Admission to Intensive Care for a trauma related to alcohol or drugs, a 'teachable moment' for the beginning of a change. / Ingreso en cuidados intensivos por un traumatismo relacionado con el consumo de alcohol o drogas, un «momento propicio de enseñanza¼ para el inicio del cambio.

OBJECTIVES: To estimate how many of the trauma patients admitted to ICU would be candidates for a secondary prevention programme for trauma related to alcohol or drug use by brief motivational intervention and to define what factors prevent that intervention being performed. METHODS: All 16-70year old trauma patients (n=242) admitted to ICU in 32 non-consecutive months (November 2011 to March 2015) were included in the study, coinciding with the implementation of a screening and brief motivational intervention programme for trauma patients related to substance consumption. The programme includes screening for exposure to substances at admission. Sociodemographic and clinical variables were collected prospectively. RESULTS: The screening for substances was not performed in 38 (15.7%) of all admitted patients. Of the patients screened, 101 (49.5%) were negative. The variables that in greater proportion impeded intervention between screening positive patients were neurological damage due to the trauma with 23 patients (37.1%) and prior psychiatric disorder with 18 (29%). Both variables were associated with substance consumption: negatives 9.9% vs positive 22.3% (P=.001) and negatives 3% vs positive 17.5% (P=.016) respectively. The number of candidates for motivational intervention was 41, 16.9% of all admitted patients. CONCLUSIONS: Almost 2 out of 10 patients were potential candidates. The factors that in a greater proportion precluded the intervention were the same as those associated with consumption. Mortality in ICU was associated with non-compliance with the screening protocol.

Exposure to pesticides and cryptorchidism: geographical evidence of a possible association.

Synthetic hormone-disrupting chemicals may play a role in the increased frequency of cryptorchidism observed in some studies. We used a spatial ecological design to search for variations in orchidopexy rates in the province of Granada in Spain and to search for relationships between these differences and geographical variations in exposure to pesticides. Orchidopexy rates were estimated for the period from 1980 to 1991 in all municipalities and health care districts served by the University of Granada Hospital. A random sample of males of the same age (1-16 years) admitted for any reason during the same period was used to estimate inpatient control rates. Each municipality was assigned to one of four levels of pesticide use. We used Poisson homogeneity tests to detect significant differences in rates of orchidopexy between districts and between levels of pesticide use. Poisson and logistic regression models were also used to estimate the strength of association between orchidopexy and level of pesticide use. Orchidopexy rates tended to be higher in districts near the Mediterranean coast where intensive farming is widespread. The city of Granada, where the reference hospital is located, also had higher figures both for orchidopexy and inpatient control rates. Regression models showed that the strength of association between orchidopexy and level of pesticide use tended to increase with higher levels of use, with the exception of level 0 (mainly in the city of Granada). Our results are compatible with a hypothetical association between exposure to hormone-disruptive chemicals and the induction of cryptorchidism. Several methodological limitations in the design make it necessary to evaluate the results with caution.

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.

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.

[Factors associated with the incidence of hospital readmission]. / Factores asociados a la incidencia de reingresos hospitalarios.

BACKGROUND: To identify factors associated with hospital readmission, especially those potentially avoidable. This information could be useful to reduce the incidence of hospital readmissions. METHODS: A paired (1:1) case-control study nested into the cohort of first admissions at the Granada University Hospital, Spain, in 1990. All patients readmitted at the hospital within 3 years after release from the index-admission by the same diagnostic or complications of it comprised the case group. For each case, a control patient was matched for both primary diagnosis on admission and index-admission date. Information on risk factors associated with hospital readmission was obtained retrospectively from medical records. The relation between these risk factors and readmission was estimated from odds ratio both crude and adjusted using conditional logistic regression analysis. For the readmitted subsample, multiple linear regression models were applied to identify factors associated to the length of time between the index episode and the first readmission. RESULTS: Variables with consistent positive associations with readmission include male sex (odds ratio = 2.86, 95% confidence interval = 1.37-5.88), widowed or single status (2.66, 10.7-6.59) and severity at index admission (3.20, 1.57-6.51). Factors related to quality of health care did not influence readmission risk. CONCLUSIONS: Factors depending of the patient seem to be the most important variables associated to the incidence of hospital readmission.

[Possible recall bias in a case-control study of congenital hip dysplasia]. / Posible sesgo anamnésico en un estudio de casos y controles de displasia congénita de cadera.

