A longitudinal study of unilateral Ménière's disease and clinical evolutionary models.

OBJECTIVE: The heterogeneity of Ménière's disease is presently defined by a variety of subtypes. This study introduced three different subtypes of unilateral Ménière's disease based on the evolution of vertigo crises from their inception. METHOD: A longitudinal descriptive study of 327 unilateral Ménière's disease patients was performed. In a subgroup of patients followed from the onset of the disease, 3 subtypes of unilateral Ménière's disease were defined according to the vertiginous crises suffered during the first 10 years of the disorder. RESULTS: Data was available for 87 patients with unilateral Ménière's disease from the start of their disease (26.6 per cent of the original sample). These patients were grouped into three models according to their symptomatic evolution. Model 3 was associated with a worse hearing prognosis, a greater number of Tumarkin's otolithic crises and the need for surgery. Model 1 presented less hearing loss. CONCLUSION: Unilateral Ménière's disease models based on the evolution of vertiginous crises present differences according to aspects such as hearing loss, vertiginous crisis, Tumarkin's otolithic crisis and the need for surgery.

[Severe SARS-CoV-2 infection: Clinical assessment and biomechanical functional evaluation one month after hospital discharge]. / Infección grave por SARS-CoV-2: valoración clínica y evaluación funcional biomecánica al mes del alta hospitalaria.

OBJECTIVE: To describe by an observational cross-sectional study the clinical and functional situation, at one month after hospital discharge, of patients admitted with COVID-19 in the hospital ICU between March and December 2020. MATERIAL AND METHODS: 59 patients were studied using different clinical scales and biomechanical analysis tests (hand dynamometry, fall risk assessment, gait and balance analysis). RESULTS: At one month after discharge, patients reported persistent symptoms: dyspnea (47.5%), arthromyalgia (45%) and cough (22%). In the EQ-5D-5L questionnaire up to 73% of patients reported levels of anxiety or depression. 74.6% and 69.5% presented alterations in the strength of the right and left hand, respectively. The risk of falls in 38% of patients was moderate to very high. The somatosensory index remained within normal parameters, while the vestibular and, to a lesser extent, the visual indexes were altered. In gait, 81.4% of patients showed no abnormalities outside the normal range, with a normal average walking speed. CONCLUSIONS: In the short term after severe COVID-19, patients have persistent symptomatology, anxiety/depression, impaired balance with increased risk of falls and loss of grip strength in both hands.

Association between antibiotic pressure and the risk of colonization/infection by multidrug-resistant Acinetobacter baumannii complex: a time series analysis.

OBJECTIVE: To analyze the association between antibiotic pressure and the risk of colonization/infection by Acinetobacter baumannii complex (AB), evaluating both the individual and general prescriptions of antibiotics. METHODS: This is an analytical, observational, case-control study on patients admitted to an Intensive Care Unit (ICU) during an AB outbreak (14 months). A five-year time series was constructed with the monthly incidence of cases of infection/colonization with strains of AB resistant to each antibiotic administered and with the monthly consumption of these antibiotics in the ICU. RESULTS: We identified 40 patients either infected (23) or colonized (17) by AB and 73 controls. We found an epidemic multidrug-resistant clone of AB in 75% of cases. Risk factors associated with the development of AB infection/colonization were: greater use of medical instruments, the presence of a tracheostomy, cutaneous ulcers, surgical lesions and prior antibiotic therapies. The regression analysis of individual use of antibiotics showed that prior treatment with ceftazidime, ceftriaxone, amoxicillin/clavulanate, imipenem, levofloxacin, linezolid, and vancomycin was a risk factor for acquiring AB. ARIMA models showed that the relationship were greatest and statistically significant when the treatment occurred between 6 months (ceftazidime) and 9 months (imipenem and levofloxacin) prior. CONCLUSIONS: The dynamic and aggregate relationship between the incidence of infection/colonization by multidrug-resistant strains of AB and prior antibiotic treatment was statistically significant for intervals of 6 to 9 months.

[Posturographic and oculomotor findings in the first 24 hours after whiplash]. / Alteraciones posturográficas y oculomotoras en las primeras 24 horas tras un latigazo cervical.

