Asociación entre periodontitis, enfermedad cerebrovascular y demencia. Informe científico del Grupo de Trabajo de la Sociedad Española de Periodoncia y la Sociedad Española de Neurología / The association between periodontitis, cerebrovascular disease, and dementia. Scientific report of the Working Group of the Spanish Society of Periodontology and the Spanish Society of Neurology

Objetivo: Revisar la evidencia científica disponible sobre la relación entre la periodontitis y las enfermedades neurológicas, en particular la enfermedad cerebrovascular y la demencia. Además, se facilitan una serie de recomendaciones en relación con la prevención y el manejo de la periodontitis y estas enfermedades neurológicas desde las consultas dentales y las unidades de neurología. Desarrollo: Se realizó una búsqueda bibliográfica sin restricción en cuanto al diseño del estudio para identificar aquellos artículos más relevantes sobre la asociación entre periodontitis, enfermedad cerebrovascular y demencia desde un punto de vista epidemiológico, de intervención, así como de mecanismos biológicos involucrados en estas relaciones, y así responder a diferentes preguntas planteadas por los miembros del Grupo de Trabajo SEPA-SEN. Conclusiones: La periodontitis aumenta el riesgo de ictus isquémico y demencia de tipo Alzheimer. Bacteriemias recurrentes con aumento de un estado inflamatorio sistémico de bajo grado parecen ser posibles mecanismos biológicos que explicarían esta asociación. Una evidencia limitada apunta a que diferentes intervenciones de salud oral pueden reducir el riesgo futuro de padecer enfermedad cerebrovascular y demencia.(AU)

Objective: This article reviews the scientific evidence on the relationship between periodontitis and neurological disease, and particularly cerebrovascular disease and dementia. We also issue a series of recommendations regarding the prevention and management of periodontitis and these neurological diseases at dental clinics and neurology units. Development: In response to a series of questions proposed by the SEPA-SEN Working Group, a literature search was performed, with no restrictions on study design, to identify the most relevant articles on the association between periodontitis and cerebrovascular disease and dementia from the perspectives of epidemiology, treatment, and the biological mechanisms involved in these associations. Conclusions: Periodontitis increases the risk of ischaemic stroke and Alzheimer dementia. Recurrent bacterial infections and increased low-grade systemic inflammation seem to be possible biological mechanisms underlying this association. Limited evidence suggests that various oral health interventions can reduce the future risk of cerebrovascular disease and dementia.(AU)

The association between periodontitis and cerebrovascular disease, and dementia. Scientific report of the working group of the Spanish Society of Periodontology and the Spanish Society of Neurology.

OBJECTIVE: This article reviews the scientific evidence on the relationship between periodontitis and neurological disease, and particularly cerebrovascular disease and dementia. We also issue a series of recommendations regarding the prevention and management of periodontitis and these neurological diseases at dental clinics and neurology units. DEVELOPMENT: In response to a series of questions proposed by the SEPA-SEN working group, a literature search was performed, with no restrictions on study design, to identify the most relevant articles on the association between periodontitis and cerebrovascular disease and dementia from the perspectives of epidemiology, treatment, and the biological mechanisms involved in these associations. CONCLUSIONS: Periodontitis increases the risk of ischaemic stroke and Alzheimer dementia. Recurrent bacterial infections and increased low-grade systemic inflammation seem to be possible biological mechanisms underlying this association. Limited evidence suggests that various oral health interventions can reduce the future risk of cerebrovascular disease and dementia.

SEOM-GECP-GETTHI Clinical Guidelines for the treatment of patients with thymic epithelial tumours (2021)

Thymic epithelial tumours (TET) represent a heterogeneous group of rare malignancies that include thymomas and thymic carcinoma. Treatment of TET is based on the resectability of the tumour. If this is considered achievable upfront, surgical resection is the cornerstone of treatment. Platinum-based chemotherapy is the standard regimen for advanced TET. Due to the rarity of this disease, treatment decisions should be discussed in specific multidisciplinary tumour boards, and there are few prospective clinical studies with new strategies. However, several pathways involved in TET have been explored as potential targets for new therapies in previously treated patients, such as multi-tyrosine kinase inhibitors with antiangiogenic properties and immune checkpoint inhibitors (ICI). One third of patient with thymoma present an autoimmune disorders, increasing the risk of immune-related adverse events and autoimmune flares under ICIs. In these guidelines, we summarize the current evidence for the therapeutic approach in patients with TET and define levels of evidence for these decisions.MethodologyThese guidelines are based on leading studies published in peer review journals. The Infectious Diseases Society of America grading system was used to assign levels of evidence and grades of recommendation.

