Poor bisphosphonate adherence for treatment of osteoporosis increases fracture risk: systematic review and meta-analysis.

UNLABELLED: Systematic review of adherence to bisphosphonates for the treatment of osteoporosis finds suboptimal levels of persistence and compliance. Poor bisphosphonate compliance increases fracture risk. INTRODUCTION: The objectives of the study were to measure the persistence and compliance with bisphosphonates for the treatment of osteoporotic patients, and to estimate the influence of compliance on fracture risk. METHODS: A systematic review of bisphosphonate adherence in clinical practise provided new evidence to perform a meta-analysis of the means of bisphosphonate persistence and compliance, with a subsequent meta-analysis of fracture risk comparing poorly versus highly compliant patients. RESULTS: Fifteen articles, totalling 704,134 patients, met our inclusion criteria. Most of the patients were postmenopausal women treated with bisphosphonates. The 3.95% of the patients received hormone replacement therapy, but the rest received bisphosphonates. The meta-analysis of five articles totalling 236,540 patients, who were followed for 1 year, provided a pooled persistence mean of 184.09 days. The meta-analysis of five articles, totalling 234,737 patients, who were also followed for 1 year, provided a pooled medication possession ratio mean of 66.93%. The meta-analysis of six articles, totalling 171,063 patients, who were followed for varying periods of time between 1 and 2.5 years, provided a pooled 46% increased fracture risk in non-compliant patients versus compliant patients. The increased fracture risk was lower for non-vertebral (16%) and hip (28%) than for clinical vertebral fractures (43%). CONCLUSIONS: Persistence and compliance are suboptimal for postmenopausal women undergoing bisphosphonate therapy for osteoporosis. The clinical consequence of this low compliance is an increased risk of fracture, which is lower for non-vertebral than for clinical vertebral fractures.

[Deaths attributable to tobacco consumption in Spain]. / Muertes atribuibles al consumo de tabaco en España.

Spain is one of the European countries with greater prevalence of tobacco consumption among general population. In order to encourage the implementation of tobacco consumption reduction programmes, the number of deaths caused by cardiovascular diseases and chief cancer localizations attributable to tobacco consumption in Spain were calculated by epidemiologic methods. Estimates suggest that, in 1983, 39.816 tobacco related deaths occurred, which accounted for 13% of total deaths reported during that year. The four tobacco related diseases producing the greatest number of deaths were ischemic cardiopathy (10.821 deaths), bronchopulmonary cancer (8.337 deaths), chronic obstructive pulmonary disease (7.473 deaths), and acute cerebrovascular accident (6.636 deaths). These results suggest that tobacco consumption is the isolated cause responsible of the greatest number of deaths in Spain, whose control must become a priority objective in our health policy.

[Mortality caused by cardiovascular diseases in Spain: where are we going?]. / Mortalidad por enfermedades cardiovasculares en España: hacia dónde vamos?

Spain is one of the european countries with a lowest mortality rate by cardiovascular diseases (although they are the leading cause of mortality) and, specifically, by ischemic heart disease. The trends in the last 16 years for which data are available point to a reduction of the former in 1.07% in males and 1.53% in females for the complete study period (1968-1984) and a trend towards the stabilization of the latter (a reduction of 0.45% in males and 1.88% in females from 1978 to 1984). The apparently unfavorable evolution of the classical risk factors of coronary artery disease, however, makes that its future outcome is uncertain. Therefore, their control is a basic aim of the policy for the control of this disease.

[Trends in the mortality attributable to tobacco use in Spain, 1978-1992: 600,000 deaths in 15 years]. / Tendencia de la mortalidad atribuible al tabaquismo en España, 1978-1992: 600.000 muertes en 15 años.

