Breastfeeding avoidance following psychological intimate partner violence during pregnancy: a cohort study and multivariate analysis.

OBJECTIVE: To evaluate if the experience of psychological intimate partner violence (IPV) adversely affects breastfeeding rates. DESIGN: A cohort study. SETTING: Maternities in 15 public hospitals, drawn using cluster sampling of obstetric services in Andalusia, Spain. POPULATION: A total of 779 consecutive mothers receiving antenatal care including ultrasound and giving birth during February-June 2010. METHODS: Trained midwives gathered IPV data using the Index of Spouse Abuse validated in the Spanish language (score ranges: 0-100, higher scores reflect more severe IPV; cut-off: psychological IPV = 25). Sociodemographic data including lack of kin support, and obstetric and neonatal outcomes were collected. Multivariate logistic regression estimated adjusted odds ratios (aOR), with 95% confidence intervals (CI), of the relationship between psychological IPV and breastfeeding, controlling for sociodemographic characteristics and obstetric complications. MAIN OUTCOME MEASURE: Breastfeeding avoidance defined as lack of breastfeeding or pumping of breast milk to feed the new baby in the immediate post-partum period. RESULTS: Response rate was 92.2%. A total of 70% (n = 545) of women initiated breastfeeding. Psychological IPV, reported by 21.0% (n = 151), increased the odds of breastfeeding avoidance (aOR = 2.0; 95% CI = 1.2-3.3) adjusting for the presence of obstetric complications (aOR = 1.6; 95% CI = 1.0-2.4). CONCLUSIONS: Mothers with psychological IPV avoid breastfeeding. Clinicians should be aware of the risks to infant arising from this deficiency due to IPV in pregnancy. TWEETABLE ABSTRACT: Psychological intimate partner violence, reported by one in five mothers in this study, on average doubles the avoidance of breastfeeding.

Impact of a 'school-based' nutrition intervention on anthropometric parameters and the metabolic syndrome in Spanish adolescents.

BACKGROUND/AIMS: In adolescents, overweight and obesity are associated with an increased cardiovascular risk. The aim of this study was to determine the impact of a school-based nutritional education program (NEP) on lifestyle changes in Spanish adolescents. METHODS: We selected 263 secondary school students (127 males) aged 12-16 years from Granada (Spain), who were followed up throughout 1 school year (2009-2010). At the beginning and end of the school year, data were gathered on the food consumption frequency, and anthropometric and biochemical profile. The NEP comprised a class on nutritional recommendations every 15 days, and administration of a daily breakfast of 275-350 kcal. RESULTS: After the intervention, the prevalence of overweight and obesity decreased among both male and female students (p < 0.001) and there was also a global reduction in the prevalence of the metabolic syndrome (MS) from 32.2 to 19.7% (p < 0.001); in addition, body mass index was significantly decreased in normal weight, overweight and obesity groups (p = 0.001 and p = 0.02, respectively), and high-density-lipoprotein cholesterol and lean body mass was increased in all groups (p = 0.001). CONCLUSION: The NEP achieved a medium-term reduction in the prevalence of overweight and obesity and had a significant and positive effect on MS components in all groups.

Sperm chromatin structure assay and classical semen parameters: systematic review.

The present study is based on a PubMed search and compares the clinical validity of classical semen parameters (CSP) and the sperm chromatin structure assay (SCSA) in different clinical contexts. The PubMed database was searched using keywords on the sperm diagnostic test for pregnancy in three clinical scenarios: (i) couples attempting to conceive; (ii) couples who had been attempting to conceive for 12months without success; and (iii) couples treated with intrauterine insemination (IUI). There was a considerable heterogeneity among the studies included. For couples attempting to conceive following a SCSA that produced an abnormal result, the likelihood of male factor infertility ranged from a pre-test value of 7.5% to a post-test value of 32.1% [95% confidence interval (CI) 15.7-54.5], while after CSP with an abnormal result, the post-test probability was 17.3% (95% CI 11.8-24.5). For a pre-test prevalence of male factor infertility of 50%, the post-test probability of male factor infertility after an abnormal test is very similar for both SCSA and CSP. In couples treated with IUI, the clinical validity of SCSA is higher than that of sperm morphology alone, but not enough to introduce SCSA as a test in male infertility work-up.

