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Concepción Carratalá-Munuera,1 Ernesto Cortés-Castell,2 Emilio Márquez-Contreras,3 José Maria Castellano,4,5 María Perez-Paramo,6 Adriana López-Pineda,1 Vicente F Gil-Guillen1 1Department of Clinical Medicine, Miguel Hernandez University, San Juan de Alicante, Spain; 2Department of Pharmacology, Pediatrics, and Organic Chemistry, Miguel Hernandez University, San Juan de Alicante, Spain; 3Primary Health Center of Molino de la Vega, Huelva, Spain; 4Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain; 5Centro Integral de Enfermedades Cardiovasculares (CIEC), Hospital Universitario Monteprincipe, Grupo HM Hospitales, Madrid, Spain; 6Medical Department, Pfizer GEP SLU, Madrid, SpainCorrespondence: Adriana López-Pineda, Miguel Hernandez University, Ctra. Nnal. 332 Alicante-Valencia s/n, San Juan de Alicante, 03550, Spain, Tel +1 34 965919309, Email adriannalp@hotmail.comPurpose: To identify the barriers affecting treatment adherence in patients with chronic disease and to determine solutions through the physician’s opinion of primary care and hospital settings.Methods: An observational study using the nominal group technique was performed to reach a consensus from experts. A structured face-to-face group discussion was carried out with physicians with more than 10 years of experience in the subject of treatment adherence/compliance in either the primary care setting or the hospital setting. The experts individually rated a list of questions using the Likert scale and prioritized the top 10 questions to identify barriers and seek solutions afterward. The top 10 questions that obtained the maximum score for both groups of experts were prioritized. During the final discussion group, participating experts analyzed the prioritized items and debated on each problem to reach consensual solutions for improvement.Results: A total of 17 professionals experts participated in the study, nine of them were from a primary care setting. In the expert group from the primary care setting, the proposed solution for the barrier identified as the highest priority was to simplify treatments, measure adherence and review medication. In the expert group from the hospital setting, the proposed solution for the barrier identified as the highest priority was training on motivational clinical interviews for healthcare workers undergraduate and postgraduate education. Finally, the expert participants proposed implementing an improvement plan with eight key ideas.Conclusion: A consensual improvement plan to facilitate the control of therapeutic adherence in patients with chronic disease was developed, taking into account expert physicians’ opinions from primary care and hospital settings about barriers and solutions to address therapeutic adherence in patients with chronic disease.Keywords: treatment adherence and compliance, chronic disease, general practitioners, family practice, hospital medicine, consensus

Introduction: Overuse of medical services is a challenge worldwide, posing a threat to the quality of care, patient safety and the sustainability of healthcare systems. Some data suggest that females receive more low-value practices (LVPs)-defined as medical interventions that provide little or no benefit to patients and can even cause harm-than males. This study aims to evaluate and compare the occurrence of LVPs in primary care among both males and females., Design: A retrospective study was conducted., Setting: Primary care in the Alicante province (Spain) during 2022., Participants: Data were extracted from the digital medical records of 978 936 patients attended by 1125 family physicians across 262 primary healthcare centres in the Alicante province., Outcome Measures: Data on age, sex, diagnosis and treatment were extracted. The primary outcome measure was the frequency of 12 selected LVPs prescribed to male and female patients. These LVPs were expected to be relatively frequent occurrences with the potential to cause harm., Results: A total of 45 955 LVPs were identified, of which 28 148 (5.27% of 534 603, CI95% 5.20-5.32) were prescribed to female patients and 17 807 (4.00% of 444 333, CI95% 3.95-4.06) to male patients (x², p value <0.0001). The most common LVPs were prescribing treatment for overactive bladder without excluding other pathologies that may cause similar symptoms (30.87%), using hypnotics without having a previous aetiological diagnosis in patients with difficulty maintaining sleep (14%) and recommending analgesics (NSAIDs, paracetamol and others) for more than 15 days per month in primary headaches that do not respond to treatment (13.33%)., Conclusions: Future clinical training, management and research must consider biological differences or those based on gender factors when analysing the frequency and causes of LVP., Trial Registration Number: NCT05233852., Competing Interests: Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 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.)

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of vascular diseases (VD) are presented. New in this edition are new sections such as obesity, chronic kidney disease and metabolic hepatic steatosis, as well as a 'Don't Do' section in the different pathologies treated. The sections have been updated: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; vascular risk (VR) and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations., (Copyright © 2024 The Authors. Publicado por Elsevier España S.L.U. All rights reserved.)

Background/Objectives : The aim was to develop a decision tree and a new prognostic tool to predict cancer-specific survival in patients with urothelial bladder cancer treated with radical cystectomy. Methods : A total of 11,834 patients with bladder cancer treated with radical cystectomy between 2004 and 2019 from the SEER database were randomly split into the derivation ( n = 7889) and validation cohorts ( n = 3945). Survival curves were estimated using conditional decision tree analysis. We used Multiple Imputation by Chained Equations for the treatment of missing values and the pec package to compare the predictive performance. We extracted data from our model following CHARMS and assessed the risk of bias and applicability with PROBAST. Results : A total of 4824 (41%) patients died during the follow-up period due to bladder cancer. A decision tree was made and 12 groups were obtained. Patients with a higher AJCC stage and older age have a worse prognosis. The risk groups were summarized into high, intermediate and low risk. The integrated Brier scores between 0 and 191 months for the bootstrap estimates of the prediction error are the lowest for our conditional survival tree (0.189). The model showed a low risk of bias and low concern about applicability. The results must be externally validated. Conclusions : Decision tree analysis is a useful tool with significant discrimination. With this tool, we were able to stratify patients into 12 subgroups and 3 risk groups with a low risk of bias and low concern about applicability.

Background: Cardiovascular diseases are becoming more frequent throughout the world. Adherence to both pharmacological and non-pharmacological treatment, as well as lifestyles, is important for good management and control of the disease. This study aims to explore the opinions and perceptions of patients with ischemic heart disease on the difficulties associated with therapeutic adherence., Methods: An interpretive phenomenological study was carried out using focus groups and one semi-structured interview. The MAXQDA qualitative data analysis program was used for inductive interpretation of the group discourses and interview. Data were coded, and these were grouped by categories and then consolidated under the main themes identified., Results: Two in-person focus groups and one remote semi-structured interview were performed. Twelve participants (6 men and 6 women) from the Hospital de San Juan de Alicante participated, two of them being family companions . The main themes identified were aspects related to the individual, heart disease, drug treatment, and the perception of the health care system., Conclusions: Adhering to recommendations on healthy behaviors and taking prescribed medications for cardiovascular disease was important for most participants. However, they sometimes found polypharmacy difficult to manage, especially when they did not perceive the symptoms of their disease. Participants related the concept of fear to therapeutic adherence, believing that the latter increased with the former. The relationship with health professionals was described as optimal, but, nevertheless, the coordination of the health care system was seen as limited., (© 2024. The Author(s).)