BACKGROUND: The main objective is to describe time trends and evolution of mortality attributable to tobacco use in Spain in the period 1978-1992. MATERIAL AND METHODS: Spanish pevalences for never smokers, current smokers and former smokers estimated from national health surveys, and relative risks for death attributed to tobacco use from the Cancer Prevention Study II were used. The proportion and number of deaths attributed to tobacco use in the Spanish population of 35 years and over have been calculated by cause of death, sex and age. The trend in mortality attributable to tobacco use over the period 1978-1992 has also been calculated, expressed as the mean percentage change per year in the standardised mortality rates, estimated by a log-lineal model. RESULTS: Tobacco consumption caused 46,226 deaths in Spain in 1992. Most of them occurred in males (93.4%). One of every 4 deaths in males, and one of every 50 in females were attributable to tobacco consumption. One third of the deaths attributed to tobacco use were premature deaths (under 65 years). Lung cancer, chronic obstructive pulmonary disease, ischemic heart disease and cerebrovascular disease caused 75% of deaths attributed to tobacco use. Lung cancer was the first specific cause in males, and chronic obstructive pulmonary disease was the main cause in females. A total of 621,678 deaths attributed to tobacco consumption were produced in the period (1978-1992). The main percentage change per year in the mortality rates shows a moderate increment of 0.1% (-0.2% in males +6.7% in females). CONCLUSIONS: Mortality attributable to tobacco use in Spain represents a high cost in terms of avoidable deaths and shows the limited impact of the interventions directed to tobacco control in Spain. One of every 4 deaths in males and a disturbing and rapidly increasing proportion in females are attributable to smoking.

[Searching for evidence. A compilation of useful resources for health technology assessment]. / Búsqueda de evidencias. Una recopilación de recursos útiles en la evaluación de tecnologías sanitarias.

The spectacular growth in the produced volume of published scientific and technical information during the last years makes it difficult to discriminate and localize the information of greater quality. The parallel development of technologies for the fast handling of great volumes of single information has partially solved the problem of the access and use of the most advisable information. Health technology assessment tries to facilitate the decision making on the introduction, diffusion or use of health technologies, being based on the best evidences available. In order to improve the process of searching for evidences, needed in the process of health technology assessment, the Agency of Health Technology Assessment of the Institute of Salud Carlos III (AETS) made a compilation of information resources that can be useful for searching biomedical information in general. This article presents the above mentioned compilation along with the description of the process of elaboration and the criteria of selection applied.

[Smoking-attributable deaths in Spain in 1998]. / Mortalidad atribuible al tabaquismo en España en 1998.

BACKGROUND: Between 1993 and 1997, smoking prevalence remained stable in Spain yet age-adjusted death rates by smoking-related diseases decreased. Our study aimed to estimate the burden of smoking-attributable mortality in Spain in 1998. POPULATION AND METHOD: Spain's smoking prevalence, mortality and relative risks for death from the Cancer Prevention Study II were used to estimate smoking-attributable mortality in the population aged 35 years and over. RESULTS: In 1998, 55,613 deaths were attributable to smoking. One out of 4 deaths in males and one out of 40 deaths in females were attributable to tobacco. Two thirds of the attributable mortality corresponded to deaths due to lung cancer, chronic obstructive pulmonary disease, ischemic heart disease and stroke. CONCLUSIONS: Smoking actually represents a remarkable burden of avoidable deaths in Spain. Smoking-attributable mortality appears to continue increasing in the last years.

[Projections of the impact of the smoking habit on the health of the Spanish population and on the potential benefits from its control]. / Proyección del impacto del hábito tabáquico sobre la salud de la población española y de los beneficios potenciales de su control.

BACKGROUND: Smoking continues to be an important public health problem in Spain. With the aim to know some of the health care consequences derived from the evolution of this habit in the Spanish population and to anticipate the health care benefits which would be a result of intervention on the same the estimations of mortality related with smoking and its control in the next few decades were predicted. METHODS: Mathematic models of simulation of the effects derived from changes in the prevalence of smoking based on the techniques of attributable risk, the multiplicity of the diseases involved and the time of reversal of the risk of death following health care intervention were used. RESULTS: In absence of intervention on smoking the number of total deaths by the causes under consideration will, in general, increase, from 1987 to 2020. The reduction of 40% in the prevalence of smoking in adult Spanish smokers over a period of 8 years (1992-2000) would potentially decrease the number of cardiovascular deaths by 6,035, deaths by COPD by 394 and the deaths by malignant tumors studied in the year 2020 by 5,237. By the year 2020 the effects of intervention would, in general, be completely manifest. A part of this reduction of mortality would translate in a gaining of 57,323 real years of life in the year 2020. These benefits are also appreciable, although lesser, in the previous years from the beginning of intervention. CONCLUSIONS: Smoking will continue to be an important public health problem in Spain in the future. The health care benefits which may be derived from correct application of effective control programs of the same would be appreciable.

