Search

Background: The COVID-19 pandemic may have adversely affected the early diagnosis of skin cancer. Objective: To compare epidemiological, clinical and histopathological characteristics in patients undergoing cutaneous squamous cell carcinoma (SCC) surgery before and after the beginning of the pandemic. Material & methods: We conducted a cross-sectional study including two case series: (1) patients operated on for SCC in the year after the first state of alarm in Spain (15 March 2020), and (2) patients with SCC operated on in the previous year. Epidemiological, clinical and histopathological variables, tumour stage and risk grade were collected. Results: 248 patients were included (127 undergoing surgery before the pandemic and 121 after the pandemic). After the beginning of the pandemic, the percentage of high-risk SCC significantly increased from 35.3% to 46.2% (p = 0.011). However, no significant differences were found in thickness, perineural invasion or metastases. Conclusions: Although there has not been a significant reduction in the number of SCC operated on after the pandemic, there has been a significant increase in high-risk SCC. All this could lead to an increase in skin cancer mortality in the future. Resumen: Antecedentes: La pandemia de COVID-19 ha podido afectar negativamente el diagnóstico precoz del cáncer de piel. Objetivo: Comparar las características epidemiológicas, clínicas e histopatológicas en los pacientes intervenidos de carcinoma de células escamosas (CCE) cutáneo antes de la pandemia y después del inicio de la pandemia. Material y métodos: Se diseñó un estudio transversal que incluía 2 series de pacientes: 1) pacientes intervenidos de CCE el año posterior a la declaración del confinamiento general en España (15 de marzo de 2020), y 2) pacientes intervenidos de CCE el año previo. Se recogieron variables epidemiológicas, clínicas e histopatológicas, así como el estadio tumoral y el grado de riesgo. Resultados: Se incluyeron 248 pacientes (127 intervenidos antes de la pandemia y 121 intervenidos después de la pandemia). Tras el inicio de la pandemia, el porcentaje de CCE de alto riesgo aumentó significativamente de 32,3 a 45,5% (p = 0,011). No obstante, no se encontraron diferencias significativas en el grosor tumoral, la invasión perineural o la presencia de metástasis. Conclusiones: Aunque no se produjo una reducción significativa en el número de CCE intervenidos después de la pandemia, ha habido un incremento significativo en los CCE de alto riesgo. Todo ello puede conllevar un incremento en la mortalidad por cáncer de piel en el futuro.

Resumen: Antecedentes: La pandemia de COVID-19 ha podido afectar negativamente el diagnóstico precoz del cáncer de piel. Objetivo: Comparar las características epidemiológicas, clínicas e histopatológicas en los pacientes intervenidos de carcinoma de células escamosas (CCE) cutáneo antes de la pandemia y después del inicio de la pandemia. Material y métodos: Se diseñó un estudio transversal que incluía 2 series de pacientes: 1) pacientes intervenidos de CCE el año posterior a la declaración del confinamiento general en España (15 de marzo de 2020), y 2) pacientes intervenidos de CCE el año previo. Se recogieron variables epidemiológicas, clínicas e histopatológicas, así como el estadio tumoral y el grado de riesgo. Resultados: Se incluyeron 248 pacientes (127 intervenidos antes de la pandemia y 121 intervenidos después de la pandemia). Tras el inicio de la pandemia, el porcentaje de CCE de alto riesgo aumentó significativamente de 32,3 a 45,5% (p = 0,011). No obstante, no se encontraron diferencias significativas en el grosor tumoral, la invasión perineural o la presencia de metástasis. Conclusiones: Aunque no se produjo una reducción significativa en el número de CCE intervenidos después de la pandemia, ha habido un incremento significativo en los CCE de alto riesgo. Todo ello puede conllevar un incremento en la mortalidad por cáncer de piel en el futuro. Abstract: Background: The COVID-19 pandemic may have adversely affected the early diagnosis of skin cancer. Objective: To compare epidemiological, clinical and histopathological characteristics in patients undergoing cutaneous squamous cell carcinoma (SCC) surgery before and after the beginning of the pandemic. Material & methods: We conducted a cross-sectional study including two case series: (1) patients operated on for SCC in the year after the first state of alarm in Spain (15 March 2020), and (2) patients with SCC operated on in the previous year. Epidemiological, clinical and histopathological variables, tumour stage and risk grade were collected. Results: 248 patients were included (127 undergoing surgery before the pandemic and 121 after the pandemic). After the beginning of the pandemic, the percentage of high-risk SCC significantly increased from 35.3% to 46.2% (p = 0.011). However, no significant differences were found in thickness, perineural invasion or metastases. Conclusions: Although there has not been a significant reduction in the number of SCC operated on after the pandemic, there has been a significant increase in high-risk SCC. All this could lead to an increase in skin cancer mortality in the future.

Aim: The aim of the study is to quantify the main ways in which the sex of the driver/occupant of a passenger car affects the severity of road crashes., Methods: All 171 230 cars occupied by the driver and one or more passengers included in the Spanish Register of Victims of Road Crashes from 2014 to 2020 were included. We designed two cohort studies: In the first one, we estimated the Incidence Rate Ratios (IRR) between the sex of the drivers and the occurrence of any death and/or severe injuries among their passengers. In the second one we estimated the conditioned IRR between the sex of the occupants of the same car and their risk of death and/or severe injuries. We used fixed Poisson models to obtain IRR estimates, crude and adjusted by individual- environment- and vehicle-related variables., Results: A consistent inverse relationship between driver's female sex and passenger's severity was found, (IRR 0.72, 95 % CI 0.68-0.77), stronger for single crashes (IRR 0.67, 95 % CI 0.60-0.65). The magnitude decreased after adjusting for vehicle- and environment-related variables (IRR 0.82, 95 % CI 0.73-0.92). In the second study, the risk of death or hospitalization was higher for occupants of female sex (IRR 1.23, 95 % CI 1.17-1.30)., Conclusions: The risk of death or severe injuries among passengers of cars involved in single crashes is lower for female drivers, probably due to safer driving. On the contrary, in similar crashes, the risk of injuries leading to hospitalization is higher for females., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: The COVID-19 pandemic may have adversely affected the early diagnosis of skin cancer., Objective: To compare epidemiological, clinical and histopathological characteristics in patients undergoing cutaneous squamous cell carcinoma (SCC) surgery before and after the beginning of the pandemic., Material & Methods: We conducted a cross-sectional study including two case series: (1) patients operated on for SCC in the year after the first state of alarm in Spain (15 March 2020), and (2) patients with SCC operated on in the previous year. Epidemiological, clinical and histopathological variables, tumour stage and risk grade were collected., Results: 248 patients were included (127 undergoing surgery before the pandemic and 121 after the pandemic). After the beginning of the pandemic, the percentage of high-risk SCC significantly increased from 35.3% to 46.2% (p=0.011). However, no significant differences were found in thickness, perineural invasion or metastases., Conclusions: Although there has not been a significant reduction in the number of SCC operated on after the pandemic, there has been a significant increase in high-risk SCC. All this could lead to an increase in skin cancer mortality in the future., (Copyright © 2023 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Our aim was to evaluate Spanish family doctors' knowledge about medications that increase the risk of traffic accidents involving older drivers, and to obtain data about the involvement of family doctors in accident prevention activities and the associations between these factors and their demographic and workplace characteristics., Methods: A cross-sectional study of 1888 family doctors throughout Spain was carried out from 2016 to 2018. Participants completed a previously validated self-administered questionnaire that explored whether family doctors distinguished between medications associated with a high or low risk of involvement in a traffic accident, investigated the appropriateness of advice given to older patients, and physicians' involvement in preventive activities. Multiple regression models were used to estimate the adjusted association of these variables with each other and with characteristics of family doctors in the sample., Results: On a scale of 1 (never or hardly ever) to 4 (always), the indexes constructed to evaluate how often family doctors believed they should oversee the use of high-risk and low-risk medications yielded values of 3.38 for the former and 2.61 for the latter (p < 0.001). Only 24% responded correctly to all three items that inquired about the appropriateness of the advice they gave to older patients. On a scale of 1 to 4, the frequency at which family doctors gave older patients advice about preventive measures was 2.85, and only 43% reported allocating time during appointments to provide this advice. These latter two variables were directly associated with appropriate values for the index used to evaluate physicians' oversight of medications associated with a high risk. The perception of risk associated with medications and involvement in preventive activities were both greater among female participants., Conclusions: Family doctors correctly identified medications according to their risk of playing a role in traffic accidents, although the recommendations they gave to their patients were not always appropriate. These findings, along with physicians' infrequent involvement in preventive activities, suggest a need to improve family doctors' competencies and increase the resources available to them so that they can provide their older patients with advice on ways to prevent involvement in traffic accidents., (© 2023. BioMed Central Ltd., part of Springer Nature.)