SEOM-GECP-GETTHI Clinical Guidelines for the treatment of patients with thymic epithelial tumours (2021).

Thymic epithelial tumours (TET) represent a heterogeneous group of rare malignancies that include thymomas and thymic carcinoma. Treatment of TET is based on the resectability of the tumour. If this is considered achievable upfront, surgical resection is the cornerstone of treatment. Platinum-based chemotherapy is the standard regimen for advanced TET. Due to the rarity of this disease, treatment decisions should be discussed in specific multidisciplinary tumour boards, and there are few prospective clinical studies with new strategies. However, several pathways involved in TET have been explored as potential targets for new therapies in previously treated patients, such as multi-tyrosine kinase inhibitors with antiangiogenic properties and immune checkpoint inhibitors (ICI). One third of patient with thymoma present an autoimmune disorders, increasing the risk of immune-related adverse events and autoimmune flares under ICIs. In these guidelines, we summarize the current evidence for the therapeutic approach in patients with TET and define levels of evidence for these decisions.

Case report of segmental odontomaxillary dysplasia with cutaneous manifestations.

BACKGROUND: Segmental odontomaxillary dysplasia is an uncommon nonhereditary growth disorder that affects the maxilla, gums and ipsilateral dentition. The disorder is diagnosed mainly based on dental (over-retention of primary teeth, dental agenesis and diastemas) and bone findings (bone sclerosis, irregular trabeculation of immature bone and reduced maxillary sinus). This paper provides a case report. CASE REPORT: A 5-year-old child with skin manifestations including hypertrichosis, facial erythema and pigmented nevus was diagnosed with type II segmental odontomaxillary dysplasia based on clinical, radiographic and histopathological analysis. CONCLUSION: The skin findings can help with the suspicion of segmental odontomaxillary dysplasia, although the definitive diagnosis is typically established by a paediatric dentist based on clinical and radiological findings.

Treatment and Outcome of Patients with Stage IS Testicular Cancer: A Retrospective Study from the Spanish Germ Cell Cancer Group.

PURPOSE: Stage IS testicular cancer is defined by the persistence of elevated serum tumor markers, including α-fetoprotein and/or ß-human chorionic gonadotropin, after orchiectomy without radiological evidence of metastatic disease. Current treatment recommendations include cisplatin based chemotherapy up front but the recommendations are based on limited single center series. MATERIALS AND METHODS: We retrospectively analyzed clinical and pathological characteristics, and long-term outcomes in 110 patients uniformly treated with primary chemotherapy between 1994 and 2016. The primary objective was to evaluate long-term disease-free survival. We also explored factors associated with the need for additional treatment. RESULTS: The elevated prechemotherapy tumor markers were α-fetoprotein in 48% of cases, ß-human chorionic gonadotropin in 14%, and α-fetoprotein and ß-human chorionic gonadotropin in 38%. Median α-fetoprotein and ß-human chorionic gonadotropin values were 71 ng/ml and 80 mIU/ml, respectively. The IGCCCG (International Germ Cell Cancer Collaborative Group) prognostic classification was good in 94% of cases. Mixed nonseminomatous germ cell tumor was found in 78% of cases. Of the patients 103 achieved a complete response to chemotherapy. In 6 patients radiological signs of progressive disease developed during chemotherapy, while 8 experienced relapse after an initial complete response. At a median followup of 108 months 108 patients were alive and disease-free. Five and 10-year disease-free survival rates were 87% and 85%, respectively. The predominance of embryonal carcinoma in the primary tumor was the only factor associated with the probability of needing additional therapy. CONCLUSIONS: Stage IS testicular cancer is more commonly associated with elevated α-fetoprotein, an IGCCCG good prognosis and mixed nonseminomatous germ cell tumor. Treatment with cisplatin based chemotherapy leads to cure in most cases. However, a proportion of patients require the integration of additional therapies, including more frequently when embryonal carcinoma is not predominant.

SEOM clinical guidelines on nutrition in cancer patients (2018).

