Exposure to green spaces, cardiovascular risk biomarkers and incident cardiovascular disease in older adults: The Seniors-Enrica II cohort.

INTRODUCTION: The impact of residential green spaces on cardiovascular health in older adults remains uncertain. METHODS: Cohort study involving 2114 adults aged ≥ 65 years without cardiovascular disease (CVD), residing in five dense municipalities (Prince et al., 2015) of the Madrid region and with detailed characterization of their socioeconomic background, health behaviors, CVD biological risk factors, and mental, physical, and cognitive health. Greenness exposure was measured using the Normalized Difference Vegetation Index (NDVI) at varying distances from participants' homes. Traffic exposure, neighborhood environment, neighborhood walkability, and socioeconomic deprivation at the census level were also assessed. Serum N-terminal pro-B-type natriuretic peptide (NT-ProBNP), high-sensitivity troponin T (hs-TnT), interleukin 6 (IL-6), and Growth Differentiation Factor 15 (GDF-15) were measured at baseline, and incident CVD events identified through electronic medical records (International Classification of Primary Care-2 codes K74, K75, K77, K90, and K92). RESULTS: After adjusting for sex, age, educational attainment, financial hardship and socioeconomic deprivation at the census level, an interquartile range (IQR) increase in NDVI at 250, 500, 750, and 1000 m around participants' homes was associated with mean differences in ProBNP of -5.56 % (95 %CI: -9.77; -1.35), -5.05 % (-9.58; -0.53), -4.24 % (-8.19, -0.19), and -4.16 % (-7.59; -0.74), respectively; and mean differences in hs-TnT among diabetic participants of -8.03 % (95 %CI: -13.30; -2.77), -9.52 % (-16.08; -2.96), -8.05 % (-13.94, -2.16) and -5.56 % (-10.75; -0.54), respectively. Of similar magnitude, although only statistically significant at 250 and 500 m, were the observed lower IL-6 levels with increasing greenness. GDF-15 levels were independent of NDVI. In prospective analyses (median follow-up 6.29 years), an IQR increase in residential greenness at 500, 750, and 1000 m was associated with a lower risk of incident CVD. The variables that contributed most to the apparent beneficial effects of greenness on CVD were lower exposure to traffic, improved cardiovascular risk factors, and enhanced physical performance. Additionally, neighborhood walkability and increased physical activity were notable contributors among individuals with diabetes. CONCLUSION: Increased exposure to residential green space was associated with a moderate reduction in CVD risk in older adults residing in densely populated areas.

Diet Quality Changes by Educational Level among Adults in Spain from 2017 to 2021.

Despite increasing attention on addressing socioeconomic disparities in diet quality, longitudinal studies are scarce. Furthermore, the effects of the COVID-19 pandemic on diet-related outcomes are yet to be fully understood. We examined changes in diet quality by educational level among adults in Madrid, Spain. We used data from recruitment (in 2017) and from 2021. At baseline, our sample included 1358 adults aged 40-75 years who were free of cardiovascular disease and completed a validated diet quality screener. Of them, 931 answered the survey in the follow-up visit in 2021. We used participants' diet quality index scores (range: 18-54; higher scores indicate better diet quality) as the dependent variable. As our independent variable, we assessed participants' educational levels (low, medium, and high). We fitted a multinomial regression using the categories of educational level as the main predictor, adjusting for age, sex, country of origin, and household composition. During the study period, 78.0% of participants sustained their diet quality, 11.6% improved it, and 10.4% moved away from a healthier dietary pattern. In descriptive analyses, we observed an increase in diet quality among less-educated females. Unadjusted multinomial models showed that a lower educational level predicted both increases and decreases in diet quality over the period. Even though the median diet quality scores did not change significantly, we observed heterogeneous changes over the four years. Variability within diet, with some improving and some worsening, seems to have increased among participants with lower educational levels. Future studies should look at the determinants of change in these population subgroups.

[Epidemiologic evidence on the role of hospitality venues in the transmission of COVID-19: A rapid review of the literature]. / Evidencia epidemiológica acerca del rol de la hostelería en la transmisión de la COVID-19: una revisión rápida de la literatura.