BackgroundMultidrug-resistant (MDR) bacteria are among chief causes of healthcare-associated infections (HAIs). In Spain, studies addressing multidrug resistance based on epidemiological surveillance systems are lacking.AimIn this observational study, cases of HAIs by MDR bacteria notified to the epidemiological surveillance system of Andalusia, Spain, between 2014-2021, were investigated. Notified cases and their spatiotemporal distribution were described, with a focus on social determinants of health (SDoH).MethodsNew cases during the study period of HAIs caused by extended-spectrum β-lactamase (ESBL)-/carbapenemase-producing Enterobacterales, MDR Acinectobacter baumannii , MDR Pseudomonas aeruginosa or meticillin resistant Staphylococcus aureus were considered. Among others, notification variables included sex and age, while socio-economic variables comprised several SDoH. Cases' spatial distribution across municipalities was assessed. The smooth standardised incidence ratio (sSIR) was obtained using a Bayesian spatial model. Association between municipalities' sSIR level and SDoH was evaluated by bivariate analysis.ResultsIn total, 6,389 cases with a median age of 68 years were notified; 61.4% were men (n = 3,921). The most frequent MDR bacteria were ESBL-producing Enterobacterales (2,812/6,389; 44.0%); the main agent was Klebsiella spp. (2,956/6,389; 46.3%). Between 2014 and 2021 case numbers appeared to increase. Overall, up to 15-fold differences in sSIR between municipalities were observed. In bivariate analysis, there appeared to be an association between municipalities' sSIR level and deprivation (p = 0.003).ConclusionThis study indicates that social factors should be considered when investigating HAIs by MDR bacteria. The case incidence heterogeneity between Andalusian municipalities might be explained by SDoH, but also possibly by under-notification. Automatising reporting may address the latter.

The World Health Organization estimates that one fifth of university students have experienced major depressive disorder at some point in their lives. Nutrition may be one of the modifiable factors that influence the development of depression. Specifically, low omega-3 fatty acid and vitamin D levels, both nutrients found in high quantities in fish, have been linked to depressive disorders. The main objective of this study was to evaluate the prevalence of depression among young Spanish university students, in addition to the pattern of fish consumption among students and the possible relationship between fish consumption and the presence of depression. Data were collected retrospectively from a nationally representative sample of 11,485 Spanish university students aged 18 years or older in 11 Spanish universities, from 2012 to 2022. The respondents were analyzed according to frequency of consumption and compliance with weekly recommendations for fish intake and the presence of depression. Regression models were also performed to determine students' odds of depression as a function of compliance with recommendations according to selected sociodemographic variables. The prevalence of depression was 10.5%; it was more prevalent in women, older students and in those with both high and low BMIs. In addition, it was also more prevalent in those that lived outside the family home, with roommates and those who were employed. Sixty-seven percent of the students met the fish intake recommendations. The most common frequency of fish consumption was 1-2 times/week (44.2%), and the least frequent was 2.3% daily fish consumption. Students from northern universities were more likely to consume fish (68.4%) than those from southern universities (66.4%). Non-consumption of fish was found to increase the risk of depression (ORa = 1.45 (1.28-1.64); AF = 31.0% (21.9-39.0)), but it was the student's own conditions that had the greatest influence on the development of the disorder. In summary, a lower consumption of fish seems to be associated with a higher incidence of depression in Spanish university students; however, other social factors of the student may influence the development of the disorder, and all of this should be taken into account for the development of prevention strategies.

Background: In cancer care, the promotion and implementation of shared decision-making in clinical practice guidelines (CPG) and consensus statements may have potential differences by gender., Objective: To systematically analyse recommendations concerning shared decision-making in CPGs and consensus statements for the most frequent cancers exclusively among males (prostate) and females (endometrial)., Search Strategy: We prospectively registered the protocol at PROSPERO (ID: RD42021241127). MEDLINE, EMBASE, Web of Science, Scopus and online sources (8 guideline databases and 65 professional society websites) were searched independently by two reviewers, without language restrictions., Inclusion Criteria: CPGs and consensus statements about the diagnosis or treatment of prostate and endometrial cancers were included from January 2015 to August 2021., Data Extraction and Synthesis: Quality assessment deployed a previously developed 31-item tool and differences between the two cancers analysed., Main Results: A total of 176 documents met inclusion criteria, 97 for prostate cancer (84 CPGs and 13 consensus statements) and 79 for endometrial cancer (67 CPGs and 12 consensus statements). Shared decision-making was recommended more often in prostate cancer guidelines compared to endometrial cancer (46/97 vs. 13/79, 47.4% vs. 16.5%; p < .001). Compared to prostate cancer guidelines (mean 2.14 items, standard deviation 3.45), compliance with the shared-decision-making 31-item tool was lower for endometrial cancer guidelines (mean 0.48 items, standard deviation 1.29) (p < .001). Regarding advice on the implementation of shared decision-making, it was only reported in 3 (3.8%) endometrial cancer guidelines and in 16 (16.5%) prostate cancer guidelines (p < .001)., Discussion and Conclusions: We observed a significant gender bias as shared decision-making was systematically more often recommended in the prostate compared to endometrial cancer guidelines. These findings should encourage new CPGs and consensus statements to consider shared decision-making for improving cancer care regardless of the gender affected., Patient or Public Contribution: The findings may inform future recommendations for professional associations and governments to update and develop high-quality clinical guidelines to consider patients' preferences and shared decision-making in cancer care., (© 2023 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Purpose: The activities related to the prevention of crash injuries in older adults (PCIOA) performed by Family Physicians (FPs) have been scarcely studied. Our aim was to estimate the frequency of PCIOA activities performed by FPs in Spain and its association with attitudes and beliefs regarding this health problem., Methods: We conducted a cross-sectional study in a nationwide sample of 1888 FPs working in Primary Health Care Services, recruited from October 2016 to October 2018. Participants completed a validated, self-administered questionnaire. Study variables included three scores related to current practices (General Practices, General Advice and Health Advice), several scores related to attitudes (General, Drawbacks and Legal), demographic and workplace characteristics. To obtain the adjusted coefficients and their 95% confidence intervals, we applied mixed effects multi-level linear regression models and the likelihood-ratio test to compare multi-level and one-level models., Results: The frequency of PCIOA activities reported by FPs in Spain was low. The General Practices Score was 0.22/1, the General Advice Score was 1.82/4, the Health Advice Score was 2.61/4, and the General Attitudes Score was 3.08/4. The importance given to road crashes in the elderly obtained 7.16/10, the role that FPs should play in the PCIOA obtained 6.73/10, and the current perceived role obtained 3.95/10. The General Attitudes Score and the importance that FPs give themselves in the PCIOA were associated with the three Current Practices Scores., Conclusion: The frequency of activities related to the PCIOA that FPs usually carry out in Spain is far below desirable standards. The average level of attitudes and beliefs about the PCIOA of the FPs working in Spain seems adequate. The variables of the most pronounced FPs associated with the prevention of traffic accidents in older drivers were age over 50 years, female sex and foreign nationality., Competing Interests: The authors report no conflicts of interest in this work., (© 2023 Jiménez-Mejías et al.)