Nutritional deficiency is a common medical problem that affects 15-40% of cancer patients. It negatively impacts their quality of life and can compromise treatment completion. Oncological therapies, such as surgery, radiation therapy, and drug therapies are improving survival rates. However, all these treatments can play a role in the development of malnutrition and/or metabolic alterations in cancer patients, induced by the tumor or by its treatment. Nutritional assessment of cancer patients is necessary at the time of diagnosis and throughout treatment, so as to detect nutritional deficiencies. The Patient-Generated Subjective Global Assessment method is the most widely used tool that also evaluates nutritional requirements. In this guideline, we will review the indications of nutritional interventions as well as artificial nutrition in general and according to the type of treatment (radiotherapy, surgery, or systemic therapy), or palliative care. Likewise, pharmacological agents and pharmaconutrients will be reviewed in addition to the role of regular physical activity.

SEOM clinical guidelines on nutrition in cancer patients (2018)

Nutritional deficiency is a common medical problem that affects 15-40% of cancer patients. It negatively impacts their quality of life and can compromise treatment completion. Oncological therapies, such as surgery, radiation therapy, and drug therapies are improving survival rates. However, all these treatments can play a role in the development of malnutrition and/or metabolic alterations in cancer patients, induced by the tumor or by its treatment. Nutritional assessment of cancer patients is necessary at the time of diagnosis and throughout treatment, so as to detect nutritional deficiencies. The Patient-Generated Subjective Global Assessment method is the most widely used tool that also evaluates nutritional requirements. In this guideline, we will review the indications of nutritional interventions as well as artificial nutrition in general and according to the type of treatment (radiotherapy, surgery, or systemic therapy), or palliative care. Likewise, pharmacological agents and pharmaconutrients will be reviewed in addition to the role of regular physical activity

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Relationship between dental occlusion and functional dependence in elderly Caucasians.

OBJECTIVE: To determine whether a relationship exists between the number of functional masticatory units (FMUs) and the level of functional dependence of elderly. SUBJECTS AND METHODS: The study group comprised 502 elderly Caucasians living in nursing homes in north-west Spain and Portugal. The number of FMUs was counted on direct visual inspection. The degree of dependence was assessed using the Barthel index. The results were validated in a group of 156 elderly. Statistical analysis of the results was performed using a generalised linear model (GLM), a logistic GLM, a ROC-GLM curve and a confusion matrix. RESULTS: The number of FMUs significantly affected the Barthel index score (explained deviance = 27.5%). The number of FMUs was significantly associated with a lower probability of dependence, both for women (explained deviance = 31%) and for men (explained deviance = 33%). The model based on FMUs showed a good discriminatory capacity for dependence (AUC = 0.84 in women and 0.82 in men). The predictive capacity of the dependence model based on FMUs was very high (sensitivity = 0.9 in women and 0.8 in men). CONCLUSIONS: In institutionalised elderly Caucasians, the number of FMUs is significantly associated with the Barthel index score and could be a predictive factor for dependence.

A Dramatic Case of Odynophagia.

We report the case of a 77-year-old male with a history of aortic stenosis and interstitial lung disease, who debuted 3 years ago with an outbreak of necrotic and very painful canker sores. The severity of the lesions and their refractory response to treatment led to several hospital admissions and multiple consultations to different specialists (ENT, rheumatology, dermatology, ophthalmology, cardiology, and internal medicine). During this time, the patient received central parenteral nutrition with an episode of catheter-related septicemia, and he came to require psychiatric assistance for autolytic ideation. Numerous diagnostic tests were performed with inconclusive results, including biopsy of the lesion (histological study, immunohistochemistry for CD68 + , CD4 + , CD8 + , CD20 + , MCT +, and cytomegalovirus, PAS, Grocott-Gomori and Zielh-Neelsen staining, and in situ hybridization for Epstein Barr virus). Numerous treatments were unsuccessfully tested until thalidomide was administered, thus completely remitting lesions but leaving retractable scarring sequelae. Since then, the patient has had two recurrences, coinciding with the reduction of thalidomide dosages, which were controlled by increasing the dose of the immunomodulator. Recurrent necrotizing major aphthous stomatitis (Sutton's disease) is a clinical variant of recurrent aphthous stomatitis that may have a dramatic course. Unfortunately, the lack of etiopathogenetic uniformity precludes any specific treatment. In severe cases, immunomodulators, including thalidomide, may represent a valid therapeutic option.

