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The objective of this study was to provide evidence-based recommendations for endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) for patients with a nonruptured abdominal aortic aneurysm (AAA). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement and adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Both low- and high surgical risk patients treated with EVAR showed decreased 30-day mortality, but the low-risk group had no differences in 4-year mortality. Compared with friendly anatomy, patients with hostile anatomy had an increased risk of type I endoleak. Young patients may prefer OSR. Endovascular aneurysm repair was not cost-effective in Europe. Four conditional recommendations were formulated: (1) OSR for low-risk patients up to 80 years old, (2) EVAR for low-risk patients older than 80 years, (3) EVAR for high-risk patients as long as is anatomically feasible, and (4) OSR in patients in whom it is not anatomically feasible to perform EVAR. Based on GRADE criteria, either OSR or EVAR can be suggested to patients with nonruptured AAA taking into account their surgical risk, hostile anatomy, and age. Given the weakness of the recommendations, personal preferences are determinant.

Objective The two main surgical treatments for abdominal aortic aneurysm (AAA) are open surgical repair (OSR) and endovascular aneurysm repair (EVAR). The aim of this study was to analyze variation among Spanish hospitals in the use of OSR or EVAR for AAA. A secondary aim was to assess changes in preferences for these two procedures over time. Methods This was a retrospective longitudinal study based on discharge data from public hospitals in Spain during 2002-2012. Patient inclusion criteria were: age >18 years, elective admission, primary diagnosis of unruptured AAA, and surgical treatment with OSR or EVAR. The characteristics of the treating center, patients, and in-hospital mortality were recorded. Results We included 16,737 patients from 114 hospitals; 6,809 (40.7%) underwent EVAR and 9,928 (59.3%) underwent OSR. The total volume of surgeries increased throughout the period, and the probability that any given procedure was EVAR increased by 20% per year (OR 1.20, P

Background: The aim of this study was to analyze the appropriateness of the type of repair (open or endovascular) performed for abdominal aortic aneurysm (AAA) in five university hospitals in Spain, according to evidence-based recommendations. Methods: A multicenter, retrospective cross-sectional study of patients with AAA who underwent elective open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Data were collected on demographic and clinical variables and type of surgical repair. A pair of vascular surgeons from each participating hospital performed a blinded assessment based on GRADE recommendations. The concordance between the two evaluators and the agreement between their evidence-based recommendation and the procedure performed were assessed. Results: A total of 186 patients were selected; 179 were included. Mean age was 72.5 years (standard deviation [SD], 8.4), mean Charlson Comorbidity Index (CCI) was 2.04 (SD, 1.9). OSR was performed in 53.2% (N.=99) and EVAR in 46.8% (N.=87) of cases. Overall, 65.9% (118/179) of interventions performed were considered appropriate: 50% (47/94) of OSRs and 83.5% (71/85) of EVARs. The patient characteristics were similar for all the hospitals, but the chosen surgical technique did show significant differences among these centers. There were no significant differences among the hospitals in the proportion of cases judged as appropriate, either overall (P=0.346) or for each type of procedure (P=0.531 and P=0.538 for OSR and EVAR, respectively). Conclusions: In this study, most of the AAA repairs performed were appropriate according to GRADE recommendations. A higher proportion of EVARs were considered appropriate than OSRs. Choice of AAA repair should be standardized using evidence-based clinical practice guidelines, while incorporating patient preferences, to reduce the existing variability and ensure appropriate selection of AAA repair technique.

BACKGROUND The aim of this study was to assess potential variability in the clinical characteristics and treatment of patients undergoing elective surgery for abdominal aortic aneurysm (AAA) across five hospitals in Spain. METHODS Multicenter, retrospective cohort study of patients diagnosed with AAA and treated with open surgical repair (OSR) or endovascular aneurysm repair (EVAR). We evaluated clinical and demographic variables, including comorbidity (Charlson Comorbidity Index [CCI]); anatomic characteristics; surgical risk (ASA Score); aneurysm characteristics; and in-hospital and overall mortality. All patients were followed for three years. RESULTS A total of 186 patients were included, mean age 72.5 (standard deviation [SD], 8.4), mean CCI 2.04 (SD, 1.9). The surgical technique was EVAR in 46.8% of cases (N.=87) and OSR in 53.2% (N.=99). The in-hospital mortality rate was 2.2%, with no differences between groups. The overall mortality rate during follow-up (mean, 2.9 years) was 24.1% for EVAR versus 8.1% for the OSR group (odds ratio [OR], 3.62; 95% confidence interval [CI], 3.60-3.64; P=0.004). EVAR was the only independent risk factor for mortality (OR, 3.89; 95% CI: 3.87-3.92; P=0.004). Inter-center variability in the type of surgery was high, with EVAR accounting for 19.4% to 75% of the surgical procedures, depending on the treating center (P

SupplementaryData05_Spanish_Group for GRADE-Based Recommendations for Surgical Repair of Nonruptured Abdominal Aortic Aneurysm by Margarita Posso, M. Jesús Quintana, Sergi Bellmunt, Laura Martínez García, José R. Escudero, Andrés Viteri-García, Claudia Valli, Xavier Bonfill and On Behalf of the AAA Spanish Study Group in Angiology