Background: The association of obesity with biochemical recurrence (BCR) after treatment of clinically localised prostate cancer (PC) shows inconsistent results. Our aim was to systematically review all evidence evaluating obesity as a prognostic factor for BCR., Methods: We searched PubMed, Web of Science and Scopus, from inception to June 1, 2021. Cohort studies reporting BCR among PC patients stratified by body mass index (BMI) were included. To assess the quality of the selected studies, we used the Newcastle-Ottawa scale (NOS). Risk of BCR among obese patients (BMI ≥ 30 kg/m 2 ) was compared with normal weight (BMI < 25), pooling individual hazard ratios (HR) in random-effect meta-analysis. Associations for continuous BMI per 5 kg/m 2 were also calculated. Subgroup analyses were conducted to assess reasons for heterogeneity and causal criteria were formally evaluated., Results: We identified 46 cohort studies including 86,490 PC patients. A total of 14,719 (17.1%) patients developed BCR. There was no consistent definition of BCR. Obesity was associated with BCR (HR: 1.25, 95% CI: 1.11-1.39, I 2 : 70.3%), and there was a 10% increase (95% CI: 4-15%, I 2 : 66.3%) in BCR per 5 kg/m 2 increase in BMI. The heterogeneity was high but decreased in the subgroup of highest-quality NOS score and when the BMI was measured by the researchers (I 2 : 0.0%). The association was consistent in patients receiving radical prostatectomy but not in patients receiving other therapies., Conclusions: Obesity showed a moderate, consistent relationship with biochemical recurrence after radical prostatectomy. Measurement of BMI and BCR was variable, highlighting the need for standardised clinical guidelines. Preventive weight control programs may have a role in reducing BCR for clinically localised PC patients., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: During adolescence and youth there are relevant changes in the consolidation, gain or loss of consumption habits and lifestyles and the family factors has a fundamental role to development these habits. The study of the consumption of toxins, such as alcohol intake, is crucial at this stage due to the repercussions that said consumption presents in adulthood. Therefore, the objective of our study was to evaluate the associations between alcohol consumption patterns and related family factors (family functioning, family history of alcohol consumption) in Spanish university students., Methods: Observational, descriptive, cross-sectional, multicenter study, carried out in first-year university students from 11 Spanish universities. Through an online questionnaire, alcohol consumption (risky consumption and intensive consumption or binge drinking), family functioning and history of alcohol in the family were evaluated. Risky alcohol consumption and binge drinking were assessed using the AUDIT test, and family functioning was assessed using the family APGAR questionnaire. A descriptive analysis of the data was performed, as well as the Chi-Square test and Student's T-Test, and non-conditional logistic regression models were carried out to examine this association., Results: The prevalence of risky alcohol consumption identified in the 10,167 respondents was 16.9% (95% CI = 16.2-17.6), and that of BD was 48.8% (95% CI = 47.9-48.8). There is a significant association between risky alcohol consumption and family functioning in students of both sexes, with greater consumption in the face of severe dysfunctional support (men OR = 1.72; p < 0.001 and women OR = 1.74; p < 0.001) and family history of consumption (p = 0.005). Regarding the binge drinking pattern, no statistically significant differences were observed., Conclusions: Risky alcohol consumption in university students is associated with dysfunctional family support, unlike the binge drinking pattern, where there is no such association. The findings of this study show the importance of creating prevention programs focused on the family approach in university students, which include alcohol screening in the population with a family history of this substance, and greater social support from health services., (© 2022. The Author(s).)

Background: Older adults present high risk of involvement in road crashes. Preventive interventions conducted by their primary healthcare physicians (PHPC) could reduce this public health issue., Objective: The objective of this study was to design and validate a self-administered questionnaire that measures the knowledge, attitudes, and current practices (CP) of PHCP in Spain regarding the prevention of road injuries in older adults., Methods: One thousand eight hundred and ninety-seven PHCP completed a questionnaire piloted previously in an expert panel and two convenience samples of physicians. It comprised 78 items grouped in five sections and was mainly focused on exploring three constructs: knowledge, attitudes, and CP. Exploratory factor analysis was used to obtain evidence of internal structure validity. Reliability was assessed through Cronbach's α coefficient. Correlation coefficients for the scores constructed for each of the extracted factors were calculated to assess convergent and discriminant validity., Results: Factor analysis extracted four factors each for the knowledge and attitudes constructs, and three factors for the CP construct, which explained more than 55% of the variance in each construct. Except for two factors of the knowledge construct regarding existing health problems associated to the risk of involvement in road crashes, the clustering pattern of all other items across the remaining nine factors was consistent and in agreement with previous knowledge. Cronbach's α values were greater than 0.7 for all constructs., Conclusions: Our questionnaire appears to be valid enough to assess the attitudes, CP, and medication-related knowledge of PHCP in Spain regarding the prevention of road injuries in older adults., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The effect of helmet use on reducing the risk of death in cyclists appears to be distorted by some variables (potential confounders, effect modifiers, or both). Our aim was to provide evidence for or against the hypothesis that cycling area may act as a confounder and effect modifier of the association between helmet use and risk of death of cyclists involved in road crashes. Data were analysed for 24,605 cyclists involved in road crashes in Spain. A multiple imputation procedure was used to mitigate the effect of missing values. We used multilevel Poisson regression with province as the group level to estimate the crude association between helmet use and risk of death, and also three adjusted analyses: (1) for cycling area only, (2) for the remaining variables which may act as confounders, and (3) for all variables. Incidence-density ratios (IDR) and their 95% confidence intervals were calculated. Crude IDR was 1.10, but stratifying by cycling area disclosed a protective, differential effect of helmet use: IDR = 0.67 in urban areas, IDR = 0.34 on open roads. Adjusting for all variables except cycling area yielded similar results in both strata, albeit with a smaller difference between them. Adjusting for cycling area only yielded a strong association (IDR = 0.42), which was slightly lower in the adjusted analysis for all variables (IDR = 0.45). Cycling area can act as a confounder and also appears to act as an effect modifier (albeit to a lesser extent) of the risk of cyclists' death after a crash., (© 2022. The Author(s).)