[Drug-related mortality among inpatients admitted in Internal Medicine]. / Mortalidad hospitalaria asociada a medicamentos en un Servicio de Medicina Interna.

BACKGROUND: To analyze the mortality associated with prescriptions, the drugs most frequently involved and the associated risk factors in patients admitted to Internal Medicine. METHODS: A retrospective, observational study. The clinical records of adult patients who died consecutively in the department of Internal Medicine in a Spanish tertiary hospital over twenty-two months were reviewed. The main variable was the prevalence of hospital death suspected of being related to the medications administered during admission. RESULTS: Out of the 455 deaths analyzed, 22.2% were related to the medications received; in 55 cases (12.1%) the drugs were suspected of being the cause of death and in 46 cases (10.1%) of contributing to it. The most frequent diagnoses in cases of death associated with drugs were cardiac arrhythmia (23.7%), severe hemorrhage (19.8%) and aspiration pneumonia (12.8%). The drugs with the highest prevalence in deaths related to pharmacological treatment were an-tithrombotic drugs (23.7%), digoxin (21.7%), antipsychotics (17.8%) and benzodiazepines (14.8%). The only independent risk factor for mortality associated with treatment was the number of medications administered (OR=1.25, 95%CI: 1.14-1.37). No significant association was found with age, sex, number of pathologies or duration of hospital stay. CONCLUSION: A high percentage of deaths of patients admitted to Internal Medicine were considered related to the medications received. Antithrombotic drugs, digoxin and psychotropic drugs were the agents most frequently implicated. This mortality is independently and significantly associated with the number of medications administered.

[Adverse drug reactions in patients visiting a general hospital: a meta-analysis of results]. / Reacciones adversas a medicamentos en pacientes que acudieron a un hospital general: un meta-análisis de resultados.

OBJECTIVES: The aim of this study was to present the results of a meta-analysis on adverse drug reactions (ADR) in spanish patients admitted to hospital and presenting to emergency department over the past 20 years. PATIENTS AND METHODS: An exhaustive review was undertaken of relevant articles in the IME (Spanish Medical Index) and MEDLINE databases and published between 1985 and 2006, rigorously selecting 12 out of 30 publications after applying inclusion and exclusion criteria. Information was required on: symptomatology, prognosis, type, drugs involved, imputability and admissions for ADR; and factors associated with ADR onset, e.g., age, sex, number of drugs, previous history of ADR, method used for ADR detection, and length of study period. A random-effects model (DerSimonian and Laird) and the STATA 9.1 programme were used for the meta-analysis. RESULTS: The combined estimation of the percentage of Spanish patients with ADR was 13% (95% CI); with severe ADR, 12 % (95% CI) and with fatal ADR, 0.1% (95% CI). ADR diagnosis was definite in 36% (95% CI), probable in 49.6% (95% CI), and type A in 71% (95% CI) of cases. Among patients in the Emergency Department for ADR, 5.1% (95% IC) were hospitalized. No association was found with number of prescriptions or previous history. Association was established with advanced age and female sex. Digestive, skin, nervous and cardiovascular systems were those most affected by ADR. The drugs most frequently implicated included NSAIDs, digoxin, IACE, calcium antagonists, furosemide, i.v. metamizol, antidiabetics, benzodiazepines, adrenergic bronchodilators and classic antipsychotics. CONCLUSIONS: ADRs constitute a major medical and economic problem with aspects that have yet to be defined. Greater efforts are warranted to unify criteria for the publication of results in observational studies on ARD and to determine the role played by some factors associated with their onset, e.g., sex, previous history and comorbidities.

Proportion of hospital deaths associated with adverse events.