INTRODUCTION AND OBJECTIVES: Instability is a frequent symptom after whiplash (WL) with alterations in postural control in chronic phases. The main objective of our study was to evaluate if there were objective alterations in postural control in the acute phases after a WL, as well as to determine the presence or absence of oculomotor alterations in early phases. MATERIAL AND METHODS: A posturographic study was carried out using the NedSVE/IBV system, as well as an oculomotor assessment, in a sample of 44 patients with WL in the first 24h after the accident. RESULTS: More than half of the patients had a global assessment below normal. The predominant sensory pattern was vestibular. The main parameters of the Romberg test (total displacement, swept area, average speed, anteroposterior and mediolateral displacement and anteroposterior force) increased following the sequence Romberg open eyes, Romberg foam rubber open eyes, Romberg closed eyes, and Romberg foam rubber closed eyes. Concerning the comparison with normality and using the reference values of the Institute of Biomechanics of Valencia, the data from the WL patients showed significant differences in all the parameters analysed, except for gait assessment and the mediolateral directional rhythmic control. CONCLUSIONS: Our data confirm that patients in the acute phase of WL have worse postural control than non-injured persons. The results suggest that patients with WL have greater visual dependence. Only a minority of patients had oculomotor abnormalities during early examination.

[Comparison between extracorporeal shockwave therapy and radial pressure wave therapy in plantar fasciitis]. / Comparación de la terapia de ondas de choque extracorpóreas focales y presión radiales en la fascitis plantar.

OBJECTIVE: Plantar fasciitis is a common cause of heel pain. The aetiology of this condition remains unclear. Patients typically have pain upon palpation of the medial plantar calcaneal region. Extracorporeal shockwave therapy has shown favourable outcomes in various studies. The aim of this study was to compare the effect of focused extracorporeal shockwave therapy with radial pressure wave therapy. PATIENTS AND METHODS: Seventy-nine non-randomised patients diagnosed with plantar fasciitis were included between January 2017 and June 2018. Patients from the Arnau de Vilanova Hospital in Valencia were treated with focused extracorporeal shockwave therapy, and patients from Llíria Hospital with radial pressure wave therapy. Measured outcome variables were: visual analog scale; ultrasonographic measurement of plantar fascia thickness; self-reported foot-specific pain and disability using the Foot Function Index; self-reported health-related quality of life using the Euroqol-5D; self-reported pain and limitations of activity using the Roles & Maudsley Scale. RESULTS: At inclusion, the 2groups showed no significant differences in demographic or clinical characteristics. Three months after treatment completion, both groups showed improvement in all outcome variables, without statistically significant differences between the 2groups. No adverse effects or complications were observed. CONCLUSIONS: Both extracorporeal shockwave therapy and radial pressure wave therapy are effective treatments for plantar fasciitis.

[Perception of the professional nursing environment in Primary Care in the Valencian Community, in departments with public and private management]. / Percepción del entorno de práctica enfermera de Atención Primaria de la Comunidad Valenciana, en departamentos con gestión pública y privada.

BACKGROUND: Nursing practice environments (NPE) improve the quality of care, satisfaction and heath results; there are no studies that compare the Primary Health Care (PHC) environments according to their management model. Our aim is to estimate and compare the perception of the quality of the NPE in the PHC in Health Departments (HD) of the Valencian Community (Spain) with management model public or indirect-private (Administrative concession). METHOD: Transversal study on PHC nurses from three HD, one with direct public management and two with indirect-private management. The Practice Environment Scale-Nursing Work Index questionnaire, validated in Spain, was administered. Sociodemographic and professional variables were recorded. Variables related to test score were analyzed by multiple linear regression. RESULTS: Two hundred and sixty-nine answers (80.3%). All HD perceived NPE quality in a positive way, both globally and for the different dimensions (except D4). Indirect private management model HD obtained higher global scores, the same tendency was observed for D1 and D2, and the opposite for D4. Global score was related to age, professional experience, being a coordinator and management model; only the age of the nurses and being a coordinator showed a significant relationship with the score in the multivariate regression model. CONCLUSIONS: The NPE of the PHC of the Valencian Community are of good quality, without significant differences according to different management models of the HD. Being a coordinator and, particularly, the age of the nurses are variables that are independently related to the global score obtained.

Impact of self-financed rotavirus vaccines on hospital stays and costs in Spain after a 3-year introductory period.

