[Space-time suicide clustering in the community of Antequera (Spain)]. / Clusters de casos de suicidio espacio-temporal en la comunidad de Antequera (España).

INTRODUCTION: Approximately 3,500 people commit suicide every year in Spain. The main aim of this study is to explore if a spatial and temporal clustering of suicide exists in the region of Antequera (Málaga, España). METHODS: Sample and procedure: All suicides from January 1, 2004 to December 31, 2008 were identified using data from the Forensic Pathology Department of the Institute of Legal Medicine, Málaga (España). Geolocalisation. Google Earth was used to calculate the coordinates for each suicide decedent's address. Statistical analysis. A spatiotemporal permutation scan statistic and the Ripley's K function were used to explore spatiotemporal clustering. Pearson's chi-squared was used to determine whether there were differences between suicides inside and outside the spatiotemporal clusters. RESULTS: A total of 120 individuals committed suicide within the region of Antequera, of which 96 (80%) were included in our analyses. Statistically significant evidence for 7 spatiotemporal suicide clusters emerged within critical limits for the 0-2.5 km distance and for the first and second semanas (P<.05 in both cases) after suicide. There was not a single subject diagnosed with a current psychotic disorder, among suicides within clusters, whereas outside clusters, 20% had this diagnosis (X2=4.13; df=1; P<.05). CONCLUSIONS: There are spatiotemporal suicide clusters in the area surrounding Antequera. Patients diagnosed with current psychotic disorder are less likely to be influenced by the factors explaining suicide clustering.

Hepatic steatosis and severity-related factors in obese children.

BACKGROUND AND AIM: Obesity is an important health-care problem in developed countries. It is considered a multisystemic disease, but it may also affect the liver, thus provoking non-alcoholic fatty liver disease. This disease has been less extensively studied among children than among adults. We propose to analyze the prevalence of hepatic steatosis among a pediatric population within an area in southern Europe besides the variables associated with its development and severity. METHODS: Cross-sectional study carried out on a population of children aged 6-14 years inclusive, using abdominal ultrasound as a method to determine the presence and severity of hepatic steatosis; in addition, anthropometric and blood-tested parameters were examined to determine which of these were associated with steatosis. RESULTS: One hundred forty-four children were analyzed, 84 male (58.3%). Steatosis was detected in 50 children (34.7%; 95% confidence interval [CI]: 26.0-42.0%). In six of these cases (12%), elevated aminotransferase levels were recorded. Factors found to be associated with steatosis were body mass index ≥ 99th percentile (odds ratio [OR] 3.58, 95% CI 1.16-15.6) and the level of alanine aminotransferase (ALT) (OR 1.08, 95% CI 1.03-1.13), while its severity was associated with ALT (OR 1.17, 95% CI 1.09-1.28). A level of ALT < 23.5 UI/dL predicted lack of severe steatosis with an area under receiver operating characteristic curve of 0.805 (95% CI 0.683-0.927). CONCLUSIONS: Non-alcoholic fatty liver disease is common in the obese pediatric population in our geographical area. High levels of ALT are associated with severe steatosis, although having ALT above the normal range is not common. Also, the lack of severity of steatosis can be predicted in a subgroup of children with obesity.

[Prognostic factors and long-term survival after initial diagnosis of heart failure]. / Factores pronósticos y supervivencia a largo plazo tras el diagnóstico inicial de insuficiencia cardiaca.