PURPOSE: To ascertain the presence of recall or report bias in a case-control study on congenital dysplasia of the hip (CDH). METHODS: A hospital case-control study was performed. Those cases and controls with other malformations or from mothers with clinical problems were discarded. 97 cases of dysplasia, and 164 controls were collected. Mother's life style was assessed. Odds ratios (OR) (crude and multiple-factor adjusted by logistic regression analysis) and their 95% confidence intervals were estimated. Risk factors were analyzed stratifying by the results of Ortolani-Barlow maneuver, since women were interviewed after knowing these results. RESULTS: Mothers of newborns with a positive Ortolani-Barlow maneuver yielded a higher OR for positive family history than those of babies with a negative one (2.27 versus 1.38). Overall smoking and alcohol consumption, and number of health exams during pregnancy yielded a negative association with CDH. In these cases closer-to-the-null ORs were obtained in newborns with positive Ortolani-Barlow. CONCLUSIONS: The presence of a report or recall bias is suggested as one of the possibilities for explaining the results.

[Influence of age and sex on various types of utilization of the primary health care]. / Influencia de la edad y sexo sobre los distintos tipos de utilización en atención primaria.

OBJECTIVE: To find out the influence of gender and age on various types of utilization of primary care services. METHOD: A random sample group containing 2662 patients over 14 years of age was observed over a continuous period of a year. Having already excluded the losses subjects, health service utilization was measured using patients whose clinical records had previously been validated. RESULTS: A small number of patients (15%) use a disproportionate amount of the total number of visits. A numerical breakdown shows: 43% of global visits (GV), 45% of acute clinical visits (ACV), 68% administrative visits (AV) and 94% programmed visits (PV). The ACV, PV and GV were significantly higher in woman (p = 0.000), though in the AV was not the case. These remained a significant difference when age was controlling factor. The coefficients of correlation between age and the logarithm of the ACV, AV, PV and GV were respectively 0.27, 0.23, 0.40 and 0.41. Gender is not a consideration with regard to use of health services below 35 and above 75 years of age. In multiple lineal regression equations age stands out as the most predictive variable, followed by gender, excluding the AV where the doctor comes before gender. CONCLUSION: A small group of highusers use a desproportionate amount of the total number of visits, particularly the AV and PV. The positive correlation between age and utilization is more clear by the PV and GV. The female is more user than the male, specially among 35 and 75 years old; although the gender is not determinant by the AV. There is not much explained variability with the age and gender, but the age is more important than the gender on utilization.

[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.

[Geographical variability in the severity of traffic accidents in Spain]. / Variabilidad geográfica de la gravedad de los accidentes de tráfico en España.

OBJECTIVE: The aim of this study is to analyze the geographical variability of the severity of traffic accidents in Spain, from 1985 to 1994, and to compare several severity indicators. METHODS: The mean values --from 1985 to 1994-- of the following indicators were obtained for each province: mortality index (deaths/accidents), harmfulness rate (victims/accidents), fatality rate (deaths/victims), motorization index (vehicles/inhabitants) and population density. Variability measures among provinces were obtained for each one. Provinces were then grouped in tertiles according to the magnitude of each indicator. Simple correlation coefficients among indicators were calculated. Poisson regression models were obtained, using severity indicators as the dependent variables. RESULTS AND CONCLUSIONS: Geographical variability was especially high for mortality index and fatality rate. For all severity indicators, lower values were found in provinces with the highest population densities and important metropolitan areas. Harmfulness and fatality rates play an independent role upon mortality index.

[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.

[The use of incidence density in assessing the risk factors for nosocomial infection]. / Utilización de la densidad de incidencia en la valoración de factores de riesgo de la infección nosocomial.

Several authors have suggested that incidence density should be used in studying nosocomial infection. We assess several risk factors for hospital infection by two ratios, the incidence density ratio (IDR) and the relative risk (RR), in an historical cohort of 843 patients. The variables analyzed were: operation, its length, type of surgical wound, severity of underlying disease, and age. The IDR figures were always lower than those yielded by the RR. For example, the IDR for operated patients was 2.78, whereas RR yielded a figure of 6.46, or the IDR for patients greater than 60 years old was 0.96, whereas the RR achieved a significant value of 1.67. This suggests that the use of IDR to analyze risk factors for nosocomial infection improves comparability of results obtained in different hospital settings. Also, it may allow a more exact quantification of an effect. These facts influence implementation of nosocomial infection control measures.

[Relationship between preoperative urine cultures and prostatic gland cultures in patients treated for benign prostatic hyperplasia]. / Relación entre los cultivos de orina preoperatorios y los cultivos de la glándula prostática en pacientes intervenidos de HBP.