Vaccination has reduced rotavirus hospitalizations by 25% in European regions with low-moderate vaccine availability. We aimed to quantify the reduction in hospital costs after the longest period in which Rotarix® and Rotateq® were simultaneously commercially available in Spain. Cases, length of stay (LOS), and diagnosis-related groups (DRGs) were retrieved from the Minimum Basic Data Set. Healthcare expenditure was estimated through the cost accounting system Gescot®. DRGs were clustered: I, non-bacterial gastroenteritis with complications; II, without complications; III, requiring surgical/other procedures or neonatal cases (highest DRG weights). Comparisons between pre (2003-2005)- and post-vaccine (2007-2009) hospital stays and costs by DRG group were made. Rotaviruses were the most common agents of specific-coded gastroenteritis (N = 1657/5012). LOS and extended LOS of rotaviruses fell significantly in 2007-2009 (ß-coefficient = -0·43, 95% confidence intervals (95% CI) -0·68 to -0·17; and odds ratio 0·62, 95% CI 0·50-0·76, respectively). Overall, costs attributable to rotavirus hospitalizations fell approximately €244 per patient (95% CI -365 to -123); the decrease in DRG group III was €2269 per patient (95% CI -4098 to -380). We concluded modest savings in hospital costs, largely attributable to cases with higher DRG weights, and a faster recovery. A universal rotavirus vaccination program deserves being re-evaluated, regarding its potential high impact on both at-risk children and societal costs.

A multifactorial regression analysis of the features of community-acquired rotavirus requiring hospitalization in Spain as represented in the Minimum Basic Data Set.

Over 10% of acute rotavirus gastroenteritis (ARGE) requires hospitalization because of complications. The aggravating factors have been widely analysed, but in an isolated way. We aimed to explore the interrelationship between the clinical and epidemiological factors that characterize rotavirus hospitalizations in Spain using information from the Minimum Basic Data Set (MBDS). Using ICD-9-CM codes, we classified acute gastroenteritis (AGE) cases by principal diagnosis fields and then categorized their comorbidities, complications, and epidemiological features by secondary fields. A multivariable, logistic, step-wise regression model was then constructed. We identified 1657 ARGE cases from 17 415 cases of AGE. Rotavirus hospitalizations were associated with place of residence, age, and season (P < 0·0001), as well as with dehydration [odds ratio (OR) 12·44, 95% confidence interval (CI) 1·52-40·38], intravenous rehydration (OR 1·74, 95% CI 1·29-2·35), metabolic acidosis (OR 1·51, 95% CI 1·24-1·83), respiratory tract infections (RTIs) (OR 1·60, 95% CI 1·09-1·98), and concomitant AGE (OR 1·52, 95% CI 1·03-2·25). Dehydration was four times more likely in patients aged <5 years (OR 4·36, 95% CI 1·20-12·96) and was associated with acidosis when ARGE and RTI were present simultaneously (P < 0·0001). Specific co-infecting viruses may play a role in acute respiratory symptoms and aggravation of gastrointestinal manifestations of rotaviruses, thus leading to complications requiring hospitalization.

[Prevalence of abdominal aortic aneurysm in a rural population of 65-80 year-old males]. / Prevalencia del aneurisma de aorta abdominal en varones de 65-80 años de una población rural.

INTRODUCTION: The prevalence of aortic aneurysm (AAA) is reported to be 3.55%-4% in men over 65. But it is not known if this prevalence, resulting from ultrasound measurements made by Family Physicians, can be extrapolated to a rural population. OBJECTIVE: To estimate the prevalence of AAA in a rural population of males aged 65-80 years, using abdominal ultrasound by family physicians, and to identify its association with different cardiovascular risk factors. SUBJECTS AND METHOD: A cross sectional study was conducted that included males of 65-80 years (n=320) in a rural population of the province of Ciudad Real, Spain. The dependent variable was the presence or not of AAA using ultrasound measurements of the aorta. Those with a diameter greater than or equal to 3cm were considered positive. Explanatory variables were measured; ankle/brachial index (ABI), body mass index (BMI), medical history of high blood pressure (hypertension), diabetes mellitus (DM), dyslipidaemia (DLP), ischemic heart disease, cerebrovascular accidents (CVA), and smoking habits. A bivariate and multivariate analysis of the prevalences was performed, as well as a study of the agreement between observers. RESULTS: The prevalence of AAA in the population was 3.3% (95% CI: 1.1-5.5%. DM and DLP were significantly associated with AAA. The agreement between observers was 0.96 (95% CI; 0.91-0.98). The high prevalence of different cardiovascular risk factors (CVRF) was particularly noteworthy. CONCLUSIONS: The prevalence of AAA in 65-80 year-old males in a rural population is similar to that found in the literature. Due to the cross-sectional nature of the study, CVRFs such as hypertension or CVA were not associated with the AAA. A screening program for the early detection of AAA could be introduced into Primary Health Care by family physicians.