Obesity is associated with negative prostate cancer outcomes (e.g., specific mortality, all-cause mortality, biochemical recurrence, etc.), according to the current scientific literature. Nevertheless, recommendations on weight loss and healthy lifestyles are poorly covered by clinicians. We aimed at identifying these recommendations from clinical practice guidelines (CPGs) for prostate cancer. We systematically searched MEDLINE, EMBASE, Web of Science, Scopus, guideline databases and online sources for CPGs updated from January 2015 to August 2021. The searches were independently conducted by two researchers, without language restrictions. A total of 97 prostate cancer guidelines, including 84 (86.6%) CPGs and 13 (13.4%) consensus statements, were included. Recommendations on reaching and maintaining a healthy weight or healthy lifestyles were provided by 7 (7.2%) and 13 (13.4%) documents, respectively. No differences regarding recommendations were found by type of document, year of publication or country. Our results suggest that professional societies and governments should update prostate cancer guidelines to include these recommendations for improving prostate cancer prognosis.

Objectives: The aim of this study was to quantify the association between driving a vehicle with an expired vehicle inspection certificate (DEVIC) and the severity of injuries sustained by drivers involved in collisions., Methods: A cohort study was designed to compare the incidence of minor injuries, major injuries, and deaths between DEVIC and non-DEVIC drivers involved in collisions. We selected all 51,305 non-responsible drivers (i.e., drivers who did not commit an error or infraction) involved in clean collisions (those in which only one driver in multivehicle collisions committed a traffic infraction or error) from the population of drivers of four-wheeled motor vehicles involved in crashes recorded in the National Register for Road Traffic Accident Victims in Spain from 2014 to 2017., Results: DEVIC was not related with a greater severity of drivers' injuries. The adjusted estimates for the association between DEVIC and major injuries or death yielded an odds ratio of 0.91 (0.66-1.25), compared to no injuries or minor injuries, and a relative risk ratio of 0.90 (0.65-1.24) compared to no injuries., Conclusions: Although we have not found an association between DEVIC and drivers' injury severity, the study limitations does not allow us to discard the usefulness of periodic vehicle inspection in reducing the risk of more severe injury among drivers involved in road crashes.

This study aimed to estimate the prevalence of vehicles on the road with a timed-out vehicle inspection certificate (TOVIC) and the associations of driver, vehicle, and environmental factors with this infraction. A quasi-induced exposure approach was used in this cross-sectional study to analyze a case series comprising 51,305 drivers passively involved in clean collisions (only one infractor driver involved) between two or more vehicles registered in the Spanish National Register of Road Crashes with Victims from 2014 to 2017. The prevalence of TOVIC was estimated in the whole sample and in subgroups defined by the variables considered. Multivariate logistic regression modeling was used to obtain adjusted odds ratios for the association between TOVIC and each category of the variables. The prevalence of TOVIC was low, although significant differences were found for certain subcategories of drivers, vehicles, and environmental factors. Significant positive adjusted associations were found between TOVIC and license-related infractions, vans (compared to cars), vehicle age, and vehicle defects. Several vehicle-related factors potentially associated with a high risk of involvement in a crash were clearly related with TOVIC, which suggests the need for measures to control this non-negligible number of high-risk vehicles on the road.

We designed a cross-sectional study in Spain, from 2014 to 2017. Our objective was to assess sex-related differences in the amount of driving exposure of car drivers, overall and stratified by the main environment-related driving conditions. We compared the sex distribution across three populations: (1) total number of person-years aged > 18 years; (2) total number of person-years aged > 18 years holding a valid car-driving license; and (3) total number of non-responsible car drivers involved in crashes with another offending driver, stratified by different environmental variables. The quasi-induced exposure approach was applied: the non-responsible drivers were considered as representative of the entire population of drivers on the road at the place and time at which the crash occurred. We calculated the female-to-male odds ratio (OR) by comparing population 2 versus 1, and population 3 versus 2. Finally, we performed separate regression models in population 3 for each environment-related variable as the dependent variable and driver's age and sex as the independent variables. The female-to-male OR for the first comparison was 1.12, but values below 1 were found for extreme age groups. In the second comparison, an OR of 0.50 (0.49-0.51) was found, with progressively lower OR values as age increased. In population 3, women were found to drive less than men in environments known to be high risk (i.e., open roads, night-time, poor light conditions, and weekends). A significant gender gap exists in the amount and type of driving exposure. Although women obtain a driving license more frequently than men, they drive much less and tend to avoid high-risk environments. These results emphasize the need to incorporate a gender perspective in the development and implementation of road safety interventions.

Background: There is a knowledge gap for implementing tele-rehabilitation (telerehab) after hip fracture. We recently conducted a clinical trial (ClinicalTrials.gov Identifier: NCT02968589) to test a novel online family caregiver-supported rehabilitation program for older adults with hip fracture, called @ctivehip. In this qualitative substudy, our objective was to use semi-structured interviews to explore family caregivers experience with the telerehab program., Methods: Twenty-one family caregivers were interviewed between three and six months after the older adults completed @ctivehip. One occupational therapist with research and clinical experience, but not involved in the main trial, conducted and transcribed the interviews. We conducted a multi-step content analysis, and two authors completed one coding cycle and two recoding cycles., Results: Family caregivers who enrolled in @ctivehip were satisfied with the program, stated it was manageable to use, and perceived benefits for older adults' functional recovery after hip fracture. They also suggested improvements for the program content, such as more variety with exercises, and increased monitoring by health professionals., Conclusions: This work extends existing literature and generates research hypotheses for future studies to test telerehab content and program implementation.

Objective: Discrimination during vital moments, such as the university period, can generate a high impact on people's behavior and health. The aim of this study was to analyze the possible association of discrimination with perceived health and with different risk behaviors, as well as to describe gender differences in Spanish university students. Discrimination during vital moments, such as college, can have a high impact on people's behavior and health., Methods: A cross-sectional study was carried out with data from first-year university students from 11 Spanish universities (n=9,862). Discrimination, perceived health, alcohol consumption, smoking, consumption of illegal substances, leisure time connected to the Internet, risky sexual relations, family function, risk of mental health problems and risk of eating disorders were assessed. Prevalences with their 95% confidence intervals were obtained and for quantitative variables the mean and standard deviation were calculated. Odds ratios with 95% confidence intervals were calculated to determine the relationship between discrimination and the other variables., Results: An association was found between discrimination and fair or poor perceived health (OR: 1.7; p=0.0001), consumption of illegal substances (OR: 1.3; p=0.002), problematic internet use (OR: 1.3; p=0.004), family dysfunction (OR: 1.8; p=0.0001), risk of mental health problems (OR: 1.9; p=0.0001) and eating disorders (OR: 1.5; p=0.0001). Regarding gender differences, higher prevalence of discrimination was observed in men with health status perceived as fair or worse (OR: 2.2; p=0.0001), family dysfunction (OR: 1.8; p=0.0001), risk of mental health problems (OR: 2.2; p=0.0001) and eating disorders (OR: 1.9; p=0.002). Women, apart from the previous variables, presented association of discrimination with consumption of illegal substances (OR: 1.3; p=0.005) and problematic internet use (OR: 1.4; p=0.002)., Conclusions: The study findings underline that there is an association between discrimination and risk behaviors among Spanish university students. In turn, discrimination was associated with poor or fair perceived health, this relationship being similar in both men and women., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: People over 64 years have a high fatality rate when they are involved in traffic accidents. Besides, older victims of road crashes are expected to rise in the future due to population aging. The purpose of the study was to document their perception on the role of the family doctor, the main facilitating factors, and the perceived barriers to the temporary or permanent restriction of their driving., Methods: This qualitative study used focus group methodology. A sample of 16 people over 65 years old was obtained through a series of segmentation criteria at an active participation centre for older adults in a small town in Jaén province (Spain). All were invited to participate in a discussion during which they were asked to express their opinions and subjective experiences concerning the role of their family doctor. The group conversation was taped, fully transcribed and analysed, and codes were generated with both deductive and inductive methods., Results: After merging the codes to generate themes, we identified 9 relevant categories: perception of age-related risk, road safety, role of public authorities, driver assessment centre, role of the family doctor, role of the family, proposals for addressing traffic accidents in older adults, consequences of the driving prohibition, and public transport. All categories help to explain the subjective driving and traffic safety experiences of older road users., Conclusions: Although family doctors do not usually ask their older patients about road driving, they are highly valued by these patients. Thus, family doctors have a great potential to act, along with the family members, for the benefit of older patients' traffic safety, in ways that can prevent their involvement in road crashes and reduce the negative consequences of having to stop driving if necessary., (© 2021. The Author(s).)