[The effects of implementing a smoking cessation intervention in Spain on morbidity, mortality and health care costs]. / Morbilidad, mortalidad y costes sanitarios evitables mediante una estrategia de tratamiento del tabaquismo en España.

OBJECTIVE: We estimated the effect that a smoking cessation intervention in the Spanish population of smokers would have on smoking-related morbidity, mortality and health care costs. METHODS: We adopted the model Health and Economic Consequences of Smoking sponsored by the WHO Health Organization and developed by the The Lewin Group. The smoking cessation intervention proposed includes pharmacological treatment to 35% of smokers who are trying to quit smoking and obtains a quit rate of 7.2%. The diseases studied are: lung cancer, heart disease, stroke, chronic obstructive pulmonary disease, asthma exacerbation, and low birth weight. The smoking-related cases of disease and of averted death and the reduction in health care expenditure due to the intervention were estimated. RESULTS: Without intervention, at year 1 of the model, 2,136,094 smokers would be affected by some smoking-related disease; health care expenditure would be 4,286 million e and deaths attributable to smoking would total 26,537. The proposed intervention would prevent 2,613, 9,192, 17,415 and 23,837 cases of smoking-related disease at years 2, 5, 10 and 20 of the model, respectively. The saving in accumulated health care costs would amount to 3.5 million e at year 2 and 386 million e over 20 years. The accumulated prevented deaths are 284 at year 2 and 9,205 over 20 years. The intervention would save a total of 78,173 life-years by the end of the period considered. CONCLUSIONS: The availability of new effective smoking cessation interventions and the increase in accessibility to such interventions may contribute significantly to reducing morbidity, mortality and health care costs associated with smoking in Spain.

[Report on the surgery for epilepsy]. / Informe sobre la cirugía de la epilepsia.

OBJECTIVE: We review the clinical indications and outcomes of surgical procedures in epilepsy which is resistant to medical treatment and the current situation and future possibilities of carrying out surgery for epilepsy in Spain. DEVELOPMENT: Search of the scientific literature included in the data base MEDLINE for the period 1995-1997, retrieval of reports in relation to agencies for the evaluation of health technology of the INAHTA network and the data base of the Cochrane library. The surgery of epilepsy reduces the frequency of seizures (the basic result analyzed) in all groups of patients, although in a very variable manner, depending on the clinical situation and type of operation. The results in patients with temporal lobe epilepsy and in those with localized lesions are particularly good (temporal lobe epilepsy and lesionectomy) (67-69% without seizures), with a follow up period of one to two years. It is estimated that in Spain between 75 and 300 new cases per year would benefit from surgery. The number of patients with drug-resistant epilepsy operated on in Spain is approximately 100-150 patients per year. CONCLUSIONS: Operations for epileptic syndromes, where there are surgically resectable lesions, should be justified by the gravity and impact of the disease on the psychosocial and functional development of the patient. Insufficiency resources are dedicated to the option of surgical treatment and perhaps they are also underused. These operations should be carried out in highly specialized centres, with adequate resources and an annual volume which guarantees excellence.

[Efficacy of the meningococcal vaccine from Group C capsular polysaccharide]. / Eficacia de la vacuna meningocócica de polisacárido capsular del grupo C.

BACKGROUND: This report is a systematic review of the effect intensity and duration of the immune response to meningococcal serogroup C vaccine. The vaccine safety, efficacy and effectiveness are also analyzed. METHODS: MEDLINE literature search in the period 1970-1996. Meningoccocal polysaccharide vaccine clinical trials and human prospective studies were specifically searched. Quality of the retrieved studies were analyzed. Information available was integrated. RESULTS: Group C meningoccal polysaccharide vaccine is a safe product. Its efficacy is over 85% among adults and children over 5 years old. 70% (CI 95%: 5-91%) under 5 years old, and 55% among children 2-3 years old. The vaccine is not effective under 2 years. The duration of protective antibody levels decrease with age. The proportion of vaccinated children effectively protected one year after vaccination is low. Vaccination does not affect the immune response to ulterior revaccination. CONCLUSIONS: Group C meningococcal polysaccharide vaccine is indicated in adults and children over 2 years old to protect them from meningococcal disease due to group C when exposed to high risk of infection. The outbreaks control is the main indication for the use of this vaccine. Routine immunization in not outbreak situation is not recommended due to the small vaccine protection in children under 2 years old, the limited efficacy in children under 5, and the short duration of the immunity in children.

