Prevalence of osteoporotic fracture risk factors and antiosteoporotic treatments in the Valencia region, Spain. The baseline characteristics of the ESOSVAL cohort.

UNLABELLED: This study provides information on the prevalence of the most important risk factors for osteoporosis and osteoporotic fracture in a large sample of women and men from the Valencia region and also provides the FRAX 10-year major and hip fracture risks for this population, as well as data about the use of diagnostic tests and antiosteoporotic treatments. INTRODUCTION: The purpose of this study was to describe demographic characteristics, osteoporosis risk factors, the 10-year risk of osteoporotic fracture, and the use of densitometry and antiosteoporotic treatments in the Valencia region, Spain. METHODS: A cross-sectional study using the ESOSVAL cohort baseline data was conducted. We analyze the data from 5,310 women and 5,725 men aged 50 and over who attended to 272 collaborating primary care centers in 2009-2010. We collected the demographic, anthropometric, clinical, and pharmacy data from the electronic medical record. RESULTS: The mean age of participants was 64.3 years old for women and 65.6 years old for men. The most frequent fracture risk factors were sedentary life (22.2 %) and previous fracture (15.8 %) in women and low calcium intake (21.4 %) and current smoker (20.9 %) in men. According to FRAX(®), the 10-year risk of presenting a major fracture was 5.5 % for the women and 2.8 % for the men. The 10-year risk for hip fracture was 1.9 and 1.1 % for the women and the men, respectively; 23.8 % of the women and 5.2 % of the men had a densitometry test, 27.7 % of the women and 3.5 % of the men were taking calcium and/or vitamin D supplements, and 28.2 % of the women (22.0 % in the 50-64 age group) and 2.3 % of the men were taking antiosteoporotic drugs. CONCLUSIONS: The prevalence of certain fracture risk factors not included in the FRAX tool (sedentary life, falls, low calcium intake) is high. In young women, their low risks estimated by FRAX contrast with the high figures for densitometry testing and treatment.

Agreement between semi-automatic radiographic morphometry and Genant semi-quantitative method in the assessment of vertebral fractures.

UNLABELLED: Semi-automatic morphometry is highly reproducible and not time intensive; however, no study has evaluated agreement between semi-automated morphometric methods and the Genant semi-quantitative method performed as a rule by radiologists. Our study shows substantial agreement between both methods; however, semi-automatic morphometry upgrades mild deformities and overestimates the prevalence of fractures. INTRODUCTION: The aim of this study was to evaluate the agreement between radiologists using the Genant semi-quantitative (SQ) method and semi-automated morphometry in the diagnosis of vertebral fractures in post-menopausal women. METHODS: Cross-sectional study was conducted in 2006-2007 in an age-stratified population-based sample of 824 post-menopausal women over the age of 50. From this population two sets of 95 and 50 X-ray were randomly extracted to test inter-rater agreement and agreement between SQ and semi-automated morphometry, and vertebral fractures were classified according to both methods. The Genant method was used to homogenise the diagnosis of fractures. Agreement was evaluated with weighted kappa. We evaluated each vertebral body independently and also the whole vertebral column (T4-L4) classifying women into the worst grade of fracture. For the qualitative interpretation of the agreement, we used the criteria described by Landis and Koch (Biometrics 33:159-174, 1977). RESULTS: The radiologists' agreement was 98.4% (Kappa, 0.75; 95% CI, 0.42-0.89). Agreement between semi-automated morphometry and SQ reached 97.6% and Kappa was 0.86 (95% CI, 0.66-0.94). In the whole evaluation of the spine semi-automated morphometry overestimates, the prevalence of fractures compared with the radiologists were 15.8% of women with fractures and 7.4% of women with moderate-severe fractures by semi-automated morphometry vs. 8.4% and 3.2% by the SQ method. The negative predictive value for MorphoXpress was 99% while the positive was 40%. CONCLUSIONS: Semi-automated morphometry shows high reliability and a substantial agreement with the SQ approach but overestimates the prevalence of fractures. Its role in routine clinical practice is limited because positive results should be reassessed by qualitative or semi-quantitative methods.