BACKGROUND AND OBJECTIVE: To assess long-term mortality and prognostic factors after initial diagnosis of heart failure (HF), to analyze the differences in function of the left ventricular ejection fraction (preserved [HFPEF] vs. systolic dysfunction [HFSD]) and to compare the results with the main series of incident cases of HF published. PATIENTS AND METHODS: Retrospective cohort study including patients first diagnosed of heart failure (Framingham criteria), between 1-01-1997 and 31-12-2001, classified according to a left ventricle ejection fraction (LVEF) above or equal to 50% (HFPEF) or below 50% (HFSD). Follow-up of patients was conducted during ten years. RESULTS: Out of 400 incident cases of heart failure, 231 patients (57,7%) presented with HFPEF. At 10 years, mortality rates were higher in the HFSD group (64,5 vs. 55,4%, p=0,04). Following a multi-variant analysis, HFPEF mortality was related with age, diabetes mellitus, ischemic heart disease, and chronic renal failure. Treatment with statins and beta-blockers was associated with improved prognosis. Among patients with HFSD, mortality predictors were similar, although patients treated with statins did not show higher survival rates. For other series of incident cases, there were differences in variables related to prognosis and mortality of patients. CONCLUSIONS: After an initial diagnosis of HF, more than half of patients die within 10 years of monitoring. Age, diabetes mellitus, ischemic heart disease and chronic renal failure are all associated with worse prognosis in these patients, whereas the use of beta-blockers and statins is associated with a better prognosis.

Complications in immediate breast reconstruction after mastectomy.

OBJECTIVES: Immediate post-mastectomy breast reconstruction (IBR) is a procedure that has proven advantages, but it also entails risks. The aim of this study was to identify risk factors for reconstruction failure. METHODS: A review was made of all the IBR carried out at a general hospital from 2002 to 2009. Retrospective information was obtained about postoperative complications and the characteristics of patients and treatments applied. The minimum follow-up period was 9 months. Cox's regression analysis was performed on the variables related to the reconstruction failure requiring the removal of the prosthesis, with an explanatory model in which all the study variables were introduced and a predictive model that contained only the variables known before the intervention. RESULTS: A total of 115 IRB interventions carried out on 112 women with breast cancer were analyzed. The mean follow-up period was 25.5 months. In sixty cases (52.2 percent), there were no complications; in sixteen cases (13.9 percent) minor complications appeared, and in 39 (33.9 percent) the complications were moderate. In twenty-six cases (22.6 percent), a reconstruction failure occurred. Cox's regression model revealed that the reconstruction failures were related to the patient's age (Hazard Ratio 1.08), to neoadjuvant chemotherapy (HR 6.24) and to postoperative tamoxifen (HR 3.10). The predictive model included the age of the patient (HR 1.05) and the use of neoadjuvant chemotherapy (HR 5.11). CONCLUSIONS: A significant proportion of the patients receiving IBR developed reconstruction failure. Multivariate analysis identified three variables related to this complication, two of which were known before the intervention.

Development and validation of clinical scores for visual outcomes after cataract surgery.

PURPOSE: To develop and validate a clinical score to predict visual acuity (VA) and functional changes after phacoemulsification on the basis of readily obtainable preoperative history data and patient assessment. DESIGN: Prospective follow-up study. PARTICIPANTS: A sample of 5512 patients on waiting lists for phacoemulsification at 17 hospitals in Spain. METHODS: Data were obtained at the baseline examination from the 5512 patients. The patients were divided randomly into 2 subgroups: derivation (n = 3285; 60%) and validation (n = 2227; 40%). The preoperative predictors of postoperative gains in VA and visual function index 14 (VF-14) were determined by multivariate logistic regression analysis and implemented using a prediction score. MAIN OUTCOME MEASURES: Probability of postoperative improvement in VA and VF-14 scores. The cutoff points were established for each outcome on the basis of the minimal clinically important difference values. RESULTS: The predictive variables for VA gain were the baseline VA, patient age, ocular comorbidity, and surgical complexity. Regarding the VF-14, the predictive factors were the preoperative VF-14, the eye with the better VA, and the surgical complexity. In the multivariate logistic model in the derivation sample, the final VA and VF-14 scores ranged from 0 to 44 and from 0 and 24, respectively. Receiver operating characteristic curves were developed in the derivation and validation samples, and no statistical significance was found when their areas under the curve were compared. Areas under the curve ranged from 65% to 80%. Both scores had a positive predictive value from 74% to 85%. CONCLUSIONS: Newly developed and validated clinical prediction scores may assist physicians and patients in decision making about the expected outcomes and benefits of cataract surgery.

Role of mental disorders in nosocomial infections after hip fracture treatment.