[Relationship between donor-receptor interface and visual acuity in DSAEK]. / Relación entre la interfase donante/receptor y la agudeza visual en trasplante corneal tipo DSAEK.

OBJECTIVE: To evaluate the relationship between best corrected visual acuity and donor-recipient interface resulting after Descemet's Stripping with Automated Endothelial Keratoplasty (DSAEK). METHODS: Retrospective review of 46 clinical histories after DSAEK intervention in which 22 patients who fulfilled the inclusion criteria (two with bilateral DSAEK), were studied. All were operated on by the same ophthalmologist from January 2010 until April 2011. Surgical indications were: 19 (72.2%) bullous keratopathy, 3 (12.5%) Fuchs endothelial dystrophy, and 2 (8.3%) previous failed keratoplasty. The visual acuity (VA) was recorded preoperatively, and at three and six months after the operation; the latter two being compared with the interface between donor and recipient after DSAEK measured in a Scheimpflug corneal topography camera (Pentacam(®) model). RESULTS: After DSAEK surgery 19 eyes had improved visual acuity at three months, and 20 eyes at six months (P<.001). This improvement was compared with the decrease in optical density of the resulting donor-receptor interface, with apositive and significant relationship being found between them (Rho interface 3 months, and improved AV 6 months 0.44, P<.001). However, the interface is negatively and significantly related with visual acuity (Rho 3 m: -0.41, P=.045). Also, patients who had a denser stroma had a worse postoperative visual acuity in relative terms when compared with those who had a less damaged stroma. CONCLUSIONS: Patients undergoing DSAEK with worse preoperative visual acuity had a greater improvement visual in absolute values and however, they may have achieved a lower relative visual acuity than could be related to a higher refractive interface, as a result of a more damaged preoperative corneal stroma.

[Interobserver agreement in detecting goitre by palpation in a school population]. / Concordancia interobservador en la detección de bocio por palpación en población escolar.

OBJECTIVE: To estimate the agreement between observers on the detection of goitre by physical exploration in a school population. METHODOLOGY: We performed a cross-sectional study to detect goitre in a representative sample of 1134 schoolchildren aged 6 to 12 years from 20 schools in the health area of La Mancha Centro. The examination was performed blinded by two observers. Five grades in thyroid size were established (0, Ia, Ib, II and III). Above grade Ia was considered as goitre. The agreement was assessed in relation to variables such as age, sex, body mass index, height, and day of examination. The weighted kappa was used to measure the agreement. RESULTS: In the 1097 schoolchildren with a dual examination, 96 (8.8%) cases of goitre were detected by observer 1, and 102 (9.3%) cases by observer 2, (P=.58). The degree of interobserver agreement in the identification and grading of goitre was moderate (kappa 0,55, 95%CI: 0,46 to 0,64) for the first, and substantial (weighted kappa 0,61; 95%CI: 0,51 to 0,71) for the second. The degree of agreement was somewhat higher in girls, older schoolchildren, increased weight, height, and body mass index. The interobserver agreement was relatively stable throughout the study. CONCLUSIONS: The interobserver agreement in detecting goitre by palpation in our study is moderate, but is lower in younger children and stable for the duration of study.

[Drug treatment adjustment to the clinical guidelines in octagenarians with acute myocardial infarction]. / Ajuste del tratamiento farmacológico a las guías de práctica clínica en pacientes octogenarios con infarto agudo de miocardio.