[Restless legs syndrome: detection, diagnosis, impact on health and utilization of health care resources]. / El síndrome de piernas inquietas: detección, diagnóstico, consecuencias sobre la salud y utilización de recursos sanitarios.

INTRODUCTION: Despite the high prevalence of Restless Legs Syndrome (RLS) reported, little information is available about this disorder in Spain. The present study was conducted to obtain information on this condition from patients identified by a simple screening questionnaire and subsequent diagnostic confirmation by the Primary Care Practitioner (PCP). MATERIALS AND METHODS: Three-stage, cross-sectional and retrospective (resource utilization), observational study in a sample of adult patients (2,047 subject) attending 10 outpatient Primary Care centers in Madrid, Barcelona and Valencia. A screening questionnaire containing the 4 RLS diagnostic criteria was used. Clinical assessment and RLS diagnosis confirmation was performed using a structured questionnaire. Other variables assessed were quality of life by SF-36 questionnaire scoring; sleep by the MOS sleep scale; symptom severity of RLS symptoms by the IRLS scales; health care resource utilization in the previous 12 months by completion of questionnaire following patient chart review. The diagnosis made by the PCP was confirmed in a small sample of patients by a neurologist expert in Movement Disorders. RESULTS: A total of 19.7% (404 out of 2,047) subjects positively answered the 4 diagnostic questions of the RLS screening questionnaire. Of these, 185 (9.0%) reported moderate to severe symptoms at least twice weekly. The PCP made a diagnosis of RLS in 79 of 154 patients completing the diagnostic interview. Thus, prevalence of RLS estimated in this adult population was 4.6%. The predictive value of the screening RLS questionnaire was 51.3%. Average age of symptom onset was 42 years (range: 20 - over 80 years). RLS symptoms were moderately (50.6%) or extremely (38%) distressing and 73.4% of RLS patients slept poorly at least two nights a week. This diagnosis represents 9.4% of all patients presenting to PCP and experiencing poor sleep. Mean score in the IRLS scale (0 - 40) was 19.4. Average score of SF-36 questionnaire (0-100) was 54.6, lower than the Spanish general reference population (61.4). About one third of the RLS patients had seen a physician because of RLS symptoms. However, a diagnosis was made in only 48% of these and only 5% the diagnosis was RLS. CONCLUSIONS: The DECODE RLS - Spain study shows that many patients with classical RLS symptoms frequently see their PCP without being adequately diagnosed and treated. Screening tools such as that used in this study may contribute to the detection of these patients.

[Interruption to treatment with combined lopinavir/ritonavir therapy in HIV positive patients]. / Interrupción del tratamiento con la terapia combinada lopinavir/ritonavir en pacientes VIH+.

OBJECTIVE: To describe the extent of interruptions to treatment with therapies which include the combination of lopinavir-ritonavir within the SNS (Spanish National Health System), as well as identify the causes of these interruptions and analyse the factors associated with the same. METHOD: Retrospective cohort of 197 seropositive patients, who began treatment with lopinavir-ritonavir between January 2000 and October 2002. The patients attended the outpatient pharmaceutical care unit and were followed-up until December 2002. Interruptions and their causes were identified and the factors associated with the interruption were analysed using proportional hazard models. RESULTS: The mean follow-up period was 263 days and 38.6% of patients interrupted therapy. The most common causes of interruption were intolerance (30.3%), non-compliance (21.1%) and therapy failure (5.26%). The mean treatment period was 487 days (95% CI: 432 to 542) and 50% of patients who interrupted treatment did so within the first 4 months. No associations were found between patient or treatment characteristics and the risk of interruption. CONCLUSIONS: The percentage of interruptions was lower than those in other observational studies, but greater than those in clinical trials. The significance of the causes of interruption was similar and no factor associated with the risk of interruption was found.