OBJECTIVES: To determine the fraction of hospital deaths potentially associated with the occurrence of adverse events (AE). DESIGN: A paired (1:1) case-control study. SETTING: An 800-bed, teaching tertiary care hospital. PATIENTS: All patients older than 14 years admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths (death rate of 3.74%) that occurred in the hospital comprised the case group. For each case, a control patient was matched for both primary diagnosis on admission and admission date. MEASUREMENTS: The proportion of hospital deaths associated with adverse events (defined as problems of any nature and seriousness faced by the patient during hospitalization, and potentially traceable to clinical or administrative management) was estimated from attributable risks adjusted for age, sex, service, severity of illness, length of stay, and quality of the medical record. RESULTS: For stays longer than 48 hours, the adjusted attributable risk for all adverse events was estimated to be 0.51 (0.40-0.61). When the data were stratified according to the category of adverse event, the attributable risks remained significant except for administrative problems. The greatest proportion of deaths associated with adverse events was observed for surgical adverse events [0.56 (0.38-0.71)] and nosocomial infection [0.22 (0.14-0.28)]. CONCLUSIONS: A significant proportion of intrahospital deaths were associated with AE. These results suggest the need to consider programs focused on the prevention of mortality from AE.

Proportion of hospital deaths potentially attributable to nosocomial infection.

OBJECTIVE: To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI). DESIGN: A matched (1:1) case-control study. SETTING: An 800-bed, tertiary-care, teaching hospital. PATIENTS: All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths that occurred in the hospital comprised the case group. For each case, a control patient was matched for primary admission diagnosis and admission date. OUTCOME MEASURES: The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record. RESULTS: For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval [CI95], 16.8%-30.5%). The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI95, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%; CI95, 4.6%-11.6%). CONCLUSIONS: NIs are associated with a large proportion of intrahospital deaths. This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death.

Variations in magnesium and zinc in hypertensive patients receiving different treatments.

We studied the influence of captopril, atenolol, and verapamil on serum and intraerythrocyte concentrations of magnesium and zinc in 30 normotensive control subjects (12 men and 18 women, aged 30 to 65 years, mean +/- SD 45.76 +/- 12.15 years) and 30 patients with untreated mild or moderate essential hypertension (14 men and 16 women, aged 30 to 65 years, mean +/- SD 49.50 +/- 13.58 years). Ten each of the hypertensive patients were treated with captopril, atenolol, or verapamil. Physical examination and biochemical analyses (serum Mg and Zn) were done in all participants at baseline, and in patients after 3 and 6 months of treatment. The results were compared according to a nested design with Neumann-Keuls test. We found no significant differences between controls and patients in serum and intraerythrocyte concentrations of Zn at the start of the study, although there was a significant decrease in serum Zn in patients after 3 (P < .01) and 6 months (P < .001) of treatment, regardless of the drug used. This decrease was thought to be attributable to the zincuric effect of captopril or to dietary measures, or both. Intraerythrocyte Zn was not significantly affected by antihypertensive treatment. Serum and intraerythrocyte concentrations of Mg were significantly lower (P < .001) in hypertensive than in normotensive subjects, and serum Mg in patients treated with verapamil was significantly lower (P < .05) than after treatment with captopril or atenolol. Serum Mg concentration was related directly with serum concentrations of high density lipoprotein cholesterol (r = 0.4043, P < .05). We conclude that supplementation with Mg may benefit patients with hypertension.

Influence of driver nationality on the risk of causing vehicle collisions in Spain.

