[Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain]. / Documento de consenso sobre el uso de la combinación paracetamol/tramadol en pacientes con dolor moderado-intenso.

OBJECTIVES: To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience. METHODS: The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥7 for each recommendation (1=total disagreement to 10=total agreement). RESULTS: A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education. CONCLUSIONS: These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain.

Clinical evidence of diabetes mellitus end-organ damage as risk factor for falls complicated by hip fracture: A multi-center study of 1225 patients.

AIMS: To identify the differential characteristics of patients with type 2 diabetes mellitus (T2DM) complicated by end-organ damage who experience a fall-related hip fracture. METHODS: We analyzed the socio-demographic data and index fall clinical characteristics of a group of patients with nephropathy, neuropathy or retinopathy related to T2DM consecutively admitted to six hospitals in Barcelona, Spain because of a fall-related hip fracture. RESULTS: Out of 1225 patients admitted because of a fall-related hip fracture, 107 (8.7%) had clinical evidence of end-organ damage related to T2DM. Among this cohort the mean number of falls during the year prior to the index admission was 2.6±3.2; and 29 of them (27.1%) had already experienced three or more falls. Most falls leading to the index admission took place at the patients' home, from a standing position, and during daylight time. An intrinsic cause of falling was identified in all but one of these patients. Multiple stepwise logistic regression analysis showed that, compared to patients without this diagnosis, patients with complicated T2DM were younger (odds ratio 0.762), had less prevalence of dementia (odds ratio 0.078), but had experienced a higher number of falls in the previous year (odds 1.183). CONCLUSIONS: A significant amount of patients with clinical evidence of end-organ damage due to T2DM who experience a fall-related hip fracture have a history of recurrent falling in the previous year. These patients should be identified and offered preventive actions aimed at reducing their risk of falling.

[Mortality-associated factors in nonagenarian. The Nona-Santfeliu Study. Two years of follow-up]. / Factores asociados a mortalidad en nonagenarios. Estudio NonaSantfeliu. Seguimiento a los dos años.

OBJECTIVES: Few studies have prospectively evaluated predictors of mortality in the very elderly. This study has aimed to determine which factors could predict death in nonagenarians after two years of follow-up. PATIENTS AND METHOD: 176 nonagenarians were evaluated prospectively, 137 (74%) of whom lived in their own home and 49 (26%) of whom were institutionalized. Sociodemographic data were collected. Functional status was determined by the Lawton-Brody and the Barthel index, and cognition by the Spanish version of the Mental State Examination (MEC). The Charlson index was used to measure overall co-morbidity. RESULTS: The sample consisted of 135 women (76.3%) and 41 men. Mean age was 93 +/- 3.2 years. Mean Barthel index was 60.8 +/- 30, Lawton index 2.1 +/- 2.2 and MEC 21 +/- 11. The mean of Charlson index was 1.4 +/- 1.7. Six-four patients had died after two years of follow-up (36.3%). Charlson index (oR 1.370, 95% Ci 1.113-1.686, p < 0.003), Lawton index (OR 0.750, 95% CI 0.586-0.960, p < 0.02) and MEC (OR 0.964, 95% CI 0.932-0.997, p < 0.003) were variables independently associated with death after 24 months of follow-up. CONCLUSION: Higher comorbidity, incapacity to perform instrumental ADL at baseline and poor cognitive status are predictors of mortality after 2 years of follow-up in nonagenarians.

Factores asociados a mortalidad en nonagenarios. Estudio NonaSantfeliu. Seguimiento a los dos años / Mortality-associated factors in nonagenarian. The Nona-Santfeliu Study. Two years of follow-up