Introduction: Evidence shows that gender has a substantial impact on health behaviours, access to and use of health systems and health system responses. This study aims to assess gender bias in patients subjected to low-value practices in the primary care setting and to develop recommendations for reducing adverse events that women experience for this reason., Methods and Analysis: A Delphi study will be performed to reach a consensus on the 'Do Not Do' recommendations with a possible gender bias. A retrospective cohort study in a random selection of medical records will then be carried out to identify the frequency of adverse events that occur when the selected 'Do Not Do' recommendations are ignored. Qualitative research techniques (consensus conference and nominal group) will be carried out to develop recommendations to address any gender bias detected, considering barriers and facilitators in clinical practice., Ethics and Dissemination: The study was approved by the ethics committee of San Juan de Alicante Hospital (San Juan de Alicante, Spain) Reference N. 21/061. We will disseminate the research findings via peer-reviewed articles, presentations at national and international scientific forums and webinars., Trial Registration Number: The study was registered at ClinicalTrials.gov (NCT05233852) on 10 February 2022., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project's objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors' level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors' opinion. Information and education are essential to improve adherence in all patients.

Bladder cancer (BC) is an important cause of premature mortality (PM, <75 years). Spain has one of the highest BC mortality rates in Europe. The objective of this study was to analyse BC mortality trends between 1999 and 2018 in Spain. The study was based on data from the National Institute of Statistics (Instituto Nacional de Estadística-INE). Age-adjusted mortality rates (AAMRs) were calculated by sex and age group. A trend analysis was performed using Joinpoint regression models and years of potential life lost (YPLL). Mortality in men resulting from BC decreased in all age groups studied. This was not observed in women, for whom mortality only decreased in the ≥75 age group. Deaths due to BC occurred prematurely in 38.6% of men and in 23.8% of women, which indicated a greater impact on YPLL in men compared to women. Over the last 20 years, there has been a significant decrease in BC mortality rate, except in women under 75 years of age. Despite this temporal trend of decreasing mortality, BC continues to have a significant impact on YPLL, mainly in men. Given this context, it is important to direct more resources towards prevention and early diagnosis strategies to correct this situation.

Background: To identify the strengths and weaknesses in a given research area, it is necessary to analyze the published literature. International studies on podiatry research productivity are scarce. This study aimed to analyze scientific productivity in the area of podiatric medicine from 1965 to 2017., Methods: This was a retrospective, observational, bibliometric study. The MEDLINE database was used to identify research published between 1965 and 2017. Literature searches were performed in 2010 and 2017 through RefWorks, and research production per year, author, document type, country, institution, journal, and language were calculated. Podiatry's contribution to global scientific production was measured by calculating the ratio of podiatry publications to total production, and Price's law was applied to analyze the temporal evolution. Author productivity index, coauthorship, geographic distribution, and the distribution by institution type and journal (Bradford's law) were analyzed., Results: The MEDLINE search yielded 1,256 publications, representing 4.75 articles per 100,000 publications in global scientific research. The growth rate followed Price's law after linear adjustment. The 2,229 identified authors presented a transience index of 85.73%; 0.38% were highly productive authors. The coauthorship index increased from 1.40 in 1965 to 5.80 in 2017. The most common document type was the journal article, whereas 2.1% were clinical trials. Only one document reported a controlled clinical trial. The United States led scientific production, with 77.15% of the documents; 60.5% of the publications were concentrated in four journals., Conclusions: Podiatry is still an emerging research field, and literature is concentrated in a small number of journals, categorized into different subjects.

Evidence shows that objectives for detecting and controlling dyslipidemia are not being effectively met, and outcomes differ between men and women. This study aimed to assess gender-related differences in diagnostic inertia around dyslipidemia. This ambispective, epidemiological, cohort registry study included adults who presented to public primary health care centers in a Spanish region from 2008 to 2012, with dyslipidemia and without cardiovascular disease. Diagnostic inertia was defined as the registry of abnormal diagnostic parameters-but no diagnosis-on the person's health record in a window of six months from inclusion. A total of 58,970 patients were included (53.7% women) with a mean age of 58.4 years in women and 57.9 years in men. The 6358 (20.1%) women and 4312 (15.8%) men presenting diagnostic inertia had a similar profile, although in women the magnitude of the association with younger age was larger. Hypertension showed a larger association with diagnostic inertia in women than in men (prevalence ratio 1.81 vs. 1.56). The overall prevalence of diagnostic inertia in dyslipidemia is high, especially in women. Both men and women have a higher risk of cardiovascular morbidity and mortality.

Background: The main barrier for an appropriate primary management of the reproductive health was lack of knowledge about the risk factors and prevention measures for infertility and the main recommendations was to involve primary care physicians in reproductive health., Aims: To reach a consensus around barriers and enablers for appropriate primary management of the reproductive health., Methods: An observational study was performed using the modified Delphi technique, from October 2017 to April 2018 in private and public assisted reproduction clinics in Spain. A questionnaire consisted of 58 items, divided into four blocks to explore consensus among a group of experts by synthesizing opinions., Results: In the first Delphi round, the response rate was 50% and panelists reached a 72.4% of consensus. In second round, the response rate was 55% and panelists reached a 25% of consensus. To minimize limitations related to the use of a structured questionnaire, a space for free text responses was provided. The following items yielded unanimous agreement: "It is necessary to promote reproductive planning-not just contraception-from secondary school," "The media should not trivialize pregnancies in women aged over 50," "Postponing family formation is the main cause of the increase in assisted reproduction treatments in Spain," and "Postponing motherhood implies an inherently decreased probability of having children.", Conclusions: These recommendations could set the basis for a public health action plan for primary management of reproductive health. The findings may be applicable to any country whose health services system provides primary healthcare.