OBJECTIVE: To review the scientific epidemiologic evidence on the role of hospitality venues in the incidence or mortality from COVID-19. METHOD: We included studies conducted in any population, describing either the impact of the closure or reopening of hospitality venues, or exposure to these venues, on the incidence or mortality from COVID-19. We used a snowball sampling approach with backward and forward citation search along with co-citations. RESULTS: We found 20 articles examining the role of hospitality venues in the epidemiology of COVID-19. Modeling studies showed that interventions reducing social contacts in indoor venues can reduce COVID-19 transmission. Studies using statistical models showed similar results, including that the closure of hospitality venues is amongst the most effective measures in reducing incidence or mortality. Case studies highlighted the role of hospitality venues in generating super-spreading events, along with the importance of airflow and ventilation inside these venues. CONCLUSIONS: We found consistent results across studies showing that the closure of hospitality venues is amongst the most effective measures to reduce the impact of COVID-19. We also found support for measures limiting capacity and improving ventilation to consider during the re-opening of these venues.

Influence of home/school environments on children's obesity, diet, and physical activity: the SUECO study protocol.

OBJECTIVE: The SUECO study examines the relationship between urban obesogenic environments and health outcomes among school-age children in the city of Madrid, Spain. We will study how features of the urban environment (related to the food- and the physical activity environment) associate with children's anthropometrics, eating habits, and physical activity levels. METHOD: We describe the study protocol of this multilevel study in a representative sample of school-age children in the city of Madrid (2017; n=5,961 children ages 3-12). Main outcome variables include anthropometrics (body mass index, waist circumference, and body fat), healthy and unhealthy consumption measures, and physical activity measures. The primary explanatory variables are grouped into food environment (e.g., unhealthy food retailers' density) and physical activity environment (e.g., walkability, physical activity opportunities) variable categories. Multilevel models will be used to calculate the associations between each indicator and obesity and physical inactivity.

Social inequities in cardiovascular risk factors in women and men by autonomous regions in Spain.

OBJECTIVE: To describe social inequities in cardiovascular risk factors in women and men by autonomous regions in Spain. METHOD: We used data from 20,406 individuals aged 18 or older from the 2017 Spanish National Health Survey. We measured socioeconomic position using occupational social class and used data on self-reported cardiovascular risk factors: high cholesterol, diabetes, hypertension, obesity, and smoking. We estimated the relative risk of inequality using Poisson regression models. Analyses were stratified by men and women and by region (autonomous communities). RESULTS: Overall, the relative risk of inequality was 1.02, 1.13, 1.06, 1.17 and 1.09 for high cholesterol, diabetes, hypertension, obesity, and current smoking, respectively. Ocuupational social class inequities in diabetes, hypertension, and obesity was stronger for women. Results showed a large regional heterogeneity in these inequities; some regions (e.g. Asturias and Balearic Islands) presented wider social inequities in cardiovascular risk factors than others (e.g. Galicia, Navarra or Murcia). CONCLUSION: In Spain, we found marked social inequities in the prevalence of cardiovascular risk factors, with wide regional and women/men heterogeneity in these inequities. Education, social, economic and health policies at the regional level could reduce health inequities in cardiovascular risk factors and, thus, prevent cardiovascular disease.

Covid-19 and lung cancer: A greater fatality rate?