Introduction The need to reduce the use of healthcare practices which provide no value has led to the development of initiatives seeking to improve the appropriateness of clinical and healthcare practice by identifying potentially inappropriate healthcare services, making recommendations, and proposing improvement actions. The online portal DianaHealth (www.dianahealth.com) identifies, gathers, classifies, and publishes clinical recommendations of diverse scientific societies from all over the world for ease of reference. Objectives To identify the awareness, perceived usefulness and clinical applicability of low-value published recommendations on diagnostic interventions considered by Spanish physicians and healthcare managers. Methods We designed a survey asking about the recommendations on diagnostic tests published for each medical specialty on DianaHealth to September 2016. It included some common questions about the knowledge and opinion concerning the most established initiatives as well as questions on specific diagnostic recommendations for each medical speciality (531 in total). Along 2017 we conducted this survey among the clinical leaders of 18 Spanish hospitals and primary care centres, using an electronic platform accessed by the people who accepted the invitation to participate. Results A total of 413 (39%) physicians from 34 different specialties participated, and the answers provided varied between centres (range 21%–100%) and specialties (range 12%–79%). Do Not Do (57%) was the most widely known initiative. Most participants (82%; range 14%–100%) stated that they knew at least one of the 13 initiatives that identify non–recommended practices, with a mean of four initiatives (range 1%–12%). The perceived usefulness was 77% (range 14%–100%), and applicability scored 74% (range 21%–100%). Sixty-one per cent (range 19%–94%) claimed to know the recommendations of their corresponding specialty. A total of 78% (range 36%–98%) agreed with them and 78% (range 37%–100%) considered them useful. We assessed 531 recommendations; 52% (range 12%–82%) were considered totally implemented in clinical practice, and perception —among those who agreed with them— of total and partial compliance was 50% (range 12%–82%) and 41% (range 16%–79%), respectively. Conclusions There is a large variability among Spanish doctors, centres and medical specialities regarding knowledge, perceived usefulness and clinical applicability of initiatives and recommendations aimed to reduce low-value diagnostic interventions. Clinical leaders continue to be little aware of the existence of initiatives addressed to improving clinical appropriateness, despite considering them useful. More dissemination actions, addressed to professionals who should know and apply these recommendations, are required.

Objective DianaHealth.com (www.dianahealth.com) is an on-line database that seeks to improve the appropriateness of care and clinical practice by identifying recommendations of low and high value clinical practices around the world. It was developed in 2013 by the Department of Clinical Epidemiology and Public Health of the Hospital de Sant Pau in Barcelona. The website is open access, independent and regularly updated. It is available in English and Spanish, and has a search engine to retrieve appraisals using one or more search criteria. The aim of this work is to describe the behaviour of DianaHealth visitors during the last 2 years. Methods The information for analysis was gathered through a web-server programme (AWStats 6.9) and included number of visits per day, month and year; unique visits per month and year; annual mean length of the visits (minutes); number of pages and hits (files requested from the server) per visit; device used (desktop or mobile device), and user country. Data were tracked throughout a period of 24 months (2016–2017). The statistical analysis included the medians of the analysed metrics. Data were collected as information aggregates, considering absolute anonymity. Results The total number of recommendations included in DianaHealth.com until May 2018 was 4019. Between 2016 and 2017 there was an increase of 3 times of the total visits and 2 times of the unique visits. In 2016 there were 17 332 total visits and 8703 unique visits; and in 2017 46 490 and 16,980, respectively. The mean length of visit for both periods was similar (2016: 4 mins 50secs; 2017: 4 mins 17secs). The mean pages per visit was 7.09 in 2016 and 3.66 in 2017. The mean hits per visit was 24.02 in 2016 and 11.45 in 2017. In 2016 the 86.6% of them were done from a desktop, 12.7% came from mobile devices and 0.7% from other devices. In 2017 an increase in the use of mobiles was noted (82.7% desktop; 16.8% mobile, and 0.5% others). Both years, most of the hits were from Spain (79,9%); among European countries, most visits came from France (2.5%), and the United Kingdom (0.8%). Conclusions DianaHealth is a helpful and increasingly used tool, fact that is proven by the increase of 3 times of visits in one year, with more than 46 000 visits in 2017. Despite this important growth, more efforts must be made to promote and disseminate this website in order to improve knowledge and easy access of general public, professionals and stakeholders to low value recommendations.