[Levels of bactericidal antibodies against meningococcus C after vaccination in 2- to 6-year-old children in Andalusia]. / Niveles de anticuerpos bactericidas frente a meningococo C tras la vacunación de niños de 2 a 6 años de edad en Andalucía.

BACKGROUND: In 1997, 18.5% of the cases of Meningococcal Disease caused b serogroup C in Andalusia were children between 2 and 4 years of age; ages where the initial immune response and the duration of the capsular A + C meningococcal polysaccharide vaccine is less than in older age groups. Research was designed in order to measure the immune response produced by this vaccine in children from 2 to 6 years of age and to compare it with the natural immunity present in unvaccinated children. METHODS: I. Dual monitoring study: a) groups of children vaccinated previously and control groups, b) groups of children who were going to be vaccinated, for pre and post-vaccination (1, 6 and 12 months) analysis and a control group. II. The bactericidal activity was measured according to the standardised protocol of the CDC with regard to the strain of N. meningitidis C-11. The sera with bactericidal activity (TAB) > 1:8 were considered to be protective. RESULTS: 1 and 2 months following vaccination, the proportion of TAB > 1:8 was significantly higher than that of the control group (65.6% and 73% in comparison to 2.2% and 12%). In the pre-vaccine and post-vaccine (after 6, 7, 12 and 13 months) verification, no significant difference between vaccinated individuals and controls was observed. CONCLUSIONS: The differences between vaccinated and unvaccinated individuals 1 and 2 months following vaccination indicate seroconversion in the vaccinated individuals. For the age group of between 2 to 6 years of age, the bactericidal activity acquired decline quickly, as, after 6 months, differences between this group and the control group are no longer observed.

[Evaluation of health technologies and benefits entitlement in advanced social systems]. / Evaluación de las tecnologías sanitarias y ordenación de las prestaciones en los sistemas sociales avanzados.

In the present study, health is considered a subject of insurance whose protection has become a Fundamental Right. In the same line, health care has acquired a contractual character whose "nature" has evolved from individual to collective, expressed in terms of "health care insurance", public or private. In such context, outcome measurement becomes necessary to be able to define the variables of the System and, subsequently, the contracting conditions. Having an understanding of the economic impact is required to analyze the costs and, in consequence, the financial necessities of the System; as well as the clinical results in order for the insured to have some realistic expectations of the benefits that can be expected from the health care that is offered. In turn, the vertiginous rhythm of technological innovation that characterizes the modern medicine forces to the continuous revision of the state of the art framed in a health sector whose multifactorial profile confers it growing complexity. In conclusion, health technology assessment becomes indispensable to identify health care effectiveness, to facilitate its efficient management, to define responsibilities and to offer guarantees to the users; all which is already part of an ethical body that, day by day with more clarity, is being configured by the legislation and that, in turn, guarantees the survival of the Health Care System.

IFN-g response to vaccination against tuberculosis in dairy heifers under commercial settings.

The purpose was to determine IFN-g release as a response to vaccination against tuberculosis in dairy heifers under commercial settings. Four-hundred pregnant heifers from ten herds were randomly allocated into four groups: (1) unvaccinated, (2) BCG vaccinated, (3) BCG vaccinated plus a CFPP400 µg+polygen boost, and (4) BCG vaccinated plus a CFP200 µg+polygen boost, under a completely randomized blocks design. A dose of 106CFU of BCG was delivered SC in the neck, then blood samples were taken at days 0, 30, 120, 210, 300 and 720 to estimate IFN-g release in response to bovine-PPD antigen. No significant difference (P > 0.05) was observed in IFN-g release between groups at days 0 and 120. At days 30 and 210, vaccinated groups show higher IFN-g release than the control group but only difference of group 3 was significant (P < 0.05). At day 300, group 1 showed significantly higher IFN-g release. No significant difference was observed at day 720. Using IFN-g release as a surrogate for vaccine efficacy, BCG plus a boost with CFP or CFPP combined with an adjuvant that improves cellular immune response has the potential to protect cattle against tuberculosis for moderate periods of time in vaccinated cattle under commercial settings.