BACKGROUND: Currently there are no reported series determining the Covid-19 infected lung cancer patient´s characteristics and outcome that allow us to clarify strategies to protect our patients. In our study we determine whether exists differences in cumulative incidence and severity of Covid-19 infection between lung cancer patients visiting our Medical Oncology department and the reference population of our center (320,000 people), in the current epicenter of the pandemic in Europe (Madrid, Spain). We also describe clinical and demographic factors associated with poor prognosis and Covid-19 treatment outcomes. PATIENTS AND METHODS: We retrospectively reviewed 1878 medical records of all Covid-19 patients who were admitted at Hospital Universitario Infanta Leonor of Madrid between March 5, 2020 and April 7, 2020, in order to detect cumulative incidence of Covid-19 in lung cancer patients. We also described Covid-19 treatment outcome, mortality and associated risk factors using univariate and multivariate logistic regression analysis. RESULTS: 17/1878 total diagnosis in our center had lung cancer (0.9 %) versus 1878/320,000 of the total reference population (p = 0.09). 9/17 lung cancer patients with Covid-19 diagnosis died (52.3 %) versus 192/1878 Covid-19 patients in our center (p < 0.0001). Dead lung cancer patients were elderly compared to survivors: 72 versus 64.5 years old (p = 0.12). Combined treatment with hydroxychloroquine and azithromycin improves the outcome of Covid-19 in lung cancer patients, detecting only 1/6 deaths between patients under this treatment versus others treatment, with statistical significance in the univariate and multivariate logistic regression (OR 0.04, p = 0.018). CONCLUSIONS: Lung cancer patients have a higher mortality rate than general population. Combined hydroxychloroquine and azithromycin treatment seems like a good treatment option. It is important to try to minimize visits to hospitals (without removing their active treatments) in order to decrease nosocomial transmission.

Effect of excess weight and immune-related adverse events on the efficacy of cancer immunotherapy with anti-PD-1 antibodies.

Immunotherapy is an effective treatment in advanced cancer, although predictors of response are limited. We studied whether excess weight influences the efficacy outcomes of immunotherapy. We have also evaluated the combined prognostic effect of excess weight and immune-related adverse events (irAEs). Efficacy of anti-PD-1 treatment was evaluated with both objective radiological response (ORR) rate and progression-free survival (PFS), and toxicity with irAEs. We studied the association between excess weight and ORR, PFS or irAEs. 132 patients diagnosed with advanced cancer were included. Median body mass index (BMI) was 24.9 kg/m2. 64 patients had normal weight (BMI<25 kg/m2), and 64 patients had excess weight (BMI≥25 kg/m2). Four patients had underweight and were excluded from further analysis. ORR was achieved in 50 patients (38.0%), median PFS was 6 months. 44 patients developed irAEs (33.3%). ORR was higher in excess weight patients than in patients with normal weight (51.6% vs 25.0%; OR 3.45, p = .0009). PFS was improved in patients with excess weight (7.25 months vs 4 months, HR 1.72, p = .01). The incidence of IrAEs was not different in patients with excess weight (54.5% vs 43.2%, p = .21). When high BMI and irAEs were combined, we observed a marked prognostic trend in ORR rate (87.5% vs 6.2%; OR 161.0, p < .00001), and in PFS (14 months vs 3 months; HR 5.89, p < .0001). Excess weight patients with advanced cancer that receive single-agent anti-PD-1 antibody therapy exhibit a significantly improved clinical outcome compared with normal BMI patients. This association was especially marked when BMI and irAEs were considered combined.

Increased HIV infection in patients with stroke in Spain. A 16-year population-based study.

INTRODUCTION: An increased incidence of stroke in HIV-infected patients has already been reported, suggesting that HIV infection may be a cerebrovascular risk factor. The objective of this study was to assess temporal trends in the proportion of HIV infection among patients with stroke in Spain. METHODS: Data were obtained from the minimum basic dataset (MBDS) of all patients hospitalized in Spain between 1997 and 2012 with a primary or secondary diagnosis of stroke. The annual proportion of HIV infection and time trends (stratifying by type of stroke and HIV stage) were calculated, and predictors of HIV infection and the social and economic impact of HIV-infected (HIV+) and non-infected (HIV-) patients were analyzed. RESULTS: Of 857,371 patients hospitalized with an incident stroke, 2134 (0.25%) had HIV infection. A 2.5% year-on-year increase (OR 1.025, 95% CI 1.015-1.036, p<0.0001) of the proportion of HIV-infected patients was observed due to an increase in the asymptomatic stage of the infection (per year OR 1.077, 95% CI 1.057-1.097, p<0.0001), as the proportion of patients with AIDS remained stable. Factors independently associated with HIV infection and stroke were active smoking, stimulating drugs and hepatitis C virus (HCV) infection. A higher mortality rate, longer hospital stay and a higher cost per hospitalized patient was observed among HIV+ patients. CONCLUSIONS: From 1997 to 2012, there was an increase in the proportion of HIV infection among patients hospitalized with stroke irrespective of the classical vascular risk factors, reinforcing the role of HIV infection as a cerebrovascular risk factor.

