients with chronic knee pain unresponsive to conservative treatments and showing radiological evidence of osteoarthritis into 2 groups of 15 patients. The test group was treated with allogeneic bone marrow MSCs by intra-articular injection of 40 × 10(6) cells. The control group received intra-articular hyaluronic acid (60 mg, single dose). Clinical outcomes were followed for 1 year and included evaluations of pain, disability, and quality of life. Articular cartilage quality was assessed by quantitative magnetic resonance imaging T2 mapping., Results: Feasibility and safety were confirmed and indications of clinical efficacy were identified. The MSC-treated patients displayed significant improvement in algofunctional indices versus the active controls treated with hyaluronic acid. Quantification of cartilage quality by T2 relaxation measurements showed a significant decrease in poor cartilage areas, with cartilage quality improvements in MSC-treated patients., Conclusions: Allogeneic MSC therapy may be a valid alternative for the treatment of chronic knee osteoarthritis that is more logistically convenient than autologous MSC treatment. The intervention is simple, does not require surgery, provides pain relief, and significantly improves cartilage quality.

Ethnobotanical Relevance: Previous research suggests that the use of medicinal plants by a given group is mainly driven by biological variables such as the chemical composition or the ecological distribution of plants. However, other studies highlight the importance of cultural aspects such as the curative meaning given to a plant, beliefs, religion or the historical context. Such aspects could play an important role in the use, diffusion or even in the effectiveness of a plant remedy., Materials and Methods: Fieldwork consisted of 233 orally consented semi-structured interviews with 178 informants about medicinal uses of plants. Interviews were conducted in four historically and geographycally delimited regions of Alava and Biscay with similar environmental conditions but different sociolinguistic backgrounds: two regions were Basque- and two Spanish-speaking. Data were structured in use-reports. A Between Class Analysis was conducted to assess the intercultural and intracultural variability of medicinal plants knowledge., Results: The results show the existence of four clearly different medicinal ethnofloras. While the four ethnofloras share remedies widely distributed through the territory, each of them also includes remedies that are only shared among closely related communities. The ecological availability and chemical composition of the plants may explain why there are widely used plant remedies. On the contrary, the distribution of the locally shared remedies matches up with the cultural heterogeneity of the territory, so cultural factors, such as, language, social networks or the meaning response of the plants seem to explain the use of many traditional plant remedies. In Addition, we also found that Basque speaking territories show higher knowledge levels than Spanish speaking territories. In this sense, the development and reinforcement of Basque identity by Basque nationalism seems to have contributed to maintain the traditional knowledge in the Basque speaking regions., Conclusions: Despite the fact that pharmacological effectiveness and ecological availability are usually considered as the main variables that shape the traditional use of medicinal plants, our results suggest that cultural factors can be at least as important as ecological and chemical factors. In fact, differences in language, in the cultural meaning of the plants, in the context related to cultural identities, and in social networks seem to play a fundamental role in the use and diffusion and maintenance or erosion of traditional knowledge about medicinal plants in the study area., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Although severely burned patients are at a high risk of developing intra-abdominal hypertension (IAH: IAP>12 mmHg) and Abdominal Compartment Syndrome (ACS) (IAP ≥ 20 mmHg), few data about its incidence and prevalence is available. Our aim was to determine the incidence and prevalence of IAH and ACS in patients with severe burns in our geographical setting. A pilot prospective, observational study was performed at the Burns Unit of the Plastic Surgery Department in Vall d'Hebron University Hospital (Barcelona), during a 12-month period. All patients with age ≥ 18 years old and burns >20% of the total body surface area (TBSA) were considered for inclusion. Patients who did not require urinary catheterization via the urethra were excluded. All patients included were followed during the first five days from their admission. Results are expressed as median (interquartile range) or frequency (percentage). During the study period, 303 patients were admitted to the Burns Unit. Twenty-five patients were included in the study (21 [84%] male, 4 [16%] female; age 42 [30-69 years]; TBSA burned 33 [25-58]%; all patients presented deep second-degree and/or third-degree burns). Eighteen (72%) patients met criteria for IAH, but only one (4%) developed ACS. The incidence of IAH and ACS was 0.56 and 0.04 cases/patient-day, respectively. Patients with IAH presented higher number of organs failure (2 [0-2.2] vs 0 [0-0]; p = 0.03). Patients with >20% TBSA burned presented a very high prevalence of IAH. Development of organ failure occurred even at moderately increased values of IAP. In this scenario, monitoring of IAP is the first step for establishing the importance of IAH/ACS in this patient population., (Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.)