We aimed to assess the effect of the 2008 crisis on road traffic collision (RTC) mortality in Spain, by socioeconomic position (SEP) and type of road use. This prospective, country-wide study covered all adults living in Spain and aged ≥30 years in November 2001. The long-term effect of the crisis was assessed by measuring the monthly percentage change (MPC) in RTC mortality between the pre-crisis (2002-2007) and crisis period (2008-2011). During the recession, RTC mortality fell more in people with low compared to high SEP, so MPCs difference between periods were of a higher magnitude in the low compared to high SEP groups, especially among men motorcyclists. RTC mortality trends were favorable following the 2008 crisis, particularly among low-SEP groups. In men motorcyclists, the upward trend of the pre-crisis period reversed course., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The aim of this study was to systematically review all evidence evaluating obesity as a prognostic factor for PC mortality. Cohort and case-control studies reporting mortality among PC patients stratified by body mass index (BMI) were included. The risk of mortality among obese patients (BMI ≥ 30) was compared with the risk for normal weight (BMI < 25) patients, pooling individual hazard ratios (HR) in random-effects meta-analyses. Reasons for heterogeneity were assessed in subgroup analyses. Dose-response associations for BMI per 5 kg/m 2 change were assessed. Among 7278 citations, 59 studies (280,199 patients) met inclusion criteria. Obesity was associated with increased PC-specific mortality (HR: 1.19, 95% CI: 1.10-1.28, I 2 : 44.4%) and all-cause mortality (HR: 1.09, 95% CI: 1.00-1.18, I 2 : 43.9%). There was a 9% increase (95% CI: 5-12%, I 2 : 39.4%) in PC-specific mortality and 3% increase (95% CI: 1-5%, I 2 : 24.3%) in all-cause mortality per 5 kg/m 2 increase in BMI. In analyses restricted to the higher quality subgroup (NOS ≥ 8), obesity was associated with increased PC-specific mortality (HR: 1.24, 95% CI: 1.14-1.35, I 2 : 0.0%) and maintained the dose-response relationship (HR: 1.11 per 5 kg/m 2 increase in BMI, 95% CI: 1.07-1.15, I 2 : 26.6%). Obesity had a moderate, consistent, temporal, and dose-response association with PC mortality. Weight control programs may have a role in improving PC survival.

This systematic review was conducted to determine the effect of periodic motor vehicle inspections on road crashes and injuries, compared to less exposure to periodic inspections or no inspections. The Medline, Web of Science, and Scopus databases were used to search the literature. Ecological studies were specifically excluded. A reverse search of the results with these databases and of other identified narrative reviews was also performed. Of the 5065 unique references initially extracted, only six of them met the inclusion criteria and were selected for review: one experimental study, two cohort studies with an internal comparison group, two cohort studies without a comparison group, and one case-control study. Two authors independently extracted the information and assessed the quality of each study. Due to the heterogeneity of the designs and the intervention or comparison groups used, quantitative synthesis of the results was not attempted. Except for the case-control study, which showed a significant association between road crashes and the absence of a valid vehicle inspection certificate, the other studies showed either a small reduction in crash rates (around 9%), no association, or a higher crash rate in vehicles with more inspections. In all observational studies, the risk of residual confounding bias was significant and could have explained the results. Therefore, although the research reviewed here suggests that periodic inspection may be associated with a slight reduction in road crashes, the marked heterogeneity along with probable residual confounding in most reports prevented us from establishing causality for this association.

Objective: In college students, higher risk alcohol consumption (drunkenness and binge drinking-BD) has negative consequences on their development and and probably facilitates risk sexual behaviors. The objective was to study if risky sexual behaviors when consuming alcohol (RSBA) are associated with higher risk consumption., Methods: Cross-sectional multicenter study with UniHcos Project, 1 st year university students from 11 universities in Spain, academic years 2011-2012 to 2017-2018 data. This data were collected by self-administered questionnaire. A uni and bivariate analysis was performed, evaluated the statistical significance of the differences in prevalence with chi-square. Mean and standard deviation were used for quantitative variables and Student's t test statistic was used., Results: 9,862 subjects (72.2% women). 90.3% reported having consumed alcohol and 60.9% had drunk the last year, 49% BD in last month. It was deteded in men, significantly higher consumption in the last month and drunkenness. Last month consumption and drunkenness were significantly higher in men and in <21 years. The RSBA were significantly higher among who were drunk (15.7% unprotected sex, 1.9% sexual abuse and 0.7% taking sexual advantage) and had BD (17.1%, 1.9% and 0.7 %). Women with both risk consumptions had more sexual abuse (2.2%), and men had greater behaviors of taking sexual advantage of someone (drunk: 1.2%; BD: 1.3%)., Conclusions: Alcohol consumption was above similar groups. BD consumption was similar by gender and age. Risk sexual behaviors appear mainly in problematic consumption. Gender differences are not detected in alcohol consumers in unprotected sex but deteded in the rest., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: To estimate the number of collateral casualties associated with road users considered responsible for a road crash., Method: We analyzed the case series comprising all 790,435 road users involved in road crashes with victims in Spain from 2009 to 2013, recorded in a nationwide police-based registry. For each road user assumed to be responsible for a crash, we collected information relative to health outcomes in other people involved in it, and obtained the total number of collateral casualties per 100 road users considered responsible for the crash. We then estimated the strength of associations between sex, age and the number of collateral casualties generated by car drivers considered responsible for the crash, and calculated rate ratios and corresponding 95% confidence intervals., Results: Pedestrians responsible for crashes were associated with the lowest number of collateral casualties (13.1/100), whereas the highest number (153/100) was observed for bus drivers responsible for crashes. Car drivers were associated with 104.4/100 collateral casualties. The youngest and the oldest car drivers responsible for crashes were associated with 33% and 41% more deaths, respectively, than the 25-34 year old group. Male drivers were associated with 22% more collateral casualties than female drivers., Conclusions: Regardless of the type of road user who was responsible for a road crash, their active contribution to the crash led to an additional number of collateral casualties in other, non-responsible users. The number and severity of collateral casualties were related to the type of vehicle and the number of people involved. These results are potentially useful to support the need to promote safer driver practices among subgroups of high-risk drivers., (Copyright © 2019 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Carbapenemase-producing Enterobacterales (CPE) are significant contributors to the global public health threat of antimicrobial resistance. OXA-48-like enzymes and their variants are unique carbapenemases with low or null hydrolytic activity toward carbapenems but no intrinsic activity against expanded-spectrum cephalosporins. CPEs have been classified by the WHO as high-priority pathogens given their association with morbidity and mortality and the scarce number of effective antibiotic treatments. In Spain, the frequency of OXA-48 CPE outbreaks is higher than in other European countries, representing the major resistance mechanism of CPEs. Horizontal transfer of plasmids and poor effective antibiotic treatment are additional threats to the correct prevention and control of these hospital outbreaks. One of the most important risk factors is antibiotic pressure, specifically carbapenem overuse. We explored the use of these antibiotics in Spain and analyzed the frequency, characteristics and prevention of CPE outbreaks. Future antibiotic stewardship programs along with specific preventive measures in hospitalized patients must be reinforced and updated in Spain.