Aims: To identify the obstacles hindering the appropriate management of chronic obstructive pulmonary disease (COPD) in Spain based on consensus amongst clinicians and administrators., Methods: A two-round modified Delphi questionnaire was sent to clinicians (pulmonologists and GPs) and administrators, all experts in COPD. The scientific committee developed the statements and selected the participating experts. Four areas were explored: diagnosis, training, treatment, and clinical management. Panellists' agreement was assessed using a 9-point Likert scale, with scores of 1 to 3 indicating disagreement and 7 to 9, agreement. Consensus was considered to exist when 70% of the participants agreed or disagreed with the statement., Results: Respective response rates for the first and second round were 68% and 91% for clinicians, and 60% and 100% for administrators. The statements attracting the highest degree of consensus were: "Not enough nursing resources (time, staff, duties) are allocated for performing spirometry" (85.3% clinicians; 75% administrators); "Nurses need specific training in COPD" (84.8% clinicians; 100% administrators); "Rehabilitation programs are necessary for treating patients with COPD" (94.1% clinicians; 91.7% administrators); and "Integrated care processes facilitate the deployment of educational programs on COPD" (79.4% clinicians; 83.3% administrators)., Conclusions: This document can inform the development and implementation of specific initiatives addressing the existing obstacles in COPD management., What's Known: COPD is a prevalent and underdiagnosed disease that causes substantial morbidity and mortality. The National COPD Strategy established objectives and work programmes to apply in Spain. There are barriers impeding the application of interventions contemplated in the COPD strategy., What's New: Different agents involved in COPD management agree that the main challenges to improve COPD management are resource shortages in primary care nursing and lack of training in the use of COPD clinical guidelines. Clinicians and administrators involved in COPD management support the implementation of urgent measures to tackle the underdiagnosis of COPD, especially in primary care, along with the routine inclusion of respiratory rehabilitation programmes for COPD., (© 2021 John Wiley & Sons Ltd.)

Evidence shows that objectives for detecting and controlling cardiovascular risk factors are not being effectively met, and moreover, outcomes differ between men and women. This study will assess the gender-related differences in diagnostic inertia around the three most prevalent cardiovascular risk factors: dyslipidemia, arterial hypertension, and diabetes mellitus, and to evaluate the consequences on cardiovascular disease incidence. This is an epidemiological and cohort study. Eligible patients will be adults who presented to public primary health care centers in a Spanish region from 2008 to 2011, with hypertension, dyslipidemia, or/and diabetes and without cardiovascular disease. Participants' electronic health records will be used to collect the study variables in a window of six months from inclusion. Diagnostic inertia of hypertension, dyslipidemia, and/or diabetes is defined as the registry of abnormal diagnostic parameters-but no diagnosis-on the person's health record. The cohort will be followed from the date of inclusion until the end of 2019. Outcomes will be cardiovascular events, defined as hospital admission due to ischemic cardiopathy, stroke, and death from any cause. The results of this study could inform actions to rectify the structure, organization and training of health care teams in order to correct the inequality.

Aims: To validate a translated and culturally adapted version of the Morisky Medication Adherence Scale for use in Spanish population, and to examine the psychometric properties of this scale in patients with type 2 diabetes mellitus in Spain., Design: This cross-sectional study was conducted in a single university hospital in Spain. Patients diagnosed with type 2 diabetes mellitus at least 1 year before inclusion, being treated with anti-diabetic medication were included., Intervention: We used the Spanish version of the scale to measure treatment adherence., Principal Measurements: three level categorical scale is broken down into low adherence (score of <6), medium adherence (score of 6 to <8) and high adherence (score of 8). To validate the questionnaire, we measured internal consistency through Cronbach's α, confirmed construct validity through an exploratory principal component analysis and assessed test-retest reliability., Results: 232 patients met the inclusion criteria. The Cronbach's α coefficient was 0.40 (95% CI 0.28-0.52). The exploratory principal component analysis showed three components. The intraclass correlation coefficient was 0.718 (95% CI 0.564-0.823)., Conclusions: the Spanish version of the Morisky Medication Adherence scale showed low internal consistency, the exploratory factor analysis identified three dimensions, and the test-retest reliability was acceptable, therefore, psychometric properties of MMAS-8 are not suitable for measuring medication adherence in type 2 diabetes mellitus patients from Spain., (Copyright © 2020 The Author(s). Publicado por Elsevier España, S.L.U. All rights reserved.)

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: Epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; Cardiovascular (CV) risk tables and recommendations for the calculation of CV risk; Main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; Indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation. The quality of testing and the strength of the recommendation are included in the main recommendations., (Copyright © 2020 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.)

This study aimed to assess atrial fibrillation (AF) incidence and predictive factors in hypertensive patients and to formulate an AF risk assessment score that can be used to identify the patients most likely to develop AF. This was a cohort study of patients recruited in primary healthcare centers. Patients aged 40 years or older with hypertension, free of AF and with no previous cardiovascular events were included. Patients attended annual visits according to clinical practice until the end of study or onset of AF. The association between AF incidence and explanatory variables (age, sex, body mass index, medical history and other) was analyzed. Finally, 12,206 patients were included (52.6% men, and mean age was 64.9 years); the mean follow-up was 36.7 months, and 394 (3.2%) patients were diagnosed with AF. The incidence of AF was 10.5/1000 person-years. Age (hazard ratio [HR] 1.06 per year; 95% confidence interval [CI] 1.05-1.08), male sex (HR 1.88; 95% CI 1.53-2.31), obesity (HR 2.57; 95% CI 1.70-3.90), and heart failure (HR 2.44; 95% CI 1.45-4.11) were independent predictors (p < 0.001). We propose a risk score based on significant predictors, which enables the identification of people with hypertension who are at the greatest risk of AF.