OBJECTIVES: 1.--Investigate the bacteriuria preoperative in patients who will be operate on for Being Prostatic Hyperplasia (BPH). 2.--Define the prevalence of the prostatic colonization or infection. 3.--Try to correlate the bacteriological findings of urine and prostate, and find the degree of concordance between the microorganisms which can be commonly found in urine and prostatic tissue. METHOD AND MATERIALS: Prospective series of 175 patients undergoing prostatectomy for obstructive symptoms. The protocol revealed, among others variables: the preoperative urine culture; the presence or the absence of catheter; and the quantitative bacteriological culture of prostatic tissue. The information could be analised and its results could be obtained later on. The analysis stages consisted of both a descriptive and an analytic study. RESULTS AND CONCLUSIONS: 1.--Only 36 patients (20.6%) presented bacteriological increase of microorganisms (> or = 10(4) UFC/ml) in the preoperative urine culture. The Escherichia coli was the most common microorganism, followed by the Enterococcus faecalis, coagulase-negative Staphylococcus and the Pseudomona aeruginosa. A single microorganism grew in 31 out of the 36 positive cultures. 2.--The prevalence of the infection or colonization of the prostatic tissue was 25.1% (44 patients). The most common isolated microorganism was the coagulase-negative Staphylococcus followed by the Escherichia coli and the Enterococcus faecalis, in concentrations of at least 10(4) UFC/gr of tissue in the 79.6%. A single microorganism was isolated in 32 out of 44 patients. 3.--The proportion of positive prostatic cultures, in patients with positive urine culture (38.3%), was significantly higher than the one obtained in patients with negative urine cultures (16.5%) (p < 0.0001). Nevertheless, 52.3% of the 44 patients with positive prostatic cultures had negative urine culture, and only 21 (58.3%) out of the 36 patients with positive urine cultures presented a bacteriological growth in prostate. The degree of concordance (Kappa index) between the microorganisms which were found in preoperative urine and prostatic tissue is low or none for the majority of them.

[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.

[Do we agree on the technical quality of our chest X-rays? A radiologist, an expert in X-ray diagnosis, and a family doctor try to find out]. / 'Estamos de acuerdo con la calidad técnica de nuestras radiografías de tórax? Un radiólogo, un técnico especialista en radiodiagnóstico y un médico de familia intentan corroborarlo.

OBJECTIVE: To appraise the degree of concordance in the interpretation of the technical quality of chest x-rays at a health centre between an expert in x-ray diagnosis, a family doctor, and a radiologist. DESIGN: Transversal study. Setting. Primary care. Cartuja Health Centre, Granada, Spain. PARTICIPANTS: Patients at the Cartuja Health Centre who had a simple chest x-ray in 2002. 150 studies were chosen by simple randomised sampling. Two were rejected because they dealt with a repeat examination of the same patient and seven because they did not reach minimum quality. The final sample was 141 x-rays. MAIN MEASUREMENTS: The observers filled in independently, for each examination, an 11-item protocol on the technical quality of the images. The kappa index between pairs of observers was calculated for each item, as was the overall kappa index. RESULTS: 96% of the examinations were conducted with large x-ray plates (3543). There was only acceptable or good concordance between the 3 observers in 2 questions (kappa, 0.559-0.858). In 5 questions concordance was homogeneously low (kappa, 0.034-0.375). In some questions there was a strong discrepancy between the appraisal of the expert and that of the 2 other observers. CONCLUSIONS: General concordance can be considered low, although it is somewhat greater between the radiologist and the family doctor than between either of these and the expert. This poses the need to improve professional training in evaluation of the technical quality of images. In addition, there was unnecessary expense in large-size x-ray plates.

Driver dependent factors and the risk of causing a collision for two wheeled motor vehicles.

OBJECTIVE: To assess the effect of driver dependent factors on the risk of causing a collision for two wheeled motor vehicles (TWMVs). DESIGN: Case control study. SETTING: Spain, from 1993 to 2002. SUBJECTS: All drivers of TWMVs involved in the 181 551 collisions between two vehicles recorded in the Spanish registry which did not involve pedestrians, and in which at least one of the vehicles was a TWMV and only one driver had committed a driving infraction. The infractor and non-infractor drivers constituted the case and control groups, respectively. MAIN OUTCOME MEASURES: Logistic regression analyses were used to obtain crude and adjusted odds ratio estimates for each of the driver related factors recorded in the registry (age, sex, nationality, psychophysical factors, and speeding infractions, among others). RESULTS: Inappropriate speed was the variable with the greatest influence on the risk of causing a collision, followed by excessive speed and driving under the influence of alcohol. Younger and older drivers, foreign drivers, and driving without a valid license were also associated with a higher risk of causing a collision. In contrast, helmet use, female sex, and longer time in possession of a driving license were associated with a lower risk. CONCLUSIONS: Although the main driver dependent factors related to the risk of causing a collision for a TWMV were similar to those documented for four wheeled vehicles, several differences in the pattern of associations support the need to study moped and motorcycle crashes separately from crashes involving other types of vehicles.