The aim of this study was to estimate the association between each cause of driving without a valid license (DWVL) and the risk of causing a road crash, considering driver, vehicle and environmental factors. A case-control study based on data from the Spanish Register of Road Accidents with Victims was carried out between 2014 and 2017. Cases included 28,620 drivers of moving private cars, vans and off-road vehicles involved in single crashes plus 50,100 drivers deemed responsible for clean collisions (i.e. those in which only one driver was labeled as responsible). In accordance with the quasi-induce exposure approach, drivers not responsible for clean collisions comprised the control group (N = 51,656). Logistic and multinomial regression models were used to estimate crude and adjusted Odds Ratios or Relative Risk Ratios between each reason for DWVL and the risk of being a case of all, single and multi-vehicle collisions. A significant association was found between all reasons for DWVL and the risk of causing a road crash. This association was particularly high for drivers with a suspended license and drivers who had never obtained a license. In these subgroups of drivers, the proportion of the relationship explained by high-risk driving behaviors is high. Our results support the need for applying continued strategies to identify and control these subgroups of drivers., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

It has been widely reported that younger and older drivers have an excess risk of causing a road crash. Two casual hypotheses may coexist: the riskier driving behaviors and age-related mechanisms in extreme age groups (direct path) and the different environmental and vehicle circumstances (indirect path). Our aim was to quantify, through a mediation analysis, the percentage contribution of both paths. A case-control study was designed from the Spanish Register of Road Crashes with victims from 2014 to 2017. Assuming a quasi-induced exposure approach, controls were non-responsible drivers involved in clean collisions between two or more vehicles ( n = 52,131). Responsible drivers for these collisions plus drivers involved in single crashes constituted the case group ( n = 82,071). A logit model in which the outcome was the log (odds) of causing a road crash and the exposure was age groups was adjusted for driver, vehicle and environmental factors. The highest crash risk was observed in extreme age groups, compared to the 35-44 year old age group: the youngest (18-24 years old, odds ratio = 2.14, 95% confidence interval: 2.06-2.24) and the oldest drivers (>74 years old, odds ratio = 3.30, 95% confidence interval: 3.04-2.58). The mediation analysis identified the direct path as the main explanatory mechanism for these increases: 89% in the youngest and 93% in the oldest drivers. These data support the hypothesis that the excess crash risk observed for younger and older drivers is mainly related to their higher frequency of risky driving behaviors and age-related loss of capabilities. Preventive strategies in extreme-aged drivers should focus on decreasing these behaviors.

Background and Objectives: In the last months great efforts have been developed to evaluate the more efficient therapeutic agents in the management of patients with COVID-19. Currently, no specific drug combination has consistently demonstrated an association with mortality. The aim of this study was to assess the pattern of associations observed between the different in-hospital treatments administered to a series of 238 patients admitted for COVID-19 and their relationship with mortality., Methods: The electronic medical records of patients that discharged or died from COVID-19 in the Hospital Universitario San Cecilio (Granada, Spain) between March 16 and April 10, 2020 were analysed. From these records, information was obtained on sex, age, comorbidities at admission, clinical information, analytical parameters, imaging tests and empirical treatments used. The outcome variable was the in-hospital mortality. To estimate the associations between the different therapeutic alternatives and the risk of mortality, Hazard Ratios adjusted for age, sex, previous pathologies and severity at discharge were estimated using Cox Regression models., Results: The most frequently used combination of drugs was low molecular weight heparins, hydroxychloroquine, and ritonavir/lopinavir. None of the analysed treatments showed independent association with mortality. The drugs that showed a greater inverse association with mortality were tocilizumab and corticoids., Conclusions: The observed association patterns are consistent with previous literature. It seems necessary to design randomized controlled clinical trials that evaluate the possible protector effect of tocilizumab and corticoids in the risk of mortality for some subgroups of COVID-19 hospitalized patients., (© 2020 Elsevier España, S.L.U. All rights reserved.)

Objectives: To systematically review and quantify the effect of motor vehicle crashes (MVCs) in pregnancy on maternal and offspring outcomes., Design: Systematic review and meta-analysis of observational data searched from inception until 1 July 2018. Searching was from June to August 2018 in Medline, Embase, Web of Science, Scopus, Latin-American and Caribbean System on Health Sciences Information, Scientific Electronic Library Online, TRANSPORT, International Road Research Documentation, European Conference of Ministers of Transportation Databases, Cochrane Database of Systematic Reviews and Cochrane Central Register., Participants: Studies were selected if they focused on the effects of exposure MVC during pregnancy versus non-exposure, with follow-up to verify outcomes in various settings, including secondary care, collision and emergency, and inpatient care., Data Synthesis: For incidence data, we calculated a pooled estimate per 1000 women. For comparison of outcomes between women involved and those not involved in MVC, we calculated ORs with 95% CIs. Where possible, we statistically pooled the data using the random-effects model. The quality of studies used in the comparative analysis was assessed with Newcastle-Ottawa Scale., Results: We included 19 studies (3 222 066 women) of which the majority was carried out in high-income countries (18/19). In population-level studies of women involved in MVC, maternal death occurred in 3.6 per 1000 (95% CI 0.25-10.42; 3 studies, 12 000 women; Tau=1.77), and fetal death or stillbirth in 6.6 per 1000 (95% CI 3.81-10.12; 8 studies, 47 992 women; I 2 =92.6%). Pooled incidence of complications per 1000 women involved in MVC was labour induction (276.43), preterm delivery (191.90) and caesarean section (166.65). Compared with women not involved in MVC, those involved had increased odds of placental abruption (OR 1.43, 95% CI 1.27-1.63; 3 studies, 1 500 825 women) and maternal death (OR 202.27; 95% CI 110.60-369.95; 1 study, 1 094 559 women)., Conclusion: Pregnant women involved in MVC were at higher risk of maternal death and complications than those not involved., Prospero Registration Number: CRD42018100788., 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: To quantify the magnitude of the association between the type of vehicle and the probability of being responsible for a collision between two or more vehicles., Method: From the registry of road crashes with victims maintained by the Spanish Traffic General Directorate (2014 and 2015), a matched case-control study was designed. Cases were offending drivers involved in the 27,630 collisions between two or more vehicles in which only one of the drivers had committed a driving mistake or offence. Each case was matched with the non-offending drivers of the vehicles involved in the same crash: in all, 31,219 controls were included. Apart from the commission of offences and the type of vehicle involved, we got information about other characteristics of the driver (age, sex, etc.) and about the vehicle (age). Odds ratios (OR) were calculated in order to quantify the association between each type of vehicle and the odds of being responsible for the collision, crude and adjusted (by conditioned logistic regression) by the rest of collected variables., Results: In comparison with private cars, bicycles had a lower risk of causing a collision (adjusted OR: .30), and also mopeds (aOR: .52) and buses (aOR: .63). Vans (aOR: 1.19) and four-wheel vehicles (aOR: 1.33) increased the risk., Conclusion: Two-wheeled vehicles and buses had a lower risk of causing collisions than private cars. This association is independent of some of the characteristics of the driver, as well as the age of the vehicle., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: To identify and quantify associations between baseline characteristics on hospital admission and mortality in patients with COVID-19 at a tertiary hospital in Spain., Methods and Findings: This retrospective case series included 238 patients hospitalized for COVID-19 at Hospital Universitario Clínico San Cecilio (Granada, Spain) who were discharged or who died. Electronic medical records were reviewed to obtain information on sex, age, personal antecedents, clinical features, findings on physical examination, and laboratory results for each patient. Associations between mortality and baseline characteristics were estimated as hazard ratios (HR) calculated with Cox regression models. Series mortality was 25.6%. Among patients with dependence for basic activities of daily living, 78.7% died, and among patients residing in retirement homes, 80.8% died. The variables most clearly associated with a greater hazard of death were age (3% HR increase per 1-year increase in age; 95%CI 1-6), diabetes mellitus (HR 2.42, 95%CI 1.43-4.09), SatO2/FiO2 ratio (43% HR reduction per 1-point increase; 95%CI 23-57), SOFA score (19% HR increase per 1-point increase, 95%CI 5-34) and CURB-65 score (76% HR increase per 1-point increase, 95%CI 23-143)., Conclusions: The patients residing in retirement homes showed great vulnerability. The main baseline factors that were independently associated with mortality in patients hospitalized for COVID-19 were older age, diabetes mellitus, low SatO2/FiO2 ratio, and high SOFA and CURB-65 scores., Competing Interests: The authors have declared that no competing interests exist.