Efficacy of tyrosine kinase inhibitors in EGFR-mutant lung cancer women in a real-world setting: the WORLD07 database

Background. The WORLD07 project is a female specific database to assess the characteristics of women with lung cancer. Methods. WORLD07 database sets up in 2007, and prospectively stores clinical characteristics, treatment, outcome, and follow-up of lung cancer women. All women with epidermal growth factor receptor (EGFR) mutation non-small cell lung cancer (NSCLC) were selected for this analysis. Results. From October 2007 to December 2012, a total of 1775 NSCLC women were recruited. EGFR mutation was identified in 34.4% of patients. Upfront EGFR tyrosine kinase inhibitor (TKI) reported a response rate of 60%, a median progression-free survival of 11.7 months, and median overall survival of 23.0 months. EGFR TKI, EGFR-mutation type, and smoking status did not impact in the outcome of treated women. Conclusion. Prevalence of EGFR mutation in women with NSCLC is higher than overall population with NSCLC. Efficacy of EGFR TKI in this real-world setting is similar to that previously reported (AU)

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Efficacy of tyrosine kinase inhibitors in EGFR-mutant lung cancer women in a real-world setting: the WORLD07 database.

BACKGROUND: The WORLD07 project is a female specific database to assess the characteristics of women with lung cancer. METHODS: WORLD07 database sets up in 2007, and prospectively stores clinical characteristics, treatment, outcome, and follow-up of lung cancer women. All women with epidermal growth factor receptor (EGFR) mutation non-small cell lung cancer (NSCLC) were selected for this analysis. RESULTS: From October 2007 to December 2012, a total of 1775 NSCLC women were recruited. EGFR mutation was identified in 34.4% of patients. Upfront EGFR tyrosine kinase inhibitor (TKI) reported a response rate of 60%, a median progression-free survival of 11.7 months, and median overall survival of 23.0 months. EGFR TKI, EGFR-mutation type, and smoking status did not impact in the outcome of treated women. CONCLUSION: Prevalence of EGFR mutation in women with NSCLC is higher than overall population with NSCLC. Efficacy of EGFR TKI in this real-world setting is similar to that previously reported.

Subcutaneous emphysema related to air-powder tooth polishing: a report of three cases.

Subcutaneous emphysema is a rare complication of dental procedures and can occasionally give rise to potentially life-threatening complications. We describe three cases of subcutaneous emphysema diagnosed in the same dental clinic. All cases occurred during tooth or implant cleaning using air polishing (KavoProphyflex® ) with a sodium bicarbonate powder (Air-N-Go Classic® ). The diagnosis was based on clinical findings and was confirmed radiologically. The cervical and facial regions were affected in all three cases, and spread to the mediastinum occurred in one case. All the episodes resolved within 3-5 days. Tooth cleaning using air polishing combined with an abrasive powder is a risk factor for subcutaneous emphysema, especially when the powder and device are from different manufacturers. Radiological assessment must be performed to rule out involvement of deep tissue planes.

Micro and macro geographical analysis of Y-chromosome lineages in South Iberia.

In this study, we intend to identify the evolutionary footprints of the South Iberian population focusing on the Berber and Arab influence, which has received little attention in the literature. Analysis of the Y-chromosome variation represents a convenient way to assess the genetic contribution of North African populations to the present-day South Iberian genetic pool and could help to reconstruct other demographic events that could have influenced on that region. A total of 26 Y-SNPs and 17 Y-STRs were genotyped in 144 samples from 26 different districts of South Iberia in order to assess the male genetic composition and the level of substructure of male lineages in this area. To obtain a more comprehensive picture of the genetic structure of the South Iberian region as a whole, our data were compared with published data on neighboring populations. Our analyses allow us to confirm the specific impact of the Arab and Berber expansion and dominion of the Peninsula. Nevertheless, our results suggest that this influence is not bigger in Andalusia than in other Iberian populations.