Background: Phenotypic traits of familial IBD relative to sporadic cases are controversial, probably related to limited statistical power of published evidence., Aim: To know if there are phenotype differences between familial and sporadic IBD, evaluating the prospective Spanish registry (ENEIDA) with 11,983 cases., Methods: 5783 patients (48.3%) had ulcerative colitis (UC) and 6200 (51.7%) Crohn's disease (CD). Cases with one or more 1st, 2nd or 3rd degree relatives affected by UC/CD were defined as familial case., Results: In UC and CD, familial cases compared with sporadic cases had an earlier disease onset (UC: 33 years [IQR 25-44] vs 37 years [IQR 27-49]; p<0.0001); (CD: 27 years [IQR 21-35] vs 29 years [IQR 22-40]; p<0.0001), higher prevalence of extraintestinal immune-related manifestations (EIMs) (UC: 17.2% vs 14%; p=0.04); (CD: 30.1% vs 23.6%; p<0.0001). Familial CD had higher percentage of ileocolic location (42.7% vs 51.8%; p=0.0001), penetrating behavior (21% vs 17.6%; p=0.01) and perianal disease (32% vs 27.1%; p=0.003). Differences are not influenced by degree of consanguinity., Conclusion: When a sufficiently powered cohort is evaluated, familial aggregation in IBD is associated to an earlier disease onset, more EIMs and more severe phenotype in CD. This feature should be taken into account at establishing predictors of disease course., (© 2013.)

Ethnopharmacological Relevance: Many ethnobotanical studies show that people in industrial countries still rely on their traditional knowledge of medicinal plants for self-treatment, although the trend might not be as common as some decades ago. Given the social and public health implications of ethnopharmacological practices, this survey aims at recording and analysing the medicinal plants used in the folk medicine of the Northwest of the Basque Country focusing on how medicinal plants knowledge and practices evolve., Materials and Methods: Fieldwork consisted of 265 orally consented semi-structured interviews with 207 informants about medicinal uses of plants. Interviews were conducted between September 2008 and January 2011. Informants were on average 76 years old (minimum 45, maximum 95), being more than half of them (112) men. Data collected were structured in use-reports (UR). Following informants' comments, medicinal use-reports were classified as abandoned-UR, when the informants reported that the use was only practiced in the past, and prevalent-UR, when the informants reported to continue the practice., Results and Discussion: A total of 2067 UR for 139 species that belong to 58 botanical families were recorded, being the most important families Asteraceae, Liliaceae sensu latu and Urticaceae. Some of the most important species are commonly used in other European areas (e.g., Chamaemelum nobile, Urtica dioica and Chelidonium majus). However, there are also plants commonly used in the area such as Helleborus viridis or Coronopus didymus, that are scarcely used in other areas, and whose record is an original contribution of the local pharmacopeia. It is also the case of remedies such as the use of Plantago leaves against strains in a local remedy called zantiritu. Overall, and for all variables analysed (total UR, medicinal use-categories, drug preparation and administration), the percentage of UR being currently practiced (prevalence ratio) was very low (near 30%) suggesting a strong decay in the use of traditional medicinal plants. Exceptionally, some species (Chamaemelum nobile, Verbena officinalis or Anagallis arvensis) had a high prevalence ratio, reflecting the fact that this erosion process is not evolving homogeneously. Informants also reported that new species and medicinal plant uses were entering into the local pharmacopeia via non-traditional sources such as books, courses, or the internet. These modern ways are now being used to spread some traditional remedies that in the past were only orally transmitted., Conclusions: This study shows that traditional knowledge is continuously changing, evolving and adapting to the new social and environmental conditions. The image of the local folk medicine as a dying reality doomed to disappear should be reviewed. It also shows the need of a culturally sensitive approach by the official health systems to these practices., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: The idea that knowledge flows through social networks is implicit in research on traditional knowledge, but researchers have paid scant attention to the role of social networks in shaping its distribution. We bridge those two bodies of research and investigate a) the structure of network of exchange of plant propagation material (germplasm) and b) the relation between a person's centrality in such network and his/her agroecological knowledge., Methods: We study 10 networks of germplasm exchange (n = 363) in mountain regions of the Iberian Peninsula. Data were collected through participant observation, semi-structured interviews, and a survey., Results: The networks display some structural characteristics (i.e., decentralization, presence of external actors) that could enhance the flow of knowledge and germplasm but also some characteristics that do not favor such flow (i.e., low density and fragmentation). We also find that a measure that captures the number of contacts of an individual in the germplasm exchange network is associated with the person's agroecological knowledge., Conclusion: Our findings highlight the importance of social relations in the construction of traditional knowledge.