The novel coronavirus disease (COVID-19) outbreak has quickly spread around the world, with Spain being one of the most severely affected countries. Healthcare professionals are an important risk group given their exposure. The aims of this study were to determine the prevalence of symptoms, main concerns as patients, preventive behaviours of healthcare professionals, and the different temporal outcomes associated with the negativization of PCR results. A total of 238 professionals were analysed and follow-up was conducted from 11 March to 21 April 2020 through clinical records, in-depth surveys, and telephone interviews. Symptoms, concerns, and preventive measures were documented, and temporal outcomes (start and end of symptoms, first positive PCR, and negativization of PCR) were analysed through survival analyses. A high prevalence of gastrointestinal symptoms (especially in women and older professionals), fever, cough, and fatigue were reported. The main concern was contagion in the work and home environment. Professionals (especially men) reported low use of face masks before the pandemic. Our analysis indicates that the median times for the negativization of PCR testing to confirm the resolution of infection is 15 days after the end of symptoms, or 25 days after the first positive PCR test. Our results suggest that these times are longer for women and for professionals aged ≥55 years, therefore follow-up strategies should be optimized in light of both variables. This is the first study we are aware of to report factors associated with the time to negativization of PCR results. We present the first rigorous estimates of time outcomes and hope that these data can be valuable to continue feeding the prediction models that are currently being developed. Similar studies are required to corroborate our results.

Antimicrobial resistance is a growing global health problem. Patients living in care homes are a vulnerable high-risk population colonized by multidrug-resistant organisms (MDRO). We identified a case series of 116 residents of care homes from a cohort of 540 consecutive patients admitted to the internal medicine service of our hospital. We performed early diagnostic tests of MDRO through anal exudates in our sample. The prevalence of MDRO colonization was 34.5% of residents and 70% of them had not been previously identified in the clinical records. Previous hospitalizations and in-hospital antibiotic administration were significantly associated with the presence of MDRO. Our results emphasize the need to consider care homes in the planning of regional and national infection control measures and for implementing surveillance systems that monitor the spread of antimicrobial resistance in Spain. Systematic early testing upon admission to hospital services with a high prevalence of patients with MDRO colonization (e.g., internal medicine) could contribute to the adoption of adequate prevention measures. Specific educational programs for care home staff should also be implemented to address this increasing problem.

The International Agency of Research in Cancer (IARC) has recently confirmed shift work as a type 2A carcinogen. The results presented in published epidemiological studies regarding prostate cancer are inconsistent and the association remains controversial. The aims of this study were: (a) to investigate the possible association between shift work and prostate cancer incidence, identifying possible sources of heterogeneity; and (b) to analyze the potential effect of publication bias. A search for cohort and case-control studies published from January 1980 to November 2019 was conducted. The quality of the articles was assessed using the Newcastle-Ottawa Scale. Pooled OR were calculated using random-effects models. Heterogeneity was evaluated using Cochran's Q test and data were stratified by potential sources of heterogeneity. Publication bias was analyzed. Eighteen studies were included. No association was found between rotating/night-shift work and prostate cancer, pooled OR 1.07 (95%CI 0.99 to 1.15), I 2 = 45.7%, p = 0.016. Heterogeneity was eliminated when only cohort studies (pooled OR 1.03; 95%CI 0.96 to 1.10; I 2 = 18.9%, p = 0.264) or high-quality studies (pooled OR 0.99; 95%CI 0.89 to 1.08; I 2 = 0.0%, p = 0.571) were considered. A publication bias was detected. An association between shift work and prostate cancer cannot be confirmed with the available current data. Future analytical studies assessing more objective homogeneous exposure variables still seem necessary.

Undercarboxylated osteocalcin (ucOC) could be a biomarker of glucose disturbances and cardiovascular risk. Our study aimed to determine the association between serum levels of ucOC and cardiovascular risk in metabolic syndrome (MetS) patients and to analyse its potential role as estimator of type 2 diabetes (T2D) risk in this population. This cross-sectional study included 235 patients with MetS, 53.2% women, aged 55-75 years. Circulating ucOC levels were measured by ELISA. Cardiovascular risk was determined as Z-score of the diagnostic criteria for MetS (CV-ZS). Linear regression model was performed to analyse the association between circulating ucOC and CV-ZS. A receiver operating curve (ROC) was performed to analyse the usefulness of ucOC as T2D risk estimator. Patients above the CV-ZS median showed significant lower ucOC levels. We found an inverse association between ucOC levels and CV-ZS in MetS patients without T2D. Patients with ucOC levels below the 25 th percentile showed worse cardiometabolic profile and higher cardiovascular and T2D risk. The area under the curve performed better when ucOC levels were included along with the classic T2D risk factors. The measurement of circulating ucOC could be a useful tool to identify increased cardiovascular and T2D risk in MetS patients without T2D.

The objective of this study was to assess the effect of the implementation of training programs for Primary Care Physicians for improving their clinical practice as regards the prevention of traffic accidents in the elderly. To do this, a systematic review was carried out following the PRISMA strategy. A total of 1,677 works were reviewed, of which only 5 were included because they met the inclusion criteria. Although none of the works was of an experimental type with a control group, it can be concluded that there is evidence that an adequate training in this subject by physicians improves their skills in the identification of elderly risk drivers, due to their pathologies and/or the use of drugs, as well as their level of confidence to communicate to the elderly and/or their families the need for restriction or, if necessary, the definitive cessation of driving., (Copyright © 2019 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.)

Tick-borne diseases (TBDs) can sometimes cause severe symptoms and lead to hospitalisation, but they often go unnoticed in the Emergency Department (ED). The aim of this study was twofold: (i) to describe the profile of patients hospitalised by TBDs; and (ii) to evaluate the data collected in the medical records from the ED in order to analyse their potential clinical consequences. A total of 84 cases that included all TBD diagnoses registered in the ED records were identified and analysed. These corresponded to all the hospitalisations by TBDs in the last 10 years (2009-2019) in two tertiary hospitals in Granada, Spain. Statistical analyses were made using RStudio. Coinciding with the absence of patient's report of exposure to ticks, 64.3% of TBDs were not suspected in the ED. Intensive care unit admission was required in 8.3% of cases, and the mortality rate was 2.4%. Non-suspected cases showed longer hospital stay (P < 0.001), treatment duration (P = 0.02) and delay in the initiation of antibiotic treatment (P < 0.001). Our findings indicate that symptoms associated with TBDs are highly non-specific. In the absence of explicit information related to potential tick exposure, TBDs are not initially suspected. As a consequence, elective treatment administration is delayed and hospitalisation time is prolonged. In conclusion, our results highlight the importance of addressing potential exposure to ticks during the ED contact with patients presenting with febrile syndrome.