A multicomponent method assessing healthy cardiovascular urban environments: The Heart Healthy Hoods Index.

Previous studies have examined the built environment mostly focusing on a single exposure construct (e.g. walkability) to examine its association with health outcomes. This study developed a multicomponent Heart Healthy Hoods Index to characterize heart-healthy urban environments and examined its relationship with the prevalence of cardiovascular disease (CVD) in Madrid, Spain. Using spatial methods, we generated two index models (model 0 unweighted and model 1 weighted) using the percentage of deaths for the main behavioral risk factors for CVD (diet, physical activity, alcohol, and tobacco environments). We performed global (Ordinal Least Square) and local (Geographically Weighed Regression) regression analyses to assess the relationship between both index models and CVD prevalence, and to identify the best index model. In the global analysis, both models showed a significant negative relationship with CVD prevalence. In the local analysis, Model 1 removed the spatial autocorrelation of residuals and showed the lowest values for the Akaike information criterion. This study provides evidence of a non-stationary relationship between the heart-healthy urban environment and CVD prevalence. The HHH index may be an effective tool to identify and prioritize geographical areas for CVD prevention.

Predictors of unknown cancer in patients with ischemic stroke.

Stroke is the second most frequent neurologic finding in postmortem studies of cancer patients. It has also been described as the first expression of an occult cancer. We have studied patients diagnosed with cancer after an ischemic stroke (IS) and we analyze differences with non-tumor patients. Single cohort longitudinal retrospective study of patients admitted to our center with IS diagnosis from 1 January 2012 to 12 December 2014. All patients were followed for 18 months. Patients with transient ischemic infarction or cerebral hemorrhage, active cancer or in the last 5 years, inability to follow-up or absence of complete complementary study (holter-EKG, echocardiogram, and dupplex/angiography-CT) were excluded. Demographic, clinical, analytical and prognostic characteristics were compared between both subgroups. From a total of 381 IS patients with no history of cancer, 29 (7.61%) were diagnosed with cancer. The mean time from stroke onset to cancer diagnosis was 6 months. The most frequent location was colon (24%). 35% were diagnosed in a metastatic stage. Older age (p = 0.003), previous cancer (p = 0.042), chronic kidney disease (CKD) (p = 0.006) and lower hemoglobin (p = 0.004) and fibrinogen (p = 0.019) values were predictors of occult neoplasm. No differences were found in other biochemical or epidemiological parameters, prognosis, etiology or clinical manifestations of the IS. In our study, older age, CKD, previous cancer and hemoglobin and fibrinogen values were related to the diagnosis of cancer after IS. More studies are needed to determine which patients could benefit from a larger study on admission that might allow an earlier diagnosis of the underlying neoplasm.

Characterizing physical activity and food urban environments: a GIS-based multicomponent proposal.

BACKGROUND: Healthier urban environments influence the distribution of cardiovascular risk factors. Our aim was to design and implement a multicomponent method based on Geographic Information Systems to characterize and evaluate environmental correlates of obesity: the food and the physical activity urban environments. METHODS: Study location comprised a socio-demographically average urban area of 12 contiguous census sections (≈16,000 residents), in Madrid, Spain. We conducted on-field audits on all food stores and street segments. We designed a synthetic index integrating continuous measures of both environments, by kernel density analyses. Index ranges from 0 to 100 (least-most healthy). RESULTS: We found a heterogeneous distribution with 75 and 50 % of the area scoring less than 36.8 and 25.5, respectively. Census sections of study area were categorized by Jenks intervals as high, medium-high, medium-low and low. 41.0 % of residents lived in an area with a low score, 23.6 % medium-low and 31.1 % medium-high and 4.2 % in a high. CONCLUSION: The proposed synthetic index may be a relevant tool to inform urban health interventions, providing a feasible way to integrate different measures of barriers and facilitators of healthy urban environments in terms of food and physical activity.