Long-term survival in advanced non-squamous NSCLC patients treated with first-line bevacizumab-based therapy

Background/Aim. First-line bevacizumab-based therapies have been shown to improve clinical outcomes in patients with non-squamous non-small-cell lung cancer (NSCLC). We aimed to descriptively analyse patients with non-squamous NSCLC who received a long-term period of maintenance bevacizumab. Patients and methods. This retrospective study included 104 patients who had already reached a progression-free survival (PFS) of at least 9 months. Results. Median overall survival and PFS were 30.7 and 15.1 months, respectively. The overall response rate was 83 %. Weight loss ≤5 %, ECOG PS = 0, or low number of metastatic sites seem to be predictive factors of good evolution. The incidence of bevacizumab-related adverse events appeared to be similar as the previous studies. Conclusion. Our findings show that there is a long-term survivor group whom the administration of bevacizumab resulted in a relevant prolongation of response without new safety signals. Due to the population heterogeneity, it was not possible to identify the standardised predictive factors (AU)

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Adherence of older people with instability in vestibular rehabilitation programmes: prediction criteria.

OBJECTIVE: To determine whether demographic characteristics or balance examination findings can predict the adherence of older people with instability to a vestibular rehabilitation programme. METHODS: A prospective case-control study was conducted of 120 patients aged 65 years or more (mean age, 77.3 ± 6.33 years). Two groups were classified according to patients' adherence with the follow-up post-rehabilitation protocol. Analysed variables included: age, sex, body mass index, Timed Up and Go test findings, computerised dynamic posturography, Dizziness Handicap Inventory scores and Short Falls Efficacy Scale - International questionnaire results, number of falls, and type of vestibular rehabilitation. RESULTS: Two groups were established: adherents (99 individuals) and non-adherents (21 individuals). There were differences between the groups regarding: sex (female-to-male ratio of 4.8:1 in adherents and 1.63:1 in non-adherents), age (higher in non-adherents) and voluntary movement posturographic test results (non-adherents had poorer scores). CONCLUSION: The patients most likely to abandon a vestibular rehabilitation programme are very elderly males with low scores for centre of gravity balancing and limits of stability.

Time to onset of bisphosphonate-related osteonecrosis of the jaws: a multicentre retrospective cohort study.

OBJECTIVES: Osteonecrosis of the jaw (ONJ) is a potentially severe adverse effect of bisphosphonates (BP). Although the risk of ONJ increases with increasing duration of BP treatment, there are currently no reliable estimates of the ONJ time to onset (TTO). The objective of this study was to estimate the TTO and associated risk factors in BP-treated patients. SUBJECTS AND METHODS: Retrospective analysis of data from 22 secondary care centres in seven countries relevant to 349 patients who developed BP-related ONJ between 2004 and 2012. RESULTS: The median (95%CI) TTO was 6.0 years in patients treated with alendronate (n = 88) and 2.2 years in those treated with zoledronate (n = 218). Multivariable Cox regression showed that dentoalveolar surgery was inversely associated, and the use of antiangiogenics directly associated, with the TTO in patients with cancer treated with zoledronate. CONCLUSIONS: The incidence of ONJ increases with the duration of BP therapy, with notable differences observed with respect to BP type and potency, route of administration and underlying disease. When data are stratified by BP type, a time of 6.0 and 2.2 years of oral alendronate and intravenous zoledronate therapy, respectively, is required for 50% of patients to develop ONJ. After stratification by disease, a time of 5.3 and 2.2 years of BP therapy is required for 50% of patients with osteoporosis and cancer, respectively, to develop ONJ. These findings have significant implications for the design of future clinical studies and the development of risk-reduction strategies aimed at either assessing or modulating the risk of ONJ associated with BP.

Long-term survival in advanced non-squamous NSCLC patients treated with first-line bevacizumab-based therapy.

BACKGROUND/AIM: First-line bevacizumab-based therapies have been shown to improve clinical outcomes in patients with non-squamous non-small-cell lung cancer (NSCLC). We aimed to descriptively analyse patients with non-squamous NSCLC who received a long-term period of maintenance bevacizumab. PATIENTS AND METHODS: This retrospective study included 104 patients who had already reached a progression-free survival (PFS) of at least 9 months. RESULTS: Median overall survival and PFS were 30.7 and 15.1 months, respectively. The overall response rate was 83 %. Weight loss ≤5 %, ECOG PS = 0, or low number of metastatic sites seem to be predictive factors of good evolution. The incidence of bevacizumab-related adverse events appeared to be similar as the previous studies. CONCLUSION: Our findings show that there is a long-term survivor group whom the administration of bevacizumab resulted in a relevant prolongation of response without new safety signals. Due to the population heterogeneity, it was not possible to identify the standardised predictive factors.