Objective: To quantify the magnitude of associations between cyclist fatalities and both cyclist and environment related characteristics in Spain during the first 24 hours after a crash., Design: Cohort study., Setting: Spain., Participants: 65 977 cyclists injured in road crashes recorded between 1993 and 2013 in the Spanish Register of Road Crashes with Victims., Main Outcome: Death within the first 24 hours after the crash., Methods: A multiple imputation procedure was used to mitigate the effect of missing values. Differences between regions were assumed and managed with multilevel analysis at the cyclist and province levels. Incidence density ratios (IDR) with 95% CI were calculated with a multivariate Poisson model., Results: Non-use of a helmet was directly associated with death (IDR 1.43, 95% CI 1.25 to 1.64). Among other cyclist characteristics, age after the third decade of life was also directly associated with death, especially in older cyclists ('over 74' category, IDR 4.61, 95% CI 3.49 to 6.08). The association with death did not differ between work-related cycling and other reasons for cycling.There was an inverse association with death for crashes in urban areas and on community roads. Any adverse meteorological condition also showed a direct association with death, whereas altered road surfaces showed an inverse association. Crashes during nighttime were directly associated with death, with a peak between 3:00 and 5:59 am (IDR 1.58, 95% CI 1.03 to 2.41)., Conclusions: We found strong direct and inverse associations between several cyclist and environment related variables and death. These variables should be considered in efforts to prioritise public health measures aimed at reducing the number of cycling-related fatalities., 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.)

Background: This ecological study aimed i) to quantify the association of age and gender with the three components of pedestrians' death rates after a pedestrian-vehicle crash: exposure, risk of crash and fatality, and ii) to determine the contribution of each component to differences in death rates according to age and gender in Spain., Methods: We analyzed data for 220 665 pedestrians involved in road crashes recorded in the Spanish registry of road crashes with victims from 1993 to 2011, and a subset of 39 743 pedestrians involved in clean collisions (in which the pedestrian did not commit an infraction). Using decomposition and quasi-induced exposure methods, we obtained the proportion of increase in death rates for each age and gender group associated with exposure, risk of collision and fatality., Results: Death rates increased with age. The main contributor to this increase was fatality, although exposure also increased with age. In contrast, the risk of collision decreased with age. Males had higher death rates than females, especially in the 24-54 year old group. Higher fatality rates in males were the main determinant of this difference, which was also related with a higher risk of collision in males. However, exposure rates were higher in females., Conclusions: The magnitude and direction of the associations between age and gender and each of the three components of pedestrians' death rates differed depending on the specific component explored. These differences need to be taken into account in order to prioritize preventive strategies intended to decrease mortality among pedestrians.

This study aimed to quantify the association between pedestrian- and driver-related factors and the risk of causing road crashes involving pedestrians in urban areas in Spain between 1993 and 2011. From the nationwide police-based registry of road crashes with victims in Spain, we analyzed all 63,205 pairs of pedestrians and drivers involved in crashes in urban areas in which only the pedestrian or only the driver was at fault. Logistic regression models were used to obtain adjusted odds ratios to assess the strength of association between each individual-related variable and the pedestrian's odds of being at fault for the crash (and conversely, the driver's odds of not being at fault). The subgroups of road users at high risk of causing a road crash with a pedestrian in urban areas were young and male pedestrians, pedestrians with psychophysical conditions or health problems, the youngest and the oldest drivers, and drivers with markers of high-risk behaviors (alcohol use, nonuse of safety devices, and driving without a valid license). These subgroups should be targeted by preventive strategies intended to decrease the rate of urban road crashes involving pedestrians in Spain., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Unlabelled: Objetive: identify whether there is an increased risk of adverse perinatal outcomes, like prematurity or decreased weight in newborns, associated with caffeine consumption during the first half of pregnancy in pregnant women of our population., Methods: transversal study carried out in 1 175 patients from Virgen de las Nieves University Hospital of Granada (Spain). Information about caffeine consumption during first half of gestation and perinatal outcomes was obtained by personal interview, medical records and telephone call after delivery. The average caffeine intake was calculated from meals and drinks included in a validated questionnaire., Results: there was no difference in caffeine consumption in pregnant women with birth weight ≥2 500 g and., (Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.)

Objective: The purpose of this study was to compare the frequency of involvement in risky driving circumstances between Guatemalan and Spanish university students and identify in both populations the differences between the involvement in such circumstances and road crashes., Materials and Methods: A cross sectional study was conducted during the academic courses 2007 to 2011 on a sample of 2 130 drivers (1 016 in Guatemala and 1 114 in Spain), who completed a self-administered questionnaire that assessed: mobility patterns, use of safety devices, driving styles and involvement in road traffic crashes., Results: Furthermore, they were involved more frequently in almost all the risky-driving circumstances compared with Spanish students, principally in: mobile use (74.4 % versus 24.3 %), distraction (47.1 % versus 18.8 %) or not using seatbelt (23.9% vs 5.9). Finally, the adjusted analysis yields an accident rate 4.8 times higher among Guatemalans (CI 95% 3.1-7.4)., Conclusions: Considering the factors more frequently associated with suffer road traffic crashes dependent on human factor, it is noted physical and social factors as well as that the car-dependent issues, must play an important role in the marked differences detected in both populations.

Purpose: The results of epidemiological studies about exposure to organochlorine pesticides (OCPs) and risk of prostate cancer (PC) are inconclusive. We conducted a meta-analysis to evaluate the association between exposure to specific OCPs and PC., Methods: We searched PubMed, Scopus, and Web of science databases for case-control and cohort studies published till March 2015 that provided data about exposure to OCPs and PC. We also contacted authors and hand-searched references of the included articles. We calculated pooled estimates using random effects model and explored heterogeneity between studies., Results: We systematically reviewed 15 articles and based our meta-analysis on 10 articles covering nine case-control studies and a large prospective cohort study. Pooled estimates of PC for highest versus lowest exposed category to p,p'-DDE was 1.02 (0.69-1.35), I (2) = 12.7 %, p = 0.333, trans-nonachlor, 0.88 (0.45-1.31), I (2) = 0.00 %, p = 0.892, oxychlordane, 0.91 (0.46-1.35), hexachlorobenzene, 0.88 (0.18-1.57), I (2) = 36.0 %, p = 0.210 from combining results of studies that applied serum OCPs measurements among the general population. For DDT, stratifying studies by exposed population revealed homogeneity, pooled estimate for serum level measurement for the highest exposed versus the lowest exposed of the general population was 0.81 (0.95-1.26), I (2) = 0.00 %, p = 0.400, and for occupational exposure 1.30 (0.94-1.67), I (2) = 13.4 %, p = 0.315. A positive but also insignificant association was obtained for pooling results for high exposure to lindane among farmers and pesticide applicators, 1.56 (0.82-2.29), I (2) = 41.7 %, p = 0.180., Conclusions: The existing epidemiological data do not support the hypothesis that exposure to specific OCPs is associated with an increased incidence of PC in the general population.