The association between mental disorders (MDs) and iatrogenic complications after hip fracture surgery has been poorly studied. Among iatrogenic complications, nosocomial infections (NIs) are a major factor in hip fracture surgery. The aim of this paper was to determine whether patients with a MD and a hip fracture develop more NIs after hip surgery than patients with no MD. We studied 912 patients who underwent surgery for a hip fracture (223 patients with a MD who underwent surgery for a hip fracture and 689 control patients without a MD who also underwent surgery for a hip fracture) and followed them after surgery. Univariable and multivariable analyses were performed using simple and multiple logistic regression analysis (confidence interval, crude and adjusted odds ratios, and P value). We found that MDs, gender, and comorbidities were not associated with a higher risk of developing a NI after surgery for a hip fracture. Only age increases the risk of a NI.

Age as a risk factor of nosocomial infection after hip fracture surgery.

Surgery for the treatment of hip fractures is considered the gold standard even among nonagerians with a heavy comorbidity burden. Therefore, a study of an association between surgical complications and some variables in elderly individuals appears to be very important. We designed a transverse study in which we determined patient age at the time of development of a nosocomial infection (NI) in patients who underwent surgery to treat a hip fracture. Univariate and multivariate analyses were performed by simple and multiple logistic regression. We found that age was a determinant in NI after surgical treatment for hip fracture. The older the patient was, the higher the risk of development of an NI after surgical treatment for hip fracture (operative hypothesis). However, the risk of infection changed depending on the treatment. No association with other variables was found.

The Andalusian trial on heroin-assisted treatment: a 2 year follow-up.

INTRODUCTION AND AIMS: In 2003, a randomised controlled trial comparing injected diacetylmorphine and oral methadone was carried out in Andalusia, Spain. The subsequent follow-up study evaluated the health and drug use status of participants, 2 years after the completion of the trial. DESIGN AND METHODS: This follow-up cohort study was carried out between March and August 2006. Data collected included information on socio-demographics, drug use, health and health-related quality of life. We compared data collected before randomisation and at 2 years for the following three groups: those currently on heroin-assisted treatment (C-HAT), those who have discontinued HAT (D-HAT), and those who have never received HAT (N-HAT). RESULTS: From the total 62 randomised participants in 2003, 54 (87%) were interviewed for this study. Participants were distributed as follow: C-HAT 44.4% (24), N-HAT 22.2% (12) and D-HAT 33.3% (18). Illicit heroin use had a statistically significant decrease in the three groups from baseline to 2 years post trial. Mean days of heroin use were 2.42 (SD = 3.02); 6.56 (SD = 9.48) and 13.92 (SD = 12.59) for the C-HAT, D-HAT and N-HAT groups, respectively. Those currently on HAT were the only group that sustained at 2 years, their marked improvement in health after 9 months of treatment during the trial period. DISCUSSION AND CONCLUSIONS: Patients who received HAT showed better outcomes compared with those not on HAT. The results of this study strengthen the evidence showing that HAT can improve and stabilise the health of long-term heroin users with severe comorbidities and high mortality.

Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis.

We searched systematically for randomized controlled trials, comparing moxibustion with a nonmoxibustion control group or other methods such as external cephalic version, postural methods, and acupuncture in databases, both Western and Chinese, up to June 2007. Six studies, with 1087 subjects and a high degree of heterogeneity, compared moxibustion vs observation or postural methods and reported a rate of cephalic version among the moxibustion group of 72.5% vs 53.2% in the control group (relative risk, 1.36; 95% confidence interval, 1.17-1.58); the number needed to treat was 5 (95% confidence interval, 4-7). In terms of safety, no significant differences were found in the comparison of moxibustion with other techniques. Moxibustion at acupuncture point BL67 has been shown to produce a positive effect, whether used alone or in combination with acupuncture or postural measures, in comparison with observation or postural methods alone, for the correction of nonvertex presentation, although these results should be viewed with caution, given the considerable heterogeneity found among studies.

Efficacy of prescribed injectable diacetylmorphine in the Andalusian trial: Bayesian analysis of responders and non-responders according to a multi domain outcome index.