[Evaluation of the quality of inter-clinic documents. Does their proper filling out by the family doctor affect the reply obtained from the specialist?]. / Evaluación de la calidad del documento de interconsulta. 'Influye la adecuada cumplimentación del médico de familia en la respuesta que obtiene del especialista?

OBJECTIVE: To analyse the filling out of the inter-clinic form (IF) at a centre with special fields of care (CS) and to assess whether its proper filling out in primary care (PC) affects the reply from specialist care. DESIGN: Cross-sectional, descriptive study. SETTING: Primary health care area in the Community of Valencia. PARTICIPANTS: Randomised sample of IFs of patients referred for the first time from PC to specialists. MAIN MEASUREMENTS: Evaluation criteria were grouped in two: those IFs were considered acceptable (IFCA) in which the family doctor included the reason for consultation or his/her diagnostic impression, as well at least one of the following: anamnesis, personal background, physical examination, further tests or current medication. The remaining IFs were considered inadequately filled out (IFCI). RESULTS: The sample analysed for the IF audit of the CS was 392 people. The result of the audit in the specialist clinics was that 243 IFs were blank (62.0%); the specialist doctor was identified in 19% of cases; the diagnosis was given in 23.5%; treatment, in 21%, and the follow-up plan, in 20%. In the PC evaluation, there were no blank IFs; anamnesis was recorded in 41.8%; reason for consultation in 73%; suspected diagnosis in 58.2%, and treatment in 11.5%. The sample to analyse the differences in the filling of the form in specialist care according to the quality of the PC filling out was 529 IFs. 56.3% of the IFs were considered acceptable. No statistically significant differences were found in the filling of any of the criteria of evaluation by the specialist doctor between the IFs from PC of acceptable and inadequate quality, except on the question of specifying treatment. CONCLUSIONS: We found no relationship between the quality of the IF from PC and the reply from specialist care. Currently, the filling out of IFs continues to be deficient.

[Influence of patient's sex on the quality of medicine taken]. / Influencia del sexo del paciente en la calidad de los medicamentos consumidos.

OBJECTIVE: To analyse the relationship between patient's sex and quality of medicine taken by monitoring the most pertinent predictive variables. DESIGN: Observational cross-sectional study. SETTING: Thirteen Health Centres in the Community of Valencia. PARTICIPANTS: Adult users, selected by consecutive sampling. MAIN MEASUREMENTS: A semi-structured questionnaire collected the following variables: social and personal details, use of medicines for health problems, frequency of use of services, and place where prescription was issued. The quality of the medication was measured by its intrinsic value (IV). RESULTS: 412 of the 812 patients were women. Men took more medication with a high IV, and women more with an unacceptable IV. Women over 45 took more medication with a not-high IV. Multivariate analysis showed: a) women took one and a half times more medicines with a not-high IV than men, with differences not significant, and b) in the 45-64 age-group, being a woman operated as a modifier of effect, increasing prevalence of consumption of not-high IV to two and a half times more than men. This was adjusted for frequency of attendance, health problems and where the prescription was issued. CONCLUSIONS: The study helped clarify the influence of gender on the quality of medicine, by pointing to the greater likelihood of women between 45 and 64 taking lower-quality medication. In addition, it showed the effect of where the prescription was issued and of health problems on explaining this difference in consumption.

[Consumption of medicinal herbs and medicines]. / Consumo de hierbas medicinales y medicamentos.