OBJECTIVES: To determine whether there is a linear association of age and aspirin, betablockers, angiotensin-converting enzyme inhibitors and statins; the extent to which elderly patients receive these treatments; and whether age is independently associated with these treatments. DESIGN: A prospective cohort study. SETTING: Coronary Unit of two hospitals in the Region of Murcia (Spain). PATIENTS: Consecutive patients admitted with the diagnosis of acute myocardial infarction between January 1998 and January 2008. INTERVENTIONS: None. MAIN OUTCOMES: Those related to the administration of aspirin, betablockers, angiotensin-converting enzyme inhibitors and statins during stay in the Coronary Care Unit. RESULTS: Regarding the remaining patients, octogenarians received a similar proportion of angiotensin-converting enzyme inhibitors (70.8% vs. 69.3%, p=0.41) and less often aspirin (90.4% vs. 94.6%, p<0.001), betablockers (44.4% vs. 69.4%, p<0,001) and statins (47.6% vs. 64.7%, p<0.001). We were only able to demonstrate an abrupt and significant decrease in the use of statins after 80 years of age. Patient age was independently associated with the use of betablockers (OR 0.59; 95%CI 0.47 - 0.73) and statins (OR 0.78; 95%CI 0.65 - 0.95). The lesser administration of these drugs was also associated with early mortality (OR 0.17, 95%CI 0.09 to 0.33 and OR 0.14; 95%CI 0.08 to 0.23, respectively). CONCLUSIONS: Octogenarians less often receive aspirin, betablockers and statins, though old age was not an independent factor associated with lesser aspirin use.

[Impact of pharmacotherapeutic warnings on the prescription of clopidogrel and proton pump inhibitors in hospitalised patients]. / Impacto de las alertas farmacoterapéuticas sobre la prescripción de clopidogrel e inhibidores de la bomba de protones en pacientes ingresados.

OBJECTIVE: To estimate the frequency of clopidogrel prescriptions in association with proton pump inhibitors (PPIs) in patients hospitalised with circulatory pathologies, after the publication of several warnings about this association. To identify and quantify the magnitude of the factors related to the prescription of both drugs. METHODOLOGY: Observational, analytical, longitudinal, and retrospective study assessing changes in prescription of clopidogrel-PPIs association after and before the first official warning (about these drugs' interactions) was published. We selected all patients with a code indicating a circulatory system disease in the Minimum Basic Data Set, who had been prescribed clopidogrel during hospital admission. We also evaluated proton pump inhibitor use in these patients (omeprazole and pantoprazole). RESULTS: 5678 patients diagnosed with circulatory diseases were admitted during 2009, and clopidogrel was prescribed in 13.6% of them. In the pre-warning period, clopidogrel-PPIs prescriptions were significantly higher than in the post-warning period (80, 8% vs 48, 6%), especially in omeprazole. The combined prescription was lower if the circulatory diagnosis was the main cause for hospitalisation, if the patient had heart disease, if the patient was admitted in Internal Medicine/Cardiology or Intensive care units, and if the period of time was further from warning. CONCLUSION: Combined prescription has decreased since the first warning, above all in patients with a primary circulatory heart disease. Omeprazole is a potent CYP2C19 inhibitor, so it was used in lower rates than pantoprazole in association with clopidogrel. Medical departments related to cardiovascular disease followed the warning more than others.

New guidelines for the management of thyroid nodules and differentiated thyroid cancer.

AIM: The aim of this paper was to evaluate the diagnostic efficiency of cytology results obtained through fine-needle aspiration (FNA) in partially cystic thyroid nodules and to examine the association between specific ultrasonographic evidence and malignancy. METHODS: A descriptive, observational, cross-sectional study examining the relationship between cytological and ultrasonographic findings in a group of patients with partially cystic thyroid nodules. The following ultrasound characteristics were examined: 1) nodule size (in mm); 2) percentage of the solid portion of the nodule (greater or less than 50%); 3) echogenicity of the solid portion (hypoechoic, isoechoic, or hyperechoic); 4) eccentricity of the solid portion; 5) regularity of the margins, and 6) presence or absence of microcalcifications. RESULTS: The ultrasound (US) and cytological characteristics of the partially cystic thyroid nodules of 145 patients, 127 women with a mean age of 53.1 years (SD 19.7) and 18 men with a mean age of 60 (SD 19.7), were reviewed. The mean size of the nodules was 28.07 mm (SD 11.23). Thirty-seven (25.5%) were solitary nodules and 98 (72.59%) formed parts of multinodular goiters. Twenty-eight (19.3%) of the cytologies proved to be inadequate samples, 104 (71.7%) were benign, 7 (4.8%) were suspicious, and 4 (2.8%) were malignant. The sensitivity for detecting malignancy was >90% when the percentage of the solid portion of the nodule was greater than 50%; these values remained unchanged when combined with other sonographic findings. The greatest specificity for malignancy was associated with the presence of microcalcifications (99%); however, none of the associations observed were statistically significant. CONCLUSION: FNA cytology is an essential diagnostic tool in both partially cystic and solid nodules. Examination of several individual ultrasound characteristics of these nodules, such as the percentage of the solid component, as well as other common characteristics, including the echogenicity or the presence of microcalcifications, may greatly facilitate the diagnostic process.