Introduction: The aim of this study is to analyse the costs of the treatment of a group of patients with severe injuries. The distribution of the costs between the different departments involved in the management of these patients is also investigated., Material and Method: The data from patients who suffered severe injuries, and recorded in the Traumasur data base, were prospectively gathered to be used in the study. The data from a total of 131 patients treated in the year 2008 were collected. Data obtained from the hospital finance office were also used, providing the overall cost as well as the separate costs of each of the departments involved in the treatment., Results: The injury severity score (ISS) and the new injury severity score (NISS) mean values were 31.8 and 39.4, respectively. The mortality rate was 17.5%. The overall costs of the patients was 3,791,879.3 €, with a mean cost per patient of 28,945 €. The mean percentage of the overall costs of the treatment incurred by the ICU and the ward was 62% and 12.7%, respectively. The cost of the ICU admission increased up to 68.4% in patients with an ISS>40. Although the patients who died had more serious injuries, they had a lower cost in all areas., Conclusion: Patients with multiple injuries represent a significant health cost, with the greater percentage being due to the hospital stay, particularly that in ICU. Other cost areas involve a lower percentage of the cost., (Copyright © 2012 AEC. Published by Elsevier Espana. All rights reserved.)

Background & Aims: To assess the effect of an enteral diet enriched with eicosapentaenoic acid (EPA), gamma-linolenic acid (GLA), and anti-oxidants on the incidence of organ dysfunction and nosocomial infections in septic patients with acute lung injury or acute respiratory distress syndrome (ARDS) compared with a standard enteral diet., Methods: This prospective, randomized, open-label study was performed in 11 Spanish intensive care units (ICU). Adult patients with sepsis and acute lung injury or ARDS were randomly allocated to receive either an EPA-GLA diet or a control diet., Results: Of the 198 patients that were eligible, 160 were randomized and 132 were studied. Patient demographics, APACHE II and SOFA scores, and nutritional variables on admission were similar between the EPA-GLA diet and control diet groups. The EPA-GLA diet group showed a trend toward a decreased SOFA score, but it was not significant. No differences were observed in the PaO(2)/FiO(2) ratio or the days on mechanical ventilation between the groups. Incidence of infections was similar in the groups. The control group stayed longer in the ICU than the EPA-GLA diet group (16 vs. 18; p = 0.02)., Conclusions: A diet enriched with EPA, GLA, and anti-oxidants does not improve gas exchange or decrease the incidence of novel organ failures in critically ill septic patients with acute lung injury or ARDS. Patients treated with the EPA-GLA diet stayed in the ICU for less time, but we did not find any differences in infectious complications., (Copyright © 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Few data are available on the efficacy of methotrexate (MTX) in ulcerative colitis (UC)., Aim: To evaluate the efficacy and safety of MTX in UC patients., Patients and Methods: UC patients who had been treated with MTX were identified from the databases of 8 Spanish IBD referral hospitals. Patients were included in the study if they received MTX for steroid dependency or steroid refractoriness. Therapeutic success was defined as the absence of UC-related symptoms, complete steroid withdrawal and no requirement of rescue therapies within the first 6 months after starting MTX., Results: Forty patients were included, 70% treated for steroid dependency and 27% for steroid refractoriness. Thiopurines had been previously attempted in 87.5% of patients. The median dose of MTX used for induction was 25mg (IIQ 17.5-25) weekly given parenterally in 82.5% of cases. Eighty-five percent of patients were on steroids when MTX was started. Forty-five percent of patients met criteria for therapeutic success. Initial treatment failures were mainly due to inefficacy (50%) or intolerance (36%). After a median follow-up of 28 months (IQR 22-47), 38% of patients with initial therapeutic success required new steroid courses, 22% started biological therapy, and only 1 patient required colectomy. The cumulative probability of maintaining steroid-free clinical remission was 60%, 48%, and 35% at 6, 12, and 24 months after starting MTX, respectively. Eleven patients (27.5%) experienced adverse events, leading to MTX discontinuation in only 8 of them., Conclusions: MTX appears to be effective to maintain clinical remission in UC, at least in the short-term, with an acceptable safety profile., (Copyright © 2011 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.)

In September and October 2010, 13 primary measles cases were identified among unvaccinated persons aged between 9 and 32 years (median: 16.5) in 11 districts in Germany. All cases had attended meetings in Taizé, France. This outbreak illustrates the risk of long distance spread of infectious diseases associated with international mass gatherings, and underlines the importance of closing immunisation gaps against measles by vaccinating non-immune adolescents and young adults.