BACKGROUND: The objective of this research was to evaluate data from a randomized clinical trial that tested injectable diacetylmorphine (DAM) and oral methadone (MMT) for substitution treatment, using a multi-domain dichotomous index, with a Bayesian approach. METHODS: Sixty two long-term, socially-excluded heroin injectors, not benefiting from available treatments were randomized to receive either DAM or MMT for 9 months in Granada, Spain. Completers were 44 and data at the end of the study period was obtained for 50. Participants were determined to be responders or non responders using a multi-domain outcome index accounting for their physical and mental health and psychosocial integration, used in a previous trial. Data was analyzed with Bayesian methods, using information from a similar study conducted in The Netherlands to select a priori distributions. On adding the data from the present study to update the a priori information, the distribution of the difference in response rates were obtained and used to build credibility intervals and relevant probability computations. RESULTS: In the experimental group (n = 27), the rate of responders to treatment was 70.4% (95% CI 53.287.6), and in the control group (n = 23), it was 34.8% (95% CI 15.354.3). The probability of success in the experimental group using the a posteriori distributions was higher after a proper sensitivity analysis. Almost the whole distribution of the rates difference (the one for diacetylmorphine minus methadone) was located to the right of the zero, indicating the superiority of the experimental treatment. CONCLUSION: The present analysis suggests a clinical superiority of injectable diacetylmorphine compared to oral methadone in the treatment of severely affected heroin injectors not benefiting sufficiently from the available treatments. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52023186.

[Use and evaluation of the health care services and the antirretroviral medication in HIV diagnosed people]. / Uso y valoración de los servicios sanitarios y de la medicación antirretroviral en personas diagnosticadas de infección por el virus de la inmunodeficiencia humana.

AIM: To analyze the use or not of antirretrovirals (ART) human inmunodeficiency virus (HIV) diagnosed people in relation to the utilization and evaluation of the health care services and sociodemographic profiles. METHODS: The data was collected with a questionnaire to 108 HIV people, in the city of Granada (Spain) between July and September 2005. Participants were contacted from three sources: infectious diseases service, HIV's nongovernmental association and from the street through peers. RESULTS: The mean age was 40 years, and the participants knew that they were seropositives since a mean of 12 years ago. At the moment of the interview, 55.6% consumed illegal drugs (cannabis not included), and 63.9% were former injecting drug users. In relation to ART, 25% did not take it, 15.7% were totally adherent, and 59.3% were in treatment but failed in the intake of the medication as prescribed. In general, participants have a positive and accurate perception of ART. The group of the adherents showed the best scores and those who do not take ART the lowest, in almost the totality of the studied variables. CONCLUSION: The present study suggests that is important continuing to improve the access to the health and social resources, to implement strategies of motivation for patients who have been many years in HIV treatment and to integrate in the health care system social excluded HIV positive people.

Pre-hospital antibiotic treatment and mortality caused by invasive meningococcal disease, adjusting for indication bias.

BACKGROUND: Mortality from invasive meningococcal disease (IMD) has remained stable over the last thirty years and it is unclear whether pre-hospital antibiotherapy actually produces a decrease in this mortality. Our aim was to examine whether pre-hospital oral antibiotherapy reduces mortality from IMD, adjusting for indication bias. METHODS: A retrospective analysis was made of clinical reports of all patients (n = 848) diagnosed with IMD from 1995 to 2000 in Andalusia and the Canary Islands, Spain, and of the relationship between the use of pre-hospital oral antibiotherapy and mortality. Indication bias was controlled for by the propensity score technique, and a multivariate analysis was performed to determine the probability of each patient receiving antibiotics, according to the symptoms identified before admission. Data on in-hospital death, use of antibiotics and demographic variables were collected. A logistic regression analysis was then carried out, using death as the dependent variable, and pre-hospital antibiotic use, age, time from onset of symptoms to parenteral antibiotics and the propensity score as independent variables. RESULTS: Data were recorded on 848 patients, 49 (5.72%) of whom died. Of the total number of patients, 226 had received oral antibiotics before admission, mainly betalactams during the previous 48 hours. After adjusting the association between the use of antibiotics and death for age, time between onset of symptoms and in-hospital antibiotic treatment, pre-hospital oral antibiotherapy remained a significant protective factor (Odds Ratio for death 0.37, 95% confidence interval 0.15-0.93). CONCLUSION: Pre-hospital oral antibiotherapy appears to reduce IMD mortality.