STUDY OBJECTIVE: To estimate the association between driver nationality and the risk of causing a collision between vehicles in motion. DESIGN: Retrospective, matched by collision, case-control study. SETTING: Collisions that occurred in Spain during the period from 1990 to 1999 were studied. PARTICIPANTS: Responsible (case) and non-responsible (control) drivers identified in the databases of the Dirección General de Tráfico (General Traffic Directorate) who were involved in a collisions between two or more four wheeled vehicles in motion, in which only one of the drivers had committed a traffic violation. MAIN RESULTS: Crude odds ratios (ORs) for the effect of driver nationality on the risk of causing a collision were significantly higher for foreign drivers than for Spanish drivers, and ranged from a minimum of 1.19 (95% CI 1.09 to 1.29) for Portuguese drivers to a maximum of 2.06 (1.88 to 2.27) for British drivers. Corresponding adjusted ORs were slightly lower, but were still significantly higher than 1 for all nationalities except Italian, Belgian, and American (USA). Adjusted ORs were usually higher for collisions that occurred in urban areas than on open roads. CONCLUSIONS: Authorities responsible for traffic safety, and drivers in general, should consider foreign drivers in Spain at particularly high risk for causing collisions, especially in urban areas.

Influence of age, sex, and hepatitis C virus infection on peripheral blood lymphocyte subsets in stable kidney transplantation.

BACKGROUND: Young age and hepatitis C virus infection (HCVI) are believed to be risk factors in kidney transplantation recipients. The first group is treated empirically with an intensive immunosuppressive regimen, because it is considered to have high immune alloreactivity. The other cohort usually receives a less intensive regimen to avoid excessive immunosuppressive effects. Our aim was to investigate the influence of age, sex, and HCVI on immune status in stable kidney transplant recipients through measurement of peripheral blood lymphocyte subsets. METHODS: Absolute CD3+, CD3+, CD4+, CD3+, CD8+, CD19+, CD16+ CD3- lymphocyte counts and CD4/CD8 ratios were assessed at five time points in 65 stable kidney allograft patients over 12 months. The subsets were compared according to age, sex, and HCVI of the recipients. RESULTS: An inverse association was observed between recipient age and absolute CD19+ and CD3+ CD4+ lymphocyte counts, which was significant at all time points with respect to CD19+ counts, and at three time points with respect to CD3+ CD4+ counts. A significant positive association was observed between recipient age and absolute CD3- CD16+ lymphocyte counts at three time points. Female recipients showed significantly lower CD3+ CD8+ counts and significantly higher CD4/CD8 ratios than male recipients at four time points. HCVI recipients showed significantly lower CD16+ CD3- counts at four time points. CONCLUSIONS: We observed links between immune status and age, sex and HCVI in stable kidney transplant recipients that could offer new insights into recommendations for maintenance immunosuppression.

Effect of mycophenolate mofetil regimen on peripheral blood lymphocyte subsets in kidney transplant recipients.

BACKGROUND AND AIMS: There is growing evidence of the effects of immunosuppressive agents on "immune targets" in renal transplantation. Immunological monitoring could indirectly measure the suppressive effect of these drugs and guide early preventive interventions in transplant recipients. Due to the selective antiproliferative effect of mycophenolate mofetil (MMF) on lymphocytes, our goal was to determine whether MMF modulates peripheral blood lymphocyte subsets (PBLS) in kidney allograft patients. METHODS: We assessed absolute CD3(+), CD3(+)CD4(+), CD3(+)CD8(+), CD19(+), CD16(+)CD3(-) PBLS counts and CD4/CD8 ratios for 12 months in three groups of kidney allograft patients stratified according to maintenance immunosuppressive regimen: group A (n = 31), which started MMF with prednisone (P) + cyclosporine A (CyA), and two control groups, B (n = 19) and C (n = 15) on P + CyA + azathioprine (Aza) and P + CyA regimens, respectively. We compared intra- and intergroup lymphocyte counts and ratios. RESULTS: Intergroup comparisons showed a significant reduction in all PBLS in group A (CD19(+) from 3 months and other subsets from 6 months), whereas there were no significant changes in PBLS in the other group analyses or comparisons. CONCLUSIONS: Our findings suggest that (1) MMF modulates all PBLS in kidney allograft patients, causing a progressive reduction occurring earlier in CD19(+), and (2) we can rule out that these changes were caused by the "natural immunological evolution" of the transplantation. These results could offer a new method for immunological monitoring of transplant patients.