Background: Hallux valgus (HV) is widely treated by Chevron osteotomy (CO); however, a modified CO may improve patient outcomes and recovery., Methods: A prospective study was designed to analyze plantar pressure measurements and clinical and radiographic outcomes of a modified CO for HV. Recruitment was between February 2016 and February 2017., Inclusion Criteria: diagnosis of moderate HV; an indication for surgical correction due to discomfort, pain or difficulty with shoe wear; and age over 18 years. Clinical and radiographic outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) guidelines and a visual analog scale (VAS)., Results: Forty-four patients met inclusion criteria. After surgery, the highest percentage in mean pressure was in the first and fifth metatarsal heads. At 12 months' follow-up, the AOFAS score improved, but differences in VAS scale were only significant at baseline., Conclusions: Modified CO is a good option for people with HV, improving foot activity compared to preoperative levels while limiting the time needed for recovery., (Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Objectives: Coupled Plasma Filtration and Adsorption (CPFA) use in septic shock remains controversial. The objective is to clarify whether the application of high doses of CPFA in addition to the current clinical practice could reduce hospital mortality in septic shock patients in Intensive Care Units at 28 days and at 90 days follow-up., Design: We designed a prospective randomised clinical trial, Reducción de la Mortalidad Plasma-Adsorción (ROMPA), to demonstrate an absolute mortality reduction of 20% (α=0.05; 1-β=0.8; n=190 (95×2))., Setting: Being aware of the pitfalls associated with previous medical device trials, we developed a training programme to improve CPFA use (especially clotting problems). The protocol was approved by the ethics committees of all participating centres. Circumstances beyond our control produced a change in recruitment conditions unacceptable to ROMPA researchers and the trial was discontinued., Participants: By closure, five centres from an initial 10 fulfilled the necessary trial criteria, with 49 patients included, 30 in the control group (CG) and 19 in the intervention group (IG)., Intervention: CPFA., Main Outcome Measures: Hospital mortality at 28 days and 90 days follow-up., Results: After 28 days, 14 patients died (46.7%) from the CG and 11 (57.9%) from the IG, not reaching statistical significance (p=0.444). At 90 days, 19 patients had died (63.3%) from the CG and 11 patients (57.9%) from the IG, (p=0.878). The adjustment by propensity score or the use of the Kaplan-Meier technique failed to achieve statistical difference, neither by Intention to Treat nor by the Actual Intervention Received., Conclusion: We herewith present the results gained from the prematurely closed trial. The results are inconclusive due to low statistical power but we consider that this data is of interest for the scientific community and potentially necessary for any ensuing debate., Register: NCT02357433 in clinicaltrials.gov., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study aimed to assess the cost-effectiveness of the "Fédération Internationale de Football Association (FIFA) 11" injury prevention programme for ankle and hamstring injuries. This retrospective cohort study included eighty-four male amateur football players aged 18-40 years. The exposed group performed the FIFA 11 protocol twice a week throughout the 2010-2011 and 2011-2012 seasons; the unexposed group performed the usual training during the 2008-2009 and 2009-2010 seasons. Lateral ankle ligament and hamstring injuries were recorded over the whole study period. We compared the mean costs associated with lateral ankle ligament and hamstring injuries in the two groups. The mean cost per player and lateral ankle injury was EUR 928 in the unexposed group versus EUR 647 in the exposed group ( p  = 0.19). The mean cost of hamstring injury per player was EUR 1271 in the unexposed group versus EUR 742 in the exposed group ( p  = 0.028). The mean total cost per player was EUR 2199 in the unexposed group versus EUR 1273 in the exposed group ( p  = 0.008). We concluded that the use of the FIFA 11 injury prevention programme reduced both the direct and indirect costs associated with lateral ankle ligament and hamstring injuries.

Background: Randomised clinical trials are considered to be the most reliable study design for assessing the efficacy and safety of health interventions., Aims: To analyse worldwide obstetrics research carried out through randomised clinical trials, from 2002 to 2013., Methods: A bibliometric analysis was performed. Publications on obstetrics that were published journals indexed in the MEDLINE database from 2002 to 2013 were analysed. The major medical subject headings used in the search were obstetrics, pregnancy complications and obstetrics surgical procedures. The main study outcome was index of research productivity., Results: Our study search strategy yielded a total of 142,659 articles and 9967 clinical trials. The growth rate of scientific production in obstetrics during this period was 55.43% (n = 5094). The growth rate of production of randomised clinical trials in this specialty, meanwhile, was 97.84% (n = 544). Most of the identified authors (n = 22,622, 71.21%) published only one paper during the study period. Patterns of co-authorship among the 20 most productive authors were identified. After applying Bradford's law, six journals in the nucleus (the most prolific journals) were found. Of all the clinical trials in obstetrics published between 2002 and 2013, 10.3% were published in journals belonging to categories other than Obstetrics and Gynecology. The most common research topic in 2002 and 2013 was the use of analgesia and anesthesia in obstetrics., Conclusions: Total scientific production rate in obstetrics increased from 2002 to 2013, especially randomised clinical trials. However, randomised clinical trials continue to represent a small proportion of total production.

Aim: To assess the association between periodontitis and preterm birth in women of childbearing age., Materials and Methods: This review included analytical case-control studies and prospective cohort studies evaluating the association between maternal periodontitis and preterm birth. Of the 3104 screened articles, 31 met the inclusion criteria for the review, and 20 met the quality criteria. The selected studies included a total of 10 215 women., Results: Twenty articles contributed to the meta-analysis; 16 used a case-control design, and 4 were prospective cohort studies. The study heterogeneity was low (Q = 24.2464; P = 0.1869; I 2  = 21.63%). A positive association between maternal periodontitis and preterm birth was found in 60% of the studies. Under the random-effects model, meta-analysis gave an odds ratio (OR) of 2.01 (95% CI 1.71, 2.36), representing a significant positive association between the explanatory and outcome variables., Conclusion: Pregnant mothers with periodontitis double the risk of preterm birth. There is a lack of international consensus for diagnosing maternal periodontitis., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Novice runners are at significantly greater risk of running-related injuries than experienced recreational runners. To develop prevention strategies for this population, it is important to identify predisposing factors that contribute to the incidence of these injuries. This study aims to assess the relationship between running-related injuries, foot posture and other factors in novice runners., Methods: Case-control study in 600 novice runners, classified as cases or controls based on incidence of running-related injuries. Participants' foot posture was measured using the Foot Posture Index, and we performed a descriptive analysis of the explanatory variables, comparing cases and controls. To assess the association between the injury and the presence of exposure and other explanatory variables, we performed a simple logistic regression for each variable and then fit a multivariable regression model., Findings: Our regression model showed that high supination was associated with 76.8 times higher odds of injury than a neutral Foot Posture Index score (P < 0.001). High pronation was associated with 20-fold higher odds of injury than neutral foot posture (P < 0.001). Other variables such as running surface, number of shoes used, and body mass index were also associated with injury. The model showed an acceptable predictive capacity, with an area under the ROC curve of 0.7753., Interpretation: If the association between Foot Posture Index and running-related injury is confirmed in large prospective studies, running programs for beginners should consider foot posture in efforts to prevent running-related injuries., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

[This corrects the article DOI: 10.1371/journal.pone.0186196.].