Ankle-brachial index in HIV infection.

Prognosis for patients with the human immunodeficiency virus (HIV) has improved with the introduction of highly active antiretroviral therapy (HAART). Evidence over recent years suggests that the incidence of cardiovascular disease is increasing in HIV patients. The ankle-brachial index (ABI) is a cheap and easy test that has been validated in the general population. Abnormal ABI values are associated with increased cardiovascular mortality. To date, six series of ABI values in persons with HIV have been published, but none was a prospective study. No agreement exists concerning the risk factors for an abnormal ABI, though its prevalence is clearly higher in these patients than in the general population. Whether this higher prevalence of an abnormal ABI is associated with a higher incidence of vascular events remains to be determined.

New therapeutic approach to Tourette Syndrome in children based on a randomized placebo-controlled double-blind phase IV study of the effectiveness and safety of magnesium and vitamin B6.

BACKGROUND: Tourette Syndrome (TS) is a neurological condition presenting chronic motor and phonic tics, and important degree of comorbidity. Considered an uncommon illness, it first becomes apparent during childhood. Current standard treatment only achieves partial control of the condition, and provokes frequent, and sometimes severe, side effects. METHODS AND DESIGN: Main aim: To show that, with respect to placebo treatment, the combination of 0.5 mEq/Kg magnesium and 2 mg/Kg vitamin B6 reduces motor and phonic tics and incapacity in cases of exacerbated TS among children aged 7-14 years, as measured on the Yale Global Tic Severity Scale (YGTSS). Secondary aims: Assess the safety of the treatment. Describe metabolic changes revealed by PET. Measure the impact of the experimental treatment on family life. METHODOLOGY: Randomized, blinded clinical trials. Phase IV study (new proposal for treatment with magnesium and vitamin B6). SCOPE: children in the geographic area of the study group. Recruitment of subjects: to include patients diagnosed with TS, in accordance with DSM-IV criteria (307.23), during a period of exacerbation, and provided none of the exclusion criteria are met. INSTRUMENTATION: clinical data and the YGTSS score will be obtained at the outset of a period of exacerbation (t0). The examinations will be made after 15 (t1), 30 (t2), 60 (t3) and 90 days (t4). PET will be performed at the t0 and t4. We evaluated decrease in the overall score (t0, t1, t2, t3, t4), PET variations, and impact made by the treatment on the patient's life (Psychological General Well-Being Index). DISCUSSION: Few clinical trials have been carried out on children with TS, but they are necessary, as current treatment possibilities are insufficient and often provoke side effects. The difficulty of dealing with an uncommon illness makes designing such a study all the more complicated. The present study seeks to overcome possible methodological problems by implementing a prior, phase II study, in order to calculate the relevant statistical parameters and to determine the safety of the proposed treatment. Providing a collateral treatment with magnesium and vitamin B6 could improve control of the illness and help reduce side effects. This protocol was approved by the Andalusian Government Committee for Clinical Trials (Spain). This study was funded by the Health Department of the Andalusian Regional Government and by the Healthcare Research Fund of the Carlos III Healthcare Institute (Spanish Ministry of Health). TRIAL REGISTRATION: Current Controlled Trials ISRCTN41082378.

Prognostic implications of emergency admission and delays in patients with breast cancer.

INTRODUCTION: This study evaluates clinical-pathological characteristics and survival rates associated with emergency admission and delays in diagnosis and treatment of 411 consecutive breast cancer patients. MATERIALS AND METHODS: Emergency admission and first symptom-first hospital visit delay were significantly associated with advanced tumor stages but only in the former case with short disease-free survival (RR 2.5, CI 95% 1.5-4.2). RESULTS: Brief diagnostic delays were significantly associated with advanced disease stage and poor survival rates (RR 2.04; CI 95% 1.08-3.82) probably because sicker patients receive prompt medical attention.