OBJECTIVE: Given the possibility of adverse side-effects, interactions with medicines and poisoning by contaminants among herbal medicine consumers (HM), we aimed to describe the consumption of HM by health centre users being treated with medicines. DESIGN: Cross-sectional, observational study.Setting. Thirteen health centres in the Community of Valencia. PATIENTS AND OTHER PARTICIPANTS: Users of either sex, over 14, chosen for a study of use of medicines to find differences between the sexes. MEASUREMENTS AND MAIN RESULTS: The study variables, age, gender, education, consumption of medicines and use of HM, were gathered from the clinical records, the long-treatment card and an ad hoc structured survey. 801 out of 812 users took medicines. 159 took HM (19.6%; 95% CI, 16.9-22.3); average age 55.8 (SD, 16.5); women 58.5% (95% CI, 50.8-66.1). They took 226 HM (mean of 1.42; 95% CI, 1.32-1.52). Men consumed more HM (p < 0.05). There were no differences in consumption of HM for age, educational background or number of medicines taken. 42.8% (95% CI, 35.1-50.2) of those who took HM attended for consultation over 10 times in the previous year. 96.9% (95% CI, 93.7-98.4) of HM were taken by self-medication. They were consumed: <> by 36.7% (95% CI, 30.4-43.0); stomach problems, 19.5% (95% CI, 14.3-24.6); nerves/depression, 12.8% (95% CI, 8.5-17.2); intestinal disorders, 10.6% (95% CI, 6.6-14.6); insomnia 5.8% (95% CI, 3.1-9.6). 49.1% (95% CI, 42.6-52.6) were manufactured HM. CONCLUSIONS: One of every five patients being treated with medicines is also taking HM by self-medication. The health authorities and doctors should advise of the risks to health and of the counter-indications of these products.

[Compliance of hormone replacement therapy in menopausal women]. / Cumplimiento del tratamiento hormonal sustitutivo en mujeres menopáusicas.

BACKGROUND: The effectiveness of a given treatment is only achieved with a due compliance. Our objective was to know the compliance degree of hormone replacement therapy (HRT) in menopausal women. METHOD: A descriptive observational study was carried out in three hospitals in the Valencia Community (Spain). We included menopausal patients who were visited in a menopause unit from 1989 to 1999 and who were administered HRT. We analyzed age, age at menopause, type of menopause, age at starting HRT, education level, prescription reason, treatment duration, information level, side effects, and causes leading to withdrawal. RESULTS: The study was performed in 363 women. There were 75% probabilities that women fulfilled the therapy for 5 years. The median of fulfillment was 11 years. Those women who had side effects were more prone to withdraw the treatment. By contrast, women who experienced benefits were less prone to withdraw it. Risk of withdrawal was also lower in cases of postsurgery menopause and in women who were younger than 55 years when they started HRT. CONCLUSIONS: In our study, the compliance level was high and it was determined either by treatment benefits or side effects, type of menopause and age at starting HRT.

[The use of drugs as a risk factor for poorly controlled arterial hypertension]. / Uso de medicamentos como factor de riesgo de hipertensión arterial mal controlada.

OBJECTIVE: To describe use of medication simultaneously with antihypertensive drugs that can cause inadequate pharmacological control of hypertension (HTA). DESIGN: A descriptive observational retrospective study. SETTING: Four urban health care center, Valencia. PARTICIPANTS: 389 patients with hypertension and chronic treatment card opened (TLT). MEASUREMENTS AND MAIN RESULTS: Were collected from de TLT and from the health history (HS) the number and type of drugs used against the hypertension and drugs with hypertensive effects, and number of potential interactions, type and duration of simultaneous treatment. 32.39% of the study subjects used drugs with potential hypertensive effects. The mean of interactions found were 1.75; 145 drugs were responsible of the 220 potential interactions found, 66.89% were non-steroids anti-inflammatory drugs (AINEs) and 23.45% antacids; 6.43% of the patients used another drug that increases by itself blood pressure; 96% of them were glucocorticoids. Jointly administration of drugs with potential antihypertensive effect occurs in 63.18% among drugs chronically prescribed. In a 28.45% the concurrent treatment was kept longer than 9 months. CONCLUSIONS: The third part of the hypertensive patients with pharmacological treatment, during a year-long period, used any moment, some drug with potential hypertensive effect. The third part of them this simultaneous treatment was kept for more than 9 months. It is necessary to take into account the use of other drugs simultaneously with antihypertensive drugs.