[Consumer satisfaction with 2 models of primary care in operation in Andalucia]. / La satisfacción de los usuarios con los dos modelos de asistencia primaria vigentes en Andalucia.

A study was completed to investigate if any differences are observed in user satisfaction with health care centres, polyclinics and solo-practice, furthermore to identify user, organizational characteristics and doctors as variables that relate to user satisfaction in health care. A sample of users was chosen from the Andalusian cities of Granada, Málaga and Sevilla with an alpha = 5%, beta = 10% and d = 11%. The variables were collected trough the use of three questionnaires. Greater satisfaction was found between health care centre users than with polyclinics and solo-practice, with values being 62.4, 58.2 and 60.6 with a p < 0.001. The variables more strongly associated with user satisfaction in health care centres are those related with doctors and organization characteristics. Therefore several are capable of improvement in order to increase user satisfaction. On the contrary in polyclinics and solo-practice the most influential variables are those related with the user characteristics, which are not modifiable by the health services intervention.

[Trends in traffic accident mortality in Spain, 1962-1994]. / Evolución de la mortalidad por accidentes de tráfico en España, 1962-1994.

OBJECTIVE: To assess the evolution of the traffic accident mortality rate in Spain from 1962 to 1994, and the role played by its four theoretical components: motorization index (vehicles/population), accidentability index (accidents/vehicles), harmfulness index (victims/accidents) and fatality index (deaths/victims). METHODS: Data from the National Population Census and the Bulletin of the Dirección General de Tráfico were collected to estimate the above mentioned indicators for all accidents and accidents in road and urban zones. Simple and multiple partial correlation coefficients among variables were calculated. Poisson regression models were also obtained. RESULTS: An increasing trend during the whole period was observed for the national traffic accident mortality rate, especially from 1982 to 1989 in the younger age groups, followed by a decrease since 1990. The aforementioned four components were significatively associated with the mortality rate. The strength of this association was especially high for the motorization index and for the harmfulness index when all accidents and road accidents were considered. For urban accidents, the fatality index rate is the component most strongly associated with mortality rate. The role played by the accidentability index in the magnitude of the mortality rate seems less important. CONCLUSIONS: The growing exposure rate to traffic accidents observed in Spain (measured by the motorization index) is not directly influenced by public heath strategies. Therefore, it seems advisable to emphasize the development of measures focused to control the other three components of traffic accident mortality rate, especially those related with harmfulness and fatality.

[Inequalities in health: perinatal and infant mortality in Spain]. / Desigualdades en salud: la mortalidad perinatal e infantil en España.

The interregional variation coefficient (VC) has been considered as an accurate measure of the dispersion of regional infant, neonatal, postneonatal and perinatal mortality rates. Thus, trends of annual VC have been analyzed, for each rate, from 1940 to 1986, to identify the evolution in time of the regional differences with respect to these mortality rates. None of the four mortality rates showed a decreasing trend in their respective VCs. This may indicate that interregional differences do not change along time. The postneonatal mortality rate has been shown to have the highest VCs during the study period (ranging from 23 to 40%), with an independent evolution with respect to neonatal mortality rate, probably because the factors that influence both rates are clearly different.

[Association of age and sex with intensity of exposure to bicycle use in Spain, 1993-2009]. / Asociación de la edad y el sexo con la intensidad de la exposición al uso de la bicicleta en España, 1993-2009.

BACKGROUND: To estimate the association of age and sex with the intensity of exposure of cyclists in Spain, between 1993 and 2009, in a global way and for subtypes of use. METHODS: From the distribution of cyclists passively involved in collisions with other vehicles included in the register of the Spanish General Traffic Directorate between 1993 and 2009, we have estimated the increase in intensity of exposure by age groups and sex, for global exposure and for subtypes of exposure (e.g. riding with or without a helmet, or riding on an open road or in urban areas), using males aged 45-49 as a reference. RESULTS: Males have a greater exposure than females and this difference increases with age, although it has tended to decrease in recent years. In both sexes the exposure is greater in young people and goes down with age, while in males the excess in young people has disappeared in recent years. Regarding subtypes of use, female underexposure riding on an open road should be highlighted, as well as overexposure in both women and extreme age groups among non-helmet users. CONCLUSION: There is a close association of age and sex with the intensity of bicycle use, which changes depending on the type of use and the time period considered. Consequently, estimations of the effect of factors affecting the accident rate and the morbidity and mortality of cyclists in Spain have to be adjusted by the age and sex of the cyclist.