[An open study evaluating the efficacy and security of magnesium and vitamin B(6) as a treatment of Tourette syndrome in children]. / Estudio piloto sin grupo control del tratamiento con magnesio y vitamina B(6) del síndrome de Gilles de la Tourette en niños.

BACKGROUND AND OBJECTIVE: We intended to ascertain the effectiveness and safety of oral solutions of magnesium and vitamin B(6) in alleviating the symptoms emerged during clinical exacerbations in children aged 7-14 years suffering from Tourette syndrome (TS). We also aimed to determine the mean and the standard deviation of such an improvement in order to estimate sample sizes in future assays with a control group. PATIENTS AND METHOD: The treatment under investigation was administered to children diagnosed with TS, in accordance with Diagnostic and Statistical Manual of Mental Disorders, fourth edition -IV, under conditions of clinical exacerbation. The effects were scored on the Yale Global Tics Severity Scale (YGTSS) at 0, 15, 30, 60 and 90 days. RESULTS: The total tics score decreased from 26.7 (t0) to 12.9 (t4) and the total effect on the YGTSS was a reduction from 58.1 to 18.8. Both results were statistically significant. With respect to the application of conventional treatment or otherwise, no significant differences were observed. No side effects were seen. CONCLUSIONS: The treatment assayed is safe and effective in reducing the harmful effects of TS in children. Further studies are needed, with a control group, and evaluation of different doses of the drugs.

[First antiretroviral therapy regimen in HIV-infected patients. Durability and factors associated with therapy changes]. / Primera pauta de tratamiento antirretroviral en pacientes con infección por el virus de la inmunodeficiencia humana. Durabilidad y factores asociados a su modificación.

AIM: To analyze the durability of the first highly active antiretroviral therapy (HAART) regimen used in naïve HIV-infected patients and the factors leading to therapy changes. METHODS: Multicenter, retrospective study of naïve HIV-infected patients from 5 hospitals in Málaga (southeast Spain), who started HAART between January 1997 and December 2003. The main outcome measure was median time to the first change in the antiretroviral regimen. A descriptive analysis was performed and Kaplan-Meier curves were used to assess durability of the first HAART used. Independent factors associated with durability were evaluated with a Cox multiple regression model. RESULTS: A total of 603 patients started HAART, and 130 (21.6%) remained under the same treatment at the latest evaluation point. Median time on the same HAART was 17.5 months, and reached 24 months when cases of simplification or structured intermittent treatment interruption were excluded from the analysis. HAART had been interrupted in 36% by one-year of follow-up. Toxicity was the main cause of switching therapy (25%), followed by simplification (19%), and virologic failure (15%). Longer durability of HAART was observed in non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens, (P < 0.046; HR, 1.58) and in those with less than 5 pills (P < 0.001; HR, 2.05). CONCLUSION: Median durability of the first HAART was almost one year and a half, and discontinuation was mainly due to toxicity. NNRTI regimens showed longer durability, which could be attributable to a lower pill burden, at least in part.

Randomised controlled study in the primary healthcare sector to investigate the effectiveness and safety of auriculotherapy for the treatment of uncomplicated chronic rachialgia: a study protocol.