Population cardiovascular health and urban environments: the Heart Healthy Hoods exploratory study in Madrid, Spain.

BACKGROUND: Our aim is to conduct an exploratory study to provide an in-depth characterization of a neighborhood's social and physical environment in relation to cardiovascular health. A mixed-methods approach was used to better understand the food, alcohol, tobacco and physical activity domains of the urban environment. METHODS: We conducted this study in an area of 16,000 residents in Madrid (Spain). We obtained cardiovascular health and risk factors data from all residents aged 45 and above using Electronic Health Records from the Madrid Primary Health Care System. We used several quantitative audit tools to assess: the type and location of food outlets and healthy food availability; tobacco and alcohol points of sale; walkability of all streets and use of parks and public spaces. We also conducted 11 qualitative interviews with key informants to help understanding the relationships between urban environment and cardiovascular behaviors. We integrated quantitative and qualitative data following a mixed-methods merging approach. RESULTS: Electronic Health Records of the entire population of the area showed similar prevalence of risk factors compared to the rest of Madrid/Spain (prevalence of diabetes: 12 %, hypertension: 34 %, dyslipidemia: 32 %, smoking: 10 %, obesity: 20 %). The food environment was very dense, with many small stores (n = 44) and a large food market with 112 stalls. Residents highlighted the importance of these small stores for buying healthy foods. Alcohol and tobacco environments were also very dense (n = 91 and 64, respectively), dominated by bars and restaurants (n = 53) that also acted as food services. Neighbors emphasized the importance of drinking as a socialization mechanism. Public open spaces were mostly used by seniors that remarked the importance of accessibility to these spaces and the availability of destinations to walk to. CONCLUSION: This experience allowed testing and refining measurement tools, drawn from epidemiology, geography, sociology and anthropology, to better understand the urban environment in relation to cardiovascular health.

[Impact of the Core Training Law on preventive medicine and public health training and other common medical specialties]. / Impacto del Real Decreto de la Troncalidad en la formación en medicina preventiva y salud pública y en otras especialidades del tronco común médico.

OBJECTIVE: The purpose of the Core Training Law (CTL) is to amend specialised medical training to include 24 months of common training. The aim of this study is to assess its potential impact on the Preventive Medicine and Public Health (PM&PH) training programme and other medical specialties. METHOD: The programmes of the 21 common medical specialties were analysed and the recommended training periods for each specialty collected, before the information was agreed upon by three observers. The training impact was calculated as the percentage of months that should be amended per specialty to adapt to the common training schedule. RESULTS: The Preventive Medicine and Public Health training programme is the specialty most affected by the Core Training Law (100%, 24 months). Intensive medicine (0%, 0 months) and medical oncology (17%, 4 months) is the least affected. CONCLUSIONS: The CTL affects the common medical specialties in different ways and requires a complete reorganisation of the activities and competencies of PM&PH professionals.

Healthcare coverage for undocumented migrants in Spain: Regional differences after Royal Decree Law 16/2012.

The economic crisis has prompted the debate on how to regulate health coverage of undocumented migrants in publicly funded healthcare systems. Spain, as one of the most heavily affected countries in Europe, can be considered a case of particular interest. In 2012 the Spanish Government issued a Royal Decree Law (RDL 16/2012) which revoked their previous full right to public healthcare coverage, now limited for some exceptions. However, the Spanish National Health System is highly decentralized, and this Central Government decree had to be implemented by the Regional Health Authorities. Our aim is to compare regional policies regarding entitlement to healthcare for undocumented migrants after RDL 16/2012 in the 17 Autonomous Regions by performing an exhaustive review of the regional health policy regulations published after the enactment of RDL 16/2012. Our analysis shows that many Regions adopted legal, legislative and administrative actions to void or limit its effects, while others applied it as intended, resulting in huge differences in healthcare coverage for irregular migrants among Spanish Regions. The unequal implementation of this Law constitutes a paradigmatic example of the complexity of nation-wide regulation of controversial key issues in decentralized health systems. In addition, our results highlight that within-country differences in access and/or entitlement can be as relevant as those reported among-country when there is healthcare decentralization.