A breath ammonia analyser for monitoring patients with end-stage renal disease on haemodialysis.

OBJECTIVE: Breath ammonia measurement has attracted increasing interest for clinical diagnosis and metabolic status monitoring. This pilot study aims to evaluate a simple detection method to measure breath ammonia levels in haemodialysis patients. MATERIALS AND METHODS: The study group comprised 44 adults undergoing haemodialysis and a control group of 44 age- and sex-matched individuals with a glomerular filtration rate >90 mL/min. To measure breath ammonia concentration, we designed a device based on that used to monitor atmospheric air, which uses a specific colorimetric tube. A single operator took two readings from each haemodialysis patient (one predialysis and one postdialysis) and one reading from each control. The results were compared with the urea concentrations in blood and saliva. RESULTS: Breath ammonia concentration correlated significantly with blood urea both predialysis (P < 0.001; R2 = 0.55) and postdialysis (P = 0.009; R2 = 0.25), as well as with predialysis saliva urea concentration (P < 0.001; R2 = 0.24). Ammonia was not detectable in breath of any of the control group. CONCLUSIONS: The collection of breath samples in polyvinyl fluoride bags and their subsequent analysis using colorimetric tubes is a simple, noninvasive method that enables variations in breath ammonia concentration to be measured rapidly in haemodialysis patients. Using this method, we found that the breath ammonia concentration correlated significantly with the blood urea concentration before and after haemodialysis.

¿Es factible una intervención en registro de tabaquismo en un centro de salud? / Is an intervention in the registry of smoking habit in a health care center feasible?

Objetivo. Analizar la variación en registro de hábito tabáquico en médicos de Atención Primaria tras una intervención de concienciación. Participantes y método. Once médicos de familia y 15.754 personas asignadas a sus cupos. Estudio de intervención con evaluación pre-post de efectividad en el registro en historia clínica. Centro de Salud Novoa Santos (Ourense). Resultados. Tasa de registro de tabaquismo pre intervención 5,79%; post: 6,87% (p < 0,001). 51,6% mujeres. Media de edad 49,11 años (IC 95%: 48,30-49,92). El registro aumentó un 15,80% tras la intervención (p < 0,0001). Médicos participantes: media de edad 56,32 años (IC 95%: 56,07-56,57 años). Entre tutores el registro inicial era menor (p < 0,0001) fueron los que más incrementaron (p < 0,001). Variables que se asociaron a mayor registro post intervención en la regresión: médicas, cupos más grandes y ex fumadores. Por turno de trabajo el impacto ha sido mayor en turno de tardes fijas o deslizantes respecto a mañanas p < 0,0001. Conclusiones. Una intervención en tabaquismo es factible y produce mejora en el registro. Las variables asociadas a mayor tendencia a registrar el hábito tabáquico fueron: trabajar en turno de tarde; ser tutor, ser exfumador o fumador activo, cupos con más de 1.450 tarjetas sanitarias, y profesionales con menos tiempo trabajando en el centro (p < 0,001) (AU)

Objective. Analyze the variation in the registry of smoking habit in Primary Care physicians after an awareness-raising intervention. Participants and methods. Eleven family physicians and 15,754 persons assigned to their quota. Intervention study with pre-post evaluation of effectiveness in the clinical record registry. Health Care Site Novoa Santos (Ourense). Results. Pre-intervention smoking habit registry rate 5.79%; post: 6.87% (p < 0.001). 51.6% women. Mean age 49.11 years (CI 95%: 48.30-49.92). The registry increased 15.80% after the intervention (p < 0.0001). Participating physicians: mean age 56.32 years (CI 95%: 56.07-56.57 years). Among tutors, the initial registry was less (p < 0.0001) and the tutors were those who showed the greatest increase (p < 0.001). Variables that were associated to a higher post-intervention registry in regression: physicians, larger quotas and ex-smokers. By work shift, the impact was greater in the fixed afternoon or changing shifts regarding the morning p < 0.0001. Conclusions. An intervention in smoking habit is feasible and produces improvement in the registry. The variables associated to a greater tendency to record the smoking habit were: working in the afternoon shift; being a tutor, being an ex-smoker or active smoker, quotas with more than 1,450 health care cards, and professionals with less time working in the center (p < 0.001) (AU)