BACKGROUND: Uncomplicated chronic rachialgia is a highly prevalent complaint, and one for which therapeutic results are contradictory. The aim of the present study is to evaluate the effectiveness and safety of treatment with auriculopressure, in the primary healthcare sector, carried out by trained healthcare professionals via a 30-hour course. METHODS/DESIGN: The design consists of a multi-centre randomized controlled trial, with placebo, with two parallel groups, and including an economic evaluation. Patients with chronic uncomplicated rachialgia, whose GP is considering referral for auriculopressure sensory stimulation, are eligible for inclusion. Sampling will be by consecutive selection, and randomised allocation to one of the two study arms will be determined using a centralised method, following a 1:1 plan (true auriculopressure; placebo auriculopressure). The implants (true and placebo) will be replaced once weekly, and the treatment will have a duration of 8 weeks. The primary outcome measure will be the change in pain intensity, measured on a visual analogue scale (VAS) of 100 mm, at 9 weeks after beginning the treatment. A follow up study will be performed at 6 months after beginning treatment. An assessment will also be made of the changes measured in the Spanish version of the McGill Pain Questionnaire, of the changes in the Lattinen test, and of the changes in quality of life (SF-12). Also planned is an analysis of cost-effectiveness and also, if necessary, a cost-benefit analysis. DISCUSSION: This study will contribute to developing evidence on the use of auriculotherapy using Semen vaccariae [wang bu liu xing] for the treatment of uncomplicated chronic rachialgia. TRIAL REGISTRATION: Current Controlled Trials ISRCTN01897462.

Effectiveness of acupuncture, special dressings and simple, low-adherence dressings for healing venous leg ulcers in primary healthcare: study protocol for a cluster-randomized open-labeled trial.

BACKGROUND: Venous leg ulcers constitute a chronic recurring complaint that affects 1.0-1.3% of the adult population at some time in life, and which corresponds to approximately 75% of all chronic ulcers of the leg. Multilayer compression bandaging is, at present, the only treatment that has been proved to be effective in treating this type of ulcer. There is no consensus, however, about the dressings that may be applied, beneath the compression, to promote the healing of this type of ulcer, as there does not seem to be any added benefit from using special dressings rather than simple, low-adherence ones. As well as analgesia, acupuncture provokes peripheral vasodilation, in skin and muscles - which has been demonstrated both experimentally and in clinical practice - probably due to the axon reflex, among other mechanisms. The aim of the present study is to measure the effectiveness and cost of compression treatment for venous leg ulcers combined with special dressings, in comparison with low-adherence ones and acupuncture. METHODS/DESIGN: Cluster-randomized open-labeled trial, at 15 primary healthcare clinics in the Sevilla-Sur Healthcare District, with a control group treated with compression bandaging and low-adherence dressings; the experiment will consist, on the one hand, of the compression treatment applied in combination with special dressings (Treatment 1), and on the other, the compression treatment applied in association with low-adherence dressings, together with acupuncture (Treatment 2). DISCUSSION: The results will be measured and recorded in terms of the median time elapsed until complete healing of the ulcer, and the rate of complete healing at 3 months after beginning the treatment. An economic analysis will also be made. This study, carried out in the context of real clinical practice, will provide information for decision-taking concerning the effectiveness of special dressings. Moreover, for the first time a high-quality study will evaluate the effectiveness of acupuncture in the process of healing venous leg ulcers. TRIAL REGISTRATION: Current Controlled Trials ISRCTN26438275.

[Pharmacological treatment adherence by older patients after hospital discharge]. / Adherencia al tratamiento farmacológico en pacientes ancianos tras el alta hospitalaria.

UNLABELLED: Little information is available on drug adherence in older patients after discharge or on predictors of non-adherence. OBJECTIVES: To determine the rate of treatment adherence and associated factors in elderly patients after hospital discharge with a view to identifying opportunities for improvement. METHOD: We performed a cross-sectional study of 70 patients aged over 65 years old discharged from an internal medicine unit who were self-sufficient regarding treatment management. RESULTS: Only 8.6% of patients complied with the recommended treatment. Eighty-five percent of the drugs were taken incorrectly: 67% were taken in excess, 33% were taken less than prescribed, and 54% were taken without following the recommendations concerning timetable and food intake. The most frequent reasons identified by the patients for not taking the medication correctly were lack of knowledge and forgetfulness. The most frequent risk factors were male gender, living with adult siblings, and taking a large number of prescribed medicines. Information given by the doctor about the treatment and assistance from a friend or relative at home increased adherence. CONCLUSIONS: Treatment adherence after hospital discharge in patients aged over 65 years old is very low. Instruments should be sought to counter forgetfulness and recommendations should be adapted to improve patients' knowledge of prescriptions.