Fundamento La identificacion de grupos de alto riesgo para infeccion genital por el virus del papi-loma humano puede contribuir a la prevencion precoz del carcinoma de cuello uterino. El estudio fue disenado para estimar la prevalencia y factores determinantes de infeccion por el virus del papiloma humano cervical y el riesgo de cancer de cuello uterino en reclusas en regimen preventivo. Pacientes y metodo Se estudiaron 157 mujeres a su ingreso en el Centro Penitenciario de Mujeres de Barcelona. Se les realizaron visita ginecologica, entrevista estructurada, exfoliado cervical y muestra de sangre para la deteccion del virus de la inmunodeficiencia humana (VIH) y virus de la hepatitis B y C. La infeccion por el virus del papiloma humano se determino me-diante reaccion en cadena de la polimerasa. Resultados La prevalencia de ADN del virus del papiloma humano fue del 46%. El 38,2% de las mujeres afirmaron haber practicado la prostitucion y el 64,3% ser usuarias de drogas por via parenteral (UDVP). El 56,1% fueron seropositivas para el VIH. La citologia cervical revelo que 19 mujeres (12,1%) presentaban alteraciones escamosas de significado desconocido y 28 (17,7%), lesiones escamosas intraepiteliales (todos los grados). La infeccion del virus del papiloma humano se asocio a UDVP durante mas de 10 anos (odds ratio de la prevalencia [POR] = 2,9) y a seropositividad por VIH (POR = 4,7). El aumento de riesgo para lesiones escamosas in-traepiteliales asociado a VIH se explica por la presencia de virus del papiloma humano. Las mujeres positivas para el VIH con recuento bajo de CD4 podrian tener mayor riesgo de presentar lesiones escamosas intraepiteliales. Conclusiones Las mujeres con VIH constituyen un grupo de alto riesgo para el virus del papiloma humano y, consecuentemente, para el desarrollo de lesiones preneoplasicas del cervix. Se recomienda un control ginecologico frecuente en las mujeres positivas para el VIH y el virus del papiloma humano.

Lung cancer is currently the most frequent cause of death from cancer worldwide, warranting periodic analysis of the development and results of strategies aimed at reducing the incidence, mortality and morbidity related to this disease in Spain. PREVENTIVE ASPECTS: Mortality reduction among men contrasts with the increase observed in women, reflecting changes in tobacco exposure in the last few decades. Prevention programs aimed specifically at women and youngsters should be developed. In addition, the current law of smoking prevention should be amplified and vigorously applied. ASPECTS RELATED TO EARLY DIAGNOSIS: So far, there is insufficient scientific evidence to initiate a population-based lung cancer screening program. Preferential health care circuits are required to guarantee coordination among centres and levels of care and to substantially reduce current delays in the diagnosis and treatment of patients with lung cancer. TREATMENT-RELATED ASPECTS: Therapeutic decisions in all lung cancer patients should be based on teamwork and scientific evidence. Palliative care deserves the same priority as oncological treatments. Lung cancer patients should participate more fully in therapeutic decisions. Better information systems are required for clinical assessment and research on this disease.

ResumenEl cáncer de pulmón es actualmente la causa más frecuente de muerte por cáncer en el mundo. Por ello, es pertinente analizar periódicamente el desarrollo y los resultados de las estrategias dirigidas a reducir su incidencia, mortalidad y morbilidad en España.Aspectos preventivosLa reducción de la mortalidad por cáncer de pulmón entre los hombres contrasta con el incremento observado entre las mujeres, lo cual plasma los cambios experimentados en la exposición al tabaco durante las últimas décadas. Es necesario desarrollar programas de prevención dirigidos específicamente a las mujeres y a los jóvenes y, asimismo, ampliar y aplicar en toda su extensión la vigente Ley de Prevención del Tabaquismo.Aspectos relacionados con el diagnóstico precozDe momento no hay suficiente evidencia científica para iniciar ningún cribado poblacional del cáncer de pulmón. Son necesarios unos circuitos asistenciales preferentes que aseguren la coordinación entre centros y niveles asistenciales y reduzcan sustancialmente las demoras actuales en el diagnóstico y el tratamiento del cáncer de pulmón.Aspectos relacionados con el tratamientoTodos los pacientes con cáncer de pulmón deberían tratarse sobre la base de decisiones colegiadas y la evidencia científica. La atención paliativa ha de recibir la misma prioridad que los tratamientos oncológicos. Hay que incrementar la participación de los pacientes con cáncer de pulmón en las decisiones terapéuticas que les atañen. Se requieren mejores sistemas de información para la evaluación y la investigación clínica de esta enfermedad.AbstractLung cancer is currently the most frequent cause of death from cancer worldwide, warranting periodic analysis of the development and results of strategies aimed at reducing the incidence, mortality and morbidity related to this disease in Spain.Preventive aspectsMortality reduction among men contrasts with the increase observed in women, reflecting changes in tobacco exposure in the last few decades. Prevention programs aimed specifically at women and youngsters should be developed. In addition, the current law of smoking prevention should be amplified and vigorously applied.Aspects related to early diagnosisSo far, there is insufficient scientific evidence to initiate a population-based lung cancer screening program. Preferential health care circuits are required to guarantee coordination among centres and levels of care and to substantially reduce current delays in the diagnosis and treatment of patients with lung cancer.Treatment-related aspectsTherapeutic decisions in all lung cancer patients should be based on teamwork and scientific evidence. Palliative care deserves the same priority as oncological treatments. Lung cancer patients should participate more fully in therapeutic decisions. Better information systems are required for clinical assessment and research on this disease.