[Endemic goiter and iodine deficiency: are they still a reality in Spain]. / Bocio endémico y déficit de yodo: 'sigue siendo una realidad en España?

OBJECTIVE: To estimate the prevalence of goiter and iodine deficiency in a health district in the Autonomous Community of Valencia, given the absence of data in this region of Spain. MATERIAL AND METHODS: We conducted a descriptive, epidemiologic, cross-sectional study, stratified by age and sex, in four interior regions of the province of Valencia. We selected students aged from 6 to 14 years old in 20 centers. Thyroid examination was performed by means of palpation and inspection (goiter > or = 0B). Urinary iodine excretion was analyzed in a routine urine sample. Sociodemographic and anthropometric data, as well as nutritional iodine status, were recorded in a standardized survey. In children with goiter, thyroid-stimulating hormone (TSH), free T4, and antithyroid antibodies were determined. RESULTS: We studied 928 children (478 boys and 450 girls). The prevalence of goiter was 33.7 % (95 % CI: 30.7-36.9 %). There were no significant differences in the prevalence of goiter by age or sex, but an inverse correlation was detected between the prevalence of goiter and parental socioeconomic position. Mean urinary iodine excretion was 155 .g/l, with no significant correlation with the prevalence of goiter. In children with goiter, 13 had positive antithyroid antibodies, 18 had high TSH (subclinical hypothyroidism), and one had suppressed TSH (subclinical hyperthyroidism). CONCLUSIONS: There is endemic goiter in the region studied. Urinary iodine levels were in the normal range and could be interpreted as indicating a transition phase to an improvement in iodine deficiency. Autoimmune diseases would only explain 4 % of cases of goiter.

Psychological well-being among hospital personnel: the role of family demands and psychosocial work environment.

BACKGROUND: This study investigates the effect of gender role and the psychosocial work environment on the psychological well-being of hospital staff in two general hospitals in the province of Valencia (Spain). METHOD: A cross-sectional survey was carried out among 313 workers by means of a self-answered questionnaire. The outcome variable (psychological well-being) was evaluated with four dimensions of the "SF-36 Health Survey" (mental health, vitality, limitations in the emotional role and limitations in the social function). The explanatory variables were: characteristics related to gender role, professional characteristics and the psychosocial working environment evaluated according to Karasek and Johnson's demand-control-support model. The adjusted odds ratios (ORs) and their 95% confidence intervals were calculated by logistical regression. RESULTS: Those who have very good marital relationship have less risk of presenting bad mental health, OR 0.43 (0.24-0.78), and limitation in the social function, OR 0.43 (0.24-0.77), and in the emotional role, OR 0.35 (0.16-0.74). Those who dedicate more than 30 h a week to domestic chores have a higher risk of limitation of social function, OR 2.48 (1.16-5.31). Those exposed to high psychological demands present a higher probability of having bad mental health, OR 1.77 (1.04-3.00). Those exposed to low job social support have a higher risk of bad mental health, OR 1.86 (1.09-3.19), low vitality, OR 2.21 (1.30-3.77), and limitation in the social function, OR 1.88 (1.10-3.22). CONCLUSION: Gender role and psychosocial work environment have a negative influence on the psychological well-being of hospital staff.

Epidemiological factors on hymenoptera venom allergy in a Spanish adult population.