[Effects of contrast, eccentricity and position in the detection of visual stimuli in humans]. / Efectos del contraste, excentricidad y posicion en la deteccion de estimulos visuales en humanos.

INTRODUCTION: Contrast, eccentricity and position of stimuli used on research of attention in human vision strongly vary among studies. AIM. To study how contrast, eccentricity and position affects detection of stimuli in humans. SUBJECTS AND METHODS: In adults with normal vision, we measured response times to stimuli (gray circles of 0.5 masculine of diameter) presented at random at eight polar coordinates, in three eccentricities with respect of fixation point (2.15, 3.83 and 5.53 masculine) and with three levels of contrast (6, 16 and 78%). RESULTS: Stimuli with eccentricity of 5.38 masculine and 6% of contrast showed the longest response times. In all eccentricities studied, longer response times were found with stimuli of 6% of contrast. Response times of stimuli of 16% and 78% of contrast showed similar response times in all eccentricities studied. Response times founded at eight polar coordinates were heterogeneous at eccentricities of 2.15 and 5.53 masculine, but not at 3.83 masculine. CONCLUSIONS: Contrast is the factor that most influence detection of visual stimuli used in this study, particularly at the biggest eccentricity employed. Response times among polar coordinates are also affected by eccentricities of 2.15 and 5.53 masculine, suggesting that distance of stimuli to fixation point is critical for visual detection of stimuli.

Comparing the likelihood ratios of two binary diagnostic tests in the presence of partial verification.

The comparison of the efficiency of two binary diagnostic tests requires one to know the disease status for all patients in the sample, by applying a gold standard. In two-phase studies the gold standard is not applied to all patients in a sample, and the problem of partial verification of the disease arises. At present, one of the approaches most used for comparing two binary diagnostic tests are the likelihood ratios. In this study, the maximum likelihood estimators of likelihood ratios are obtained. The tests of hypothesis to compare the likelihood ratios of two binary diagnostic tests when both are applied to the same random sample in the presence of verification bias are deduced, and simulation experiments are performed in order to investigate the asymptotic behaviour of the tests of hypothesis. The results obtained have been applied to the study of Alzheimer's disease.

Predictive value of a screen for gestational diabetes mellitus: influence of associated risk factors.

BACKGROUND: There is a need for solid evidence of the relative advantages of universal vs. selective screening for gestational diabetes mellitus. Our study of a broad obstetric population determines the positive predictive value of the 50-g oral glucose challenge test for screening in the presence and absence of classical gestational diabetes risk factors. METHODS: A retrospective cohort study was carried out with a total of 2,574 pregnant women. Clinical information was obtained from hospital records and each patient's medical history, and gestational diabetes risk factors were quantified for each pregnant woman. The positive predictive value of a screen was determined with respect to the number of risk factors. RESULTS: Age 30 or over, family history of diabetes, obesity (BMI > or =27) and previous fetal macrosomia were established as the most frequent risk factors. Just over half (54.2%) of our population presented one or more risk factors. Screening covered 75% of the population, and was positive in 15% of the cases. Diagnosis was confirmed in 64 cases, 57 of them at risk, and seven with no risk factors. We obtained an overall positive predictive value of 21.8% (CI 17.3-27.0). This figure increases with the number of risk factors, from 12% for the women with no risk factors, to 40% for those presenting three or more risk factors. CONCLUSIONS: A selective screening program that takes into account the clinical background and characteristics of each pregnant woman allows a high yield of true positives while reducing the possible undesirable effects associated with false positives.