Objective: To validate electronic prescriptions (e-prescriptions) as a method for measuring treatment adherence in patients with hypertension., Methods: This prospective study initially included 120 patients treated for hypertension in primary care centers. Adherence was measured using the gold standard, the medication event monitoring system (MEMS), versus the index test, the e-prescription program, at baseline and at 6, 12, 18 and 24 months. We calculated the adherence rate using the MEMS and the medication possession ratio (MPR) for the e-prescriptions. We considered patients adherent if they had an adherence rate of 80% to 100%. To validate the e-prescription, we obtained measures of diagnostic accuracy, the Kappa concordance index, and the area under the ROC curve (AUC)., Results: We included 102 patients. Overall adherence was 77.4% by MEMS (95%CI: 66.8-88) and 80.4% (95%CI: 70.3-90.5) by MPR. At 24 months, sensitivity was 87% and specificity, 93.7%. The AUC was 0.903 (95%CI: 0.817-0.989)., Conclusion: Measures of treatment adherence were not significantly different between e-prescription and gold standard at most visits, and the e-prescription showed good discriminatory diagnostic capacity., Practice Implications: If patients are included in an e-prescription program for at least 2 years, e-prescription is an inexpensive method to measure adherence in hypertension., (Copyright © 2018 Elsevier B.V. All rights reserved.)

To provide a better understanding of the actions taken within health systems and their results, this study aims to assess clinicians&rsquo; adherence to clinical practice guidelines regarding recommended treatments in patients with cardiovascular disease in primary care settings, and to determine the associated factors. We conducted an ambispective cohort study in 21 primary care centres in 8 Spanish regions. Patients diagnosed with coronary heart disease, stroke and/or peripheral arterial disease were included. Patients who received the treatment recommended in the European guidelines on cardiovascular disease prevention (CPG&rsquo;s adherent group) were compared with patients who did not (CPG&rsquo;s non-adherent group). The outcome variables were cardiovascular hospital admissions, all-cause and cardiovascular mortality during follow-up. Of the 438 participants, 38.6% ( n = 169) received the drug therapies recommended in the guidelines. The factors that increased the likelihood of good adherence to CPG&rsquo;s were being diagnosed with hypertension ( p = 0.001), dyslipidaemia ( p < 0.001) or diabetes ( p = 0.001), and not having a psychiatric disorder ( p = 0.005). We found no statistically significant association between good adherence to CPG&rsquo;s and lower incidence of events ( p = 0.853). Clinician adherence to guidelines for secondary prevention of cardiovascular disease was low in the primary care setting.

Objective: To analyse the relationship between the implementation of 'the 11' protocol during the regular season in a men's amateur soccer team and the rate of hamstring and lateral ankle ligament (LAL) injuries, and to estimate the clinical benefit of the programme according to the type of injury and the position field., Methods: This cohort study was conducted in two different men's amateur soccer teams. During two seasons, the exposed group (43 players) performed 'the 11' protocol twice a week, and the unexposed group (43 players) performed the regular training programme. All players trained three times per week for 1.5 hours per day. Data collection was performed for every 1000 hours of play., Results: 18 hamstring injuries (injury rate (IR) of 2.26 injuries/1000 training+competition hours) and 15 LAL injuries (IR of 1.88 injuries/1000) were registered in the exposed group. In the unexposed group, there were 25 LAL injuries (IR of 3.14 injuries/1000) and 35 hamstring injuries (IR of 4.39 injuries/1000). The number needed to treat to prevent one new case was 3.9 in LAL injuries, 3.31 in biceps femoris injuries and 10.7 in recurrent hamstring injuries., Conclusions: 'The 11' programme reduced the incidence of hamstring and LAL injuries in amateur players. According to the field position, the programme was effective for defenders and midfielders. In accordance with the type of injury, the exposed group had a lower risk of LAL, biceps femoris and hamstring injuries compared with those in the unexposed group., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The growth of the aging population leads to the increase of chronic diseases, of the burden of multimorbility, and of the complexity polypharmacy. The prevalence of medication errors rises in patients with polypharmacy in primary care, and this is a major concern to healthcare systems. This study reviews the published literature on the inappropriate use of medicines in order to articulate recommendations on how to reduce it in chronic patients, particularly in those who are elderly, polymedicated, or multipathological. A systematic review of articles published from January 2000 to October 2015 was performed using MEDLINE, EMBASE, PsychInfo, Scopus, The Cochrane Library, and Index Medicus databases. We selected 80 studies in order to analyse the content that addressed the question under consideration. Our literature review found that half of patients know what their prescribed treatment is; that most of elderly people take five or more medications a day; that in elderly, polymedicated people, the probability of a medication error occurring is higher; that new tools have been recently developed to reduce errors; that elderly patients can understand written information but the presentation and format is an important factor; and that a high percentage of patients have remaining doubts after their visit. Thus, strategies based on the evidence should be applied in order to reduce medication errors., Competing Interests: The authors declare no conflict of interest.

These data are linked to the research article, entitled Hyperuricemia as a prognostic factor after acute coronary syndrome published in Atherosclerosis. Data from patients admitted for acute coronary syndrome between 2008 and 2013 were collected during the hospitalization, and a follow-up until endpoint or end of study was carried out. Multivariate analysis of variables associated with long term mortality after acute coronary syndrome in patients stratified by the presence of diabetes, hypertension or kidney failure is provided in this article.