Objetivos. Pocos estudios han evaluado los factores predictores de mortalidad en las personas muy ancianas. El objetivo del presente estudio fue evaluar qué factores podían predecir la muerte en pacientes nonagenarios después de dos años de seguimiento. Pacientes y método. Se evaluaron 176 nonagenarios, de los que el 73% vivían en su domicilio y el resto en residencia. Se recogieron datos sociodemográficos, la capacidad para realizar actividades básicas con el índice de Barthel (IB) y para instrumentales con el índice de Lawton (IL). Se valoró la cognición con el miniexamen cognitivo de Lobo (MEC) y la comorbilidad con el índice de Charlson. Resultados. Se trataba de 135 mujeres (76,3%) y 41 varones, con una edad media de 93 ± 3 años. La media del IB fue 60,8 ± 30, la del IL 2,1 ± 2,2, la del MEC 21 ± 11 y la del índice de Charlson 1,4 ± 1,7. Sesenta y cuatro pacientes habían fallecido a los dos años de seguimiento (36,3%). El índice de Charlson (OR: 1,370; IC 95%: 1,113-1,686; p < 0,003), IL (OR: 0,750; IC 95%: 0,586-0,960; p < 0,02) y MEC (OR: 0,964; IC 95%: 0,932-0,997; p < 0,003), resultaron factores independientes de mortalidad a los 2 años de seguimiento. Conclusiones. Una mayor comorbilidad, la incapacidad para realizar actividades instrumentales y la disfunción cognitiva son predictores de mortalidad después de 2 años de seguimiento en las personas mayores de 89 años (AU)

Objectives. Few studies have prospectively evaluated predictors of mortality in the very elderly. This study has aimed to determine which factors could predict death in nonagenarians after two years of follow-up. Patients and method. 176 nonagenarians were evaluated prospectively, 137 (74%) of whom lived in their own home and 49 (26%) of whom were institutionalized. Sociodemographic data were collected. Functional status was determined by the Lawton-Brody and the Barthel index, and cognition by the Spanish version of the Mental State Examination (MEC). The Charlson index was used to measure overall co-morbidity. Results. The sample consisted of 135 women (76.3%) and 41 men. Mean age was 93 ± 3.2 years. Mean Barthel index was 60.8 ± 30, Lawton index 2.1 ± 2.2 and MEC 21 ± 11. The mean of Charlson index was 1.4 ± 1.7. Six-four patients had died after two years of follow-up (36.3%). Charlson index (oR 1.370, 95% Ci 1.113-1.686, p < 0.003), Lawton index (OR 0.750, 95% CI 0.586-0.960, p < 0.02) and MEC (OR 0.964, 95% CI 0.932-0.997, p < 0.003) were variables independently associated with death after 24 months of follow-up. Conclusion. Higher comorbidity, incapacity to perform instrumental ADL at baseline and poor cognitive status are predictors of mortality after 2 years of follow-up in nonagenarians (AU)

Characteristics of falls producing hip fractures in nonagenarians.

OBJECTIVES: To evaluate the characteristics associated with falls causing hip fracture in patients 90 years of age or older (nonagenarians). A second objective was to compare these characteristics with those present in younger patients (65-79 year-olds). DESIGN: Prospective, observational study. SETTING: Six hospitals in Barcelona (Spain) and its surrounding area. PARTICIPANTS: 105 nonagenarians diagnosed with hip fracture after a fall. Most patients were women (78; 74%), with a mean age of 92.2+/-2 years. All of them were living in the community, except for eight institutionalized patients. 221 patients aged 65 to 79 composed the younger patient's comparison group. MEASUREMENTS: Characteristics of falls causing hip fracture were analyzed: location, time and the risk factor for the fall, classified as intrinsic, extrinsic or combined. RESULTS: The mean number of falls in the previous year was 1.5 - 22% of the patients reported having fallen two or more times. Falls usually happened while at home (70%) and during the day (64%). An intrinsic risk factor was considered the most likely cause in 37% of the cases, an extrinsic risk factor in 35%, and a combination in 28%. Multiple stepwise logistic regression analysis showed that nonagenarians were characterized by lower BI scores, more falls happening during night time, a higher use of, benzodiazepines and diuretics, and a lower use of non-benzodiazepinic hypnotics. CONCLUSIONS: Most falls causing hip fracture in nonagenarians happen during the day and at home. Falls in nonagenarians happening more frequently during nighttime, and these oldest subjects had lower