BACKGROUND: The prevalence and risk factors of hymenoptera venom allergy (HVA) have been studied in several countries. However, there are few studies on the general population and these have very variable results. METHODS: An observational, prospective and cross-sectional study was carried out on a sample of 1064 subjects in a total working population of 7887 subjects (Ford factory, Spain) in order to know the prevalence of HVA in this population and the influence of several risk factors in its development. RESULTS: The rate of exposure to stings was 84.1% (ci 95%: 81.8-86.3%). The prevalence of HVA was 7.6% (ci 95%: 6.1-9.4%), with local severe reactions (LSR) in 5.3% (ci 95%: 4-6.8%) and systemic reactions (SR) in 2.3% (ci 95%: 1.5-3.4%). More than 82% of individuals over 20 years had already had some exposure, a figure that did not change in the age groups of older decades. In our study, the prevalence of HVA was not dependent on either age (similar age in all groups), sex: for LSR OR 2.75 (ci 95%: 0.37-20.30), for SR OR 0.54 (ci 95%: 0.12-2.38), or atopy OR 0.96 (ci 95%: 0.50-1.83); SR being more frequent among the residents of rural habitats, with ranges approaching statistically significant levels OR 2.15 (ci 95%: 0.95-4.81). The number of stings was larger in HVA group with respect a control group. The degree of venom sensitization measure by skin test and CAP-RAST was more intensive in SR group versus LSR group. Among vespids, sensitization to Polistes was more frequent than Vespula. CONCLUSIONS: HVA in our sample has a similar prevalence to other countries located in similar geo-climatic environments. Rural habitat and the number of stings suffered along life are risk factors of HVA development.

Pre-endoscopic prognostic factors in non-varicose upper gastrointestinal bleeding. Development of a predictive algorithm.

OBJECTIVE: Upper gastrointestinal or digestive bleeding (UDB) is a common problem requiring hospitalization and implying important morbidity-mortality. The aim of the present study is to identify clinical and laboratory factors predictive of a serious course of non-varicose UDB, based on the development of a simple algorithm for application in the clinical setting. METHODS: A longitudinal study was made of 803 hospitalized patients with non-varicose UDB. Clinical and laboratory parameters were recorded in the Emergency Service before endoscopy. A first non-conditional logistic regression model was developed, including those variables exhibiting a greater capacity for predicting a serious outcome. This model was posteriorly simplified to facilitate clinical application. The prognostic performance was estimated by calculating the area under the ROC curve. RESULTS: The initial predictive model included 11 variables, with an area under the ROC curve of 0.74 (95%CI: 0.71-0.77), while in the second model these same variables were dichotomized, exhibiting an area under the ROC curve of 0.74 (95%CI: 0.70-0.77). Based on the corresponding regression coefficients, the prognostic variables were classified as either major (shock, liver disease, anticoagulant therapy, urea/creatinine ratio > 62) or minor (hematocrit < 33%, renal failure, presentation as hematemesis and melenas, systolic arterial pressure < 110 mmHg, regular alcohol consumption, a history of UDB, and a patient age of > 75 years). UDB was predicted to take an unfavorable course in the presence of one major factor or two minor factors. CONCLUSIONS: The proposed algorithm includes pre-endoscopy clinical and laboratory variables, and allows early classification of patients with non-varicose UDB in terms of their possible clinical course.

Comparative incidence of upper gastrointestinal bleeding associated with individual non-steroidal anti-inflammatory drugs.

OBJECTIVE: The existence of two isoforms of cyclo-oxygenase (COX), COX-1 and COX-2, is now well established. Because inhibition of COX-1 by nonsteroidal anti-inflammatory drugs (NSAIDs) is linked to gastrointestinal (GI) damage, agents with a better COX-2/COX-1 inhibition ratio may have less GI toxicity. The aim of this study was to compare the incidence of upper gastrointestinal bleeding (UGIB) in association with specific NSAIDs including the new "COX-2 preferential" inhibitors. PATIENTS Y METHOD: Individual incidence of NSAID-related UGIB in a health-authority area was estimated, based on cases of UGIB, sales of non-aspirin NSAIDs, and data of used doses in community subjects, during a four-year period. Comparisons were made by calculating individual rate-ratio (RR) and 95% confidence interval (CI) taking as a reference the specific NSAID with the lowest incidence of UGIB. RESULTS: The incidence of UGIB associated with thirteen specific NSAIDs included in the study varied greatly, from 1.7 per 1,000 person-years for aceclofenac to 25.8 per 1,000 person-years for ketorolac. The use of "COX-1 preferential" inhibitors versus "COX-2 preferential" inhibitors was associated with a RR of 5.3 (95% CI, 2.78-10.04), and between NSAIDs with "COX-1-COX-2 mixed" inhibition RR was 2.2 (95% CI, 1.13-4.28). CONCLUSIONS: Our results show that there are differences in GI toxicity according to specific NSAIDs. A substantial reduction in number of cases of UGIB could result from the use of NSAIDs with a "COX-2 preferential" inhibition.