Background and Aims: Many studies have reported the independent association between uric acid and cardiovascular disease, its role as a risk predictor for outcomes in people with acute coronary syndrome remains controversial. This study aims to assess the association between hyperuricemia and medium/long-term clinical outcomes in people with acute coronary syndrome and determine whether adding hyperuricemia to the GRACE score improves its predictive capability., Methods: This cohort study included patients admitted for acute coronary syndrome between 2008 and 2013. Outcomes were cardiovascular and total mortality, and major cardiovascular events. We used a multivariate model to adjust for potential confounding covariates and presented event rates with Kaplan-Meier curves. After adding hyperuricemia to the GRACE score, we compared scores from the reclassification table and the net reclassification improvement., Results: 1119 participants were included and followed-up for a mean of 36 months. Multivariate models showed hyperuricemia was independently associated with higher cardiovascular mortality (HR:1.91; 95% CI:1.32-2.76; p < 0.01), higher all-cause mortality (HR:1.59; 95% CI:1.18-2.15; p < 0.01) and higher major cardiovascular event rates (HR:1.36; 95% CI:1.11-1.67; p < 0.01). The hyperuricemia addition to GRACE score led to reclassifying 26% of the participants, and net reclassification improvement was 34%. However, the area under the curve increase was 0.009 and not statistically significant (p > 0.05)., Conclusions: Hyperuricemia is associated with higher medium/long-term mortality and major cardiovascular event rates in patients following acute coronary syndrome. The addition of hyperuricemia to the GRACE score seems to improve risk classification but the discrimination of the new predictive model did not change. Hyperuricemic patients had higher all-cause mortality in medium and high-risk score categories., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: The potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all-cause mortality and hospitalization due to cardiovascular events in a high-risk population., Methods: This prospective registry included high risk adults over 30 years old free of cardiovascular disease (2008-2012). Diagnosis of hypertension, dyslipidemia or diabetes mellitus was inclusion criterion. Lipid biomarkers were evaluated. Primary endpoints were all-cause mortality and hospital admission due to coronary heart disease or stroke. We estimated adjusted rate ratios (aRR), absolute risk differences and population attributable risk associated with adverse lipid profiles., Results: 51,462 subjects were included with a mean age of 62.6 years (47.6% men). During an average follow-up of 3.2 years, 919 deaths, 1666 hospitalizations for coronary heart disease and 1510 hospitalizations for stroke were recorded. The parameters that showed an increased rate for total mortality, coronary heart disease and stroke hospitalization were, respectively, low HDL-Cholesterol: aRR 1.25, 1.29 and 1.23; high Total/HDL-Cholesterol: aRR 1.22, 1.38 and 1.25; and high Triglycerides/HDL-Cholesterol: aRR 1.21, 1.30, 1.09. The parameters that showed highest population attributable risk (%) were, respectively, low HDL-Cholesterol: 7.70, 11.42, 8.40; high Total/HDL-Cholesterol: 6.55, 12.47, 8.73; and high Triglycerides/HDL-Cholesterol: 8.94, 15.09, 6.92., Conclusions: In a population with cardiovascular risk factors, HDL-cholesterol, Total/HDL-cholesterol and triglycerides/HDL-cholesterol ratios were associated with a higher population attributable risk for cardiovascular disease compared to other common biomarkers.

Aims: The aim of this study was to quantify diagnostic inertia (DI) when the physician fails to diagnose hypertension and determine its associated factors., Methods: This cross-sectional, observational study involved all patients without a diagnosis of hypertension who had their blood pressure (BP) measured at least three times during the second half of 2010 (N = 48,605). Patients with altered mean BP figures (≥ 140/90 mmHg) were considered to experience DI. Secondary variables: gender, atrial fibrillation, diabetes mellitus, dyslipidemia, cardiovascular disease, age and the physician having attended a cardiovascular training course (ESCARVAL). Associated factors were assessed by multivariate logistic regression analysis., Results: Diagnostic inertia was present in 6450 patients (13.3%, 95% CI: 13.0-13.6%). Factors significantly associated with DI were: male gender (OR = 1.46, 95% CI: 1.37-1.55, p < 0.001), atrial fibrillation (OR = 0.73, 95% CI: 0.58-0.92, p = 0.007), the ESCARVAL cardiovascular course (OR = 0.88, 95% CI: 0.81-0.96, p = 0.005), diabetes mellitus (OR = 0.93, 95% CI: 0.87-0.99, p = 0.016), cardiovascular disease (OR = 0.77, 95% CI: 0.67-0.88, p < 0.001) and older age (years) (18-44→OR = 1; 45-59→OR = 12.45, 95% CI: 11.11-13.94; 60-74→OR = 18.11, 95% CI: 16.30-20.12; ≥ 75→OR = 20.43, 95% CI: 18.34-22.75; p < 0.001). The multivariate model had an area under the ROC curve of 0.81 (95% CI: 0.80-0.81, p < 0.001)., Conclusions: This study will help clinical researchers differentiate between the two forms of DI (interpretation of a positive screening test and interpretation of positive diagnostic criteria). The results found here in patients with hypertension suggest that this problem is prevalent, and that a set of associated factors can explain the outcome well (AUC>0.80)., (© 2016 John Wiley & Sons Ltd.)

Aim: To determine the population incidence of intracerebral haemorrhage and its preventable incidence, associated risk factors and prognosis of death and disability., Subjects and Methods: We examined a sample of 240 consecutive patients with a first episode of intracerebral haemorrhage between 1st April 2006 and 30th June 2015. The main variables are: NIHSS scale, comorbidity, pharmacological information, Barthel index, Rankin scale, time within therapeutic window, prognosis and destination on hospital discharge. The 'unnecessarily premature and sanitarily avoidable mortality' (MIPSE) classification was applied to define the cases as 'preventable incidence'., Results: The rate of population incidence of haemorrhagic cerebrovascular disease was 23.5 cases per 100,000 inhabitants/year; an exponential increase occurred from the age of 55 years in males and 75 years in females. The rate ratio was 0.682. The preventable incidence would account for 66.6% of all the cases in those under 75 years of age and 22.7% in those aged 75 or over. The chances of survival and functional autonomy were significantly lower in females, and age, anticoagulant treatment, the presence of polymedication and treatment with serotonin reuptake inhibitor antidepressants were factors that were independent of the prognosis., Conclusions: The incidence of haemorrhagic cerebrovascular disease does not appear to be modified within the period, but just the opposite occurs with the factors associated according to sex and age. According to the MIPSE classification, the preventability of haemorrhagic cerebrovascular disease could be as high as 36%.

Objective: To assess the barriers that make it difficult for the health care professionals (physicians, nurses and health care managers) to achieve a better control for dyslipidemia in Spain., Methods: The study has an observational design and was performed using the modified Delphi technique. One hundred and forty-nine panel members from medicine, nursing and health care management fields and from different Spanish regions were selected randomly and were invited to participate. Individual and anonymous opinions were asked by answering a 42-items questionnaire via e-mail (two rounds were done). Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the three groups (Kappa index and McNemar chi-square)., Results: Response rate: 81%. The agreement index was 33.3 (95% CI: 18.9-47.7). Regarding the non-compliance with therapy, it improves with patient education degree in dyslipidemia, patient motivation, the agreement on decisions with the patient and with the use of cardiovascular risk measure and it gets worse with lack of information on the objectives to achieve. Clinical inertia improves with professional's motivation, cardiovascular risk calculation, training on objectives and the use of indicators and it gets worse with lack of treatment goals., Conclusion: Different perceptions and attitudes between medicine, nursing and health care management were found. An agreement in interventions in non-compliance and clinical inertia to improve dyslipidemia control was reached., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: A number of large trials have confirmed the benefits of thrombolysis in acute stroke, but there are gender differences. We sought to examine the relationship between sex and outcome after thrombolysis., Methods: This was a prospective cohort study including 1,272 incident ischemic strokes (597 in women) from April 1, 2006 to December 31, 2014. Statistical approaches were used for analyzing survival outcomes and their relationship with thrombolysis therapy., Results: The death rates were lower (p = 0.003) in the thrombolysis therapy group with an incidence ratio of 0.57 (95% CI 0.39-0.83). 113 (8.8%) patients (53 women) received thrombolysis. They were significantly younger (69.2 ± 12.7 vs. 73.9 ± 12.5 years; p < 0.001), had higher NIHSS score (12.7 ± 6.3 vs. 7.3 ± 7.0; p < 0.001), spent more days in hospital (10.4 ± 8.3 vs. 8.3 ± 7.9; p < 0.001), and had a higher average Barthel score at discharge (85.5 ± 24.4 vs. 79.2 ± 28.6; p = 0.023). The male/female incidence ratio showed a significant decrease (p = 0.01) in the incidence of mortality in women and a better Barthel score. The thrombolysis improved the survival in the overall group with thrombolysis versus without thrombolysis (p = 0.028), in women versus in men with thrombolysis (p = 0.023), and in women with thrombolysis versus in those without thrombolysis (p < 0.001) but not in men with thrombolysis versus in those without thrombolysis (p = 0.743). The protective factors as regards mortality were thrombolysis therapy (95% CI 0.37-0.80; p = 0.002), Barthel score ≥ 60 (95% CI 0.81-0.94; p = 0.002), and cardiovascular secondary prevention 1 year after stroke (0.13, 95% CI 0.06-0.28)., Conclusions: The stroke death rates were lower in women after thrombolysis treatment and suggest significant benefit for women in this setting. The overall benefit on survival of the patients treated with thrombolysis might be explained by the beneficial effect of the thrombolysis on the women.

Background: Older persons following a prolonged complex drug regimen often make mistakes when taking their medication. Currently, the widespread use of tablets and smartphones has encouraged the development of applications to support self-management of medication., Objective: The aim of this study was to design, develop and assess an app that transforms medication-associated ean-13 (barcodes) and Quick Response codes (QR) into verbal instructions, to enable safer use of medication by the elderly patients taking multiple medications., Methods: Meetings were held in which participated a total of 61 patients., Results: The results showed that patients appreciated the application and found it useful for safer use of medicines., Conclusions: The study results support the use of such technology to increase patient safety taking multiple medications safety., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: This study aimed to examine the effectiveness of the use of oral anticoagulation (OAC) medication, recommended by national guidelines for stroke prevention but reportedly underused in AF patients with moderate to high stroke risk., Method: A multicentre and cross-sectional study of undiagnosed AF among out-of-hospital patients over 60 years old was carried out, visiting 3,638 patients at primary health centres or at home for AF diagnosis using the IDC-10 classification. The main outcome measures were CHA₂DS₂VASC, HAS-BLED scores, cardiovascular comorbidity, pharmacological information, TTR, and SAMe-TT2R2 scores., Results: The main findings were undiagnosed AF in 26.44% of cases; 31.04% registered with AF but not using OAC despite 95.6% having a CHA₂DS₂VASC ≥ 2 score; a risk of bleeding in important subgroups using OAC without indication (37.50% CHA₂DS₂VASC < 2 score); the use of OAC with TTR < 60% (33.1%), of whom 47.6% had a HAS-BLED score ≥3. Thus, 35.4% of the expected AF prevalence achieved an optimal time in the therapeutic range., Conclusions: The expected AF prevalence was 10.9% (n 5267), but the registered prevalence was 7.5% (n 3638). Only 35.04% (CI = 95%, 33.7-36.3) of AF patients treated with vitamin K antagonists (VKAs) achieve the goal of TTR > 60%.

Background: The most common factor associated with poor control of hypertension is treatment nonadherence to antihypertensive drug therapy. , Objective: To measure drug nonadherence and associated factors in pharmacologically treated hypertensive patients., Methods: A prospective observational study was carried out from March 2007 to August 2009 at a community pharmacy in Spain. A pharmacist invited a convenience sample of hypertensive patients aged 50 years and older taking antihypertensive medication for at least 3 months prior to participate in the study. Drug nonadherence was analyzed by 3 separate methods: pill count, as the gold standard method, and Haynes-Sackett and Morisky-Green questionnaires. A descriptive analysis of drug nonadherence and variables associated with nonadherence was performed. Logistic regression models were used to determine the variables associated with nonadherence. , Results: Data were recorded from 419 patients. The drug nonadherence ratio varied depending on the method used: 62.8% by pill count, 3.1% by the Haynes-Sackett self-report test, and 36% according to the Morisky-Green test. In the multivariate model, the variable associated with a decrease in drug nonadherence was years of known hypertension (OR = 0.962, 95% CI = 0.937-0.988), and the variables associated with an increase in drug nonadherence were loose-pill combination therapy versus fixed-dose combination therapy or monotherapy (OR = 4.099, 95% CI = 2.494-6.757) and good perception of quality of life (OR = 1.276, 95% CI = 1.109-1.471)., Conclusions: The magnitude of drug nonadherence varies depending on the method of measurement. The pill count method (reference method) revealed that 2 out of 3 patients with hypertension did not have good adherence. This study highlights the lack of antihypertensive drug adherence and the pharmacist's ability to detect the associated factors in order to find the best way to deal with nonadherence.

Background: Delphi technique allows developing a multidisciplinary consensus to establish solutions., Aim: To identify barriers and solutions to improve control in patients with Type-2 Diabetes Mellitus (DM2)., Methods: An observational study using the 2-round Delphi technique (June-August 2011). A panel of 108 experts in DM2 from medical and nursing fields (primary care providers and specialists) from different regions completed via email a questionnaire with 41 Likert statements and 9 scores for each one. Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the two groups (Kappa index and McNemar chi-square)., Results: Response rate: 65%. Degree of agreement: 63.4% (95% CI 48.7-78.1%) in medicine, and 78.1% (95% CI 65.4-90.8) in nursing (p > 0.05). Overall level of agreement: Kappa = 0.43, (χ(2) = 2.5 p > 0.05). Regarding non-compliance with therapy, it improves with: the information to the partner/family/caregiver, patient education degree in diabetes, patient motivation and ability to share and agree on decisions with the patient. Clinical inertia improves with: motivation degree of healthcare professionals and the calculation of cardiovascular risk; and gets worse with: the shortage of time in consultation, absence of data in medical record, border high limits measurements accepted as normal readings, lack of a treatment goals, lack of teamwork (Physician/Nurse), scarcity of resources and lack of alarm systems in the electronic medical record on goals to achieve., Conclusion: The participants achieved an agreement in interventions in non-therapeutic compliance and clinical inertia to improve DM2 control., (© 2013 John Wiley & Sons Ltd.)

Background: To evaluate the effectiveness of a new multifactorial intervention to improve health care for chronic ischemic heart disease patients in primary care. The strategy has two components: a) organizational for the patient/professional relationship and b) training for professionals., Methods/design: Experimental study. Randomized clinical trial. Follow-up period: one year., Study Setting: primary care, multicenter (15 health centers). For the intervention group 15 health centers are selected from those participating in ESCARVAL study. Once the center agreed to participate patients are randomly selected from the total amount of patients with ischemic heart disease registered in the electronic health records. For the control group a random sample of patients with ischemic heart disease is selected from all 72 health centers electronic records., Discussion: This study aims to evaluate the efficacy of a multifactorial intervention strategy involving patients with ischemic heart disease for the improvement of the degree of control of the cardiovascular risk factors and of the quality of life, number of visits, and number of hospitalizations., Trial Registration: NCT01826929.

Objective: To present an international view of the scientific production in the field of primary care in the period 1985-2004., Design: Retrospective, observational study. Bibliometric analysis., Location: Medline database. WebSPIRS access through version 4.3. We analysed two periods: 2000-2004 (cross-sectional) and 1985-2004 (developmental). Search based on "MeSH Major" with descriptors: Primary Care or Primary Health Care, Family Practice, Family Physicians, Nurse Practitioners, and Entry Terms associated with these., Key Measures: We analysed the bibliometric indicators of production, circulation, dispersion, and visibility., Results: In 2000-2004, published 20911 articles were published, 0.73% of total production. There was a growth rate (1985-2004) of 221%, which was 2.4 times more than average. Transience rate was 83.17%. The English language is predominant (88.81%) over 34 languages, with Spanish being the next (2.6%). Sixteen countries produce 95.67% of the articles. Spain occupies the 7th place. Universities (52%) are the most productive institutions. There are 1074 different journals with the 10 most productive being: Br J Gen Pract, Adv Nurse Pract, Aust Fam Physician, Fam Pract, Fam Med, BMJ, Aten Primary Health Serv J, Can Fam Physician, J Fam Pract. The proportion of trials (5.43%) in PC is similar to other disciplines and has increased by 453% (1985-2004)., Conclusions: The production of Primary care is about 1% of the total scientific output, with a noticeable and higher than average growth over 20 years. The proportion of clinical trials is similar to other disciplines. Although Anglo-Saxon countries and journals are the highest producers, Spain and the journal Aten Primaria is among those highlighted., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Aim: To determine the mortality, degree of dependence, survival, and years of life lost (YLL) after first episode of stroke., Design: Cohort study., Location: Community based register., Participants: A total of 553 subjects between 15-90 years with a first episode of definitive or transitory stroke were recruited between 01/04/2006 and 31/03/2008., Measurements: The analyses were performed with the use of time-to-event methods, according to the intention-to-treat principle. The level of dependency was assessed according to the Barthel Scale one year after stroke; YLL (1-70 years) from the mean life expectancies at birth; survival analysis by Kaplan-Meier's curves, bivariate analysis comparing the variables between patients who had survived and those who died, and Cox's multivariate., Results: The mean age was 73.3 (±11.6 years. The mean time of follow-up was 29.7 ± 13,4 months, during which 26.6% of the patients died. The mean Barthel score fell by >20%, particularly among women. There was moderate or greater dependence in 41.5% (95%CI 30.6-52.8%) of the subjects. The overall accumulative probability of survival was 0.96 (95% CI 0.94-0.97) in the first month and 0.69 (95% CI 0.65-0.72) in the fourth year. The thrombolytic treatment showed a protective effect on mortality, particularly among the women. The main predictive variables were, history of recurrent cardiovascular event (RR 6.7, 95% CI 2.2-21.7) and aging (RR 1.08, 95% CI 1.01-1.2). The average YLL was 11.5/10000/year SD7.2, and higher among men., Conclusion: There are differences in functional outcome, mortality, and potential years of life lost by gender. A new cardiovascular event is an independent prognostic factor of survival., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Objectives: To evaluate three different strategies (without or with mydriasis) for community based screening for sight threatening diabetic retinopathy (STDR)., Design: A masked cross-sectional comparative study., Setting: Primary care centre., Participants: 216 type-1 and type-2 diabetic patients (432 eyes)., Interventions: Screening for STDR was performed with the Topcon CRW6S non-mydriatic camera (NMC), compared with the grading of the seven-field standard stereoscopic photographs, 30 degrees field photographs with mydriasis as the gold standard method. Three fields were studied: Field 1 centred on the macula; field 2 centred on the disc and the macula and field 3 centred on the disc, on the macula and temporal upper to the macula all without and with mydriasis., Main Outcome Measures: Sensitivity and specificity of screening method and prevalence of STDR. Strategies: field 1 (macular), addition of field 2 (nasal), addition of field 3 (superior temporal) all without and with mydriasis., Results: The prevalence of STDR was 14.3%. When screening without mydriasis is performed, the percentage of referred patients increases from 14% (STDR) to almost 33% because of ungradable photographs. Sensitivity of detection of STDR by NMC using single field with mydriasis was 82% (95% confidence interval 72-92%) and without mydriasis 67% (54-80%). Specificity was 99% (97-100%) for single field with mydriasis and 99% (98-100%) without mydriasis. Sensitivity of detection using two fields with mydriasis was 95% (89-100%); without mydriasis (54-80%), slightly better than single field with mydriasis (72-92%). Specificity was similar., Conclusions: Screening for STDR with NMC can be performed effectively with one non-stereoscopic retinal photograph per eye with mydriasis using tropicamide 0.5%. Screening without mydriasis increases the number of patients to be referred.