[Helicobacter pylori: 6-day triple therapy in duodenal ulcer]. / Helicobacter pylori: triple terapia de 6 días en el ulcus duodenal.

OBJECTIVES: To find the effectiveness of short-term eradication treatment of Helicobacter pylori in the duodenal ulcer. DESIGN: Intervention study, open controlled, randomised with parallel groups. SETTING: Three Health Centres in the city of Valencia. PATIENTS: Patients with a duodenal ulcer diagnosis and a Helicobacter pylori infection who attended the Primary Care physician. INTERVENTION: The study group (48 patients) was treated for six days with the triple therapy: Amoxycillin, Clarithromycin and Omeprazole. The control group (40 patients) was treated with Omeprazole for six weeks. MEASUREMENTS AND MAIN RESULTS: The observance period lasted a year, after which the Elisa test was conducted. Eradication was successful for 65% of those treated with the triple therapy, but for only 30% of those treated with monotherapy. The consumption of medication for the ulcer during the year of observance was almost three times greater in the group treated with monotherapy than in the triple-therapy group. CONCLUSIONS: Eradicative triple therapy was shown to be more effective and efficient than monotherapy. It is feasible to use it in Primary Care. Eradicative triple therapy is not advisable within six days: a longer treatment period should be employed with this recommendable therapy.

[Health visit to the newborn]. / Visita de salud al recién nacido.

Each child's medical record was reviewed to pick out any health problems detected in 1) the Newborn Checkup, 2) the first 15 days of life, and 3) during the child's first year. The number of visits was also recorded. Each mother was interviewed about the acceptability/usefulness of these checkups. The newborn checkup facilitates compliance with programmed checkups in the health plan for a healthy child. This program is useful to detect health problems precociously, to increase the knowledge mothers possess, to build confidence in nurses, and in general, to build up links with the pediatrics services of a health center.

[Pertinence of analysis requests in primary care]. / Pertinencia de las peticiones analíticas en atención primaria.

OBJECTIVE: To find the relevance of analytic tests requested by the Primary Care doctor. DESIGN: A descriptive crossover study. Relevance was decided by the definition of criteria through consensus techniques. SETTING: Three urban Health Centres in Area 4 of the City of Valencia. PARTICIPANTS: All the requests for analysis made by 31 general practitioners over four days were included in the study. MEASUREMENTS AND MAIN RESULTS: Relevance was evaluated by four assessors. The reliability of the method used was calculated through the simple concordance index (0.708-0.842) and the Kappa index (0.421-0.661). 355 path analyses were examined. Three of the assessors found between 60 and 63% of the requests relevant; the fourth found 48% relevant. The most frequent reason for irrelevance was that the request did not fit the requisite procedure. CONCLUSIONS: Relevance of requests for analytic tests could be improved. The present study is a starting-point, which allows us to deduce that an improvement in tests' relevance could be achieved with greater circulation of information on agreed diagnostic and follow-up procedures.

[Collection of data on primary care activities by sampling]. / Obtención de datos de actividad en atención primaria por muestreo.

OBJECTIVES: To choose, as part of a strategy of change in the records system, the best sampling design for obtaining data on primary care activity and to evaluate the appropriateness of introducing this design. DESIGN: An experimental study of the errors committed and the precision of four different sampling designs. A: 8 days a month at random. B: 8 consecutive days a month. C: one day in three systematically (7 days a month). D: one day in four systematically (5 days a month). MEASUREMENTS AND MAIN RESULTS: The calculations of activity indicators obtained monthly for each of the two health centres (31 doctors in general medicine and paediatrics) were compared with the real values, which we already knew from a prior exhaustive search. Type B samples gave the worst results while D contributed the best. In the variables referring to health programmes, unacceptable errors were obtained for all of them. CONCLUSIONS: Type D sampling was selected as the most appropriate. However, the positive and negative aspects to do with the necessity for, and use of, each piece of data, the required precision, the redistribution of tasks needed and the improvement in recording acceptability, must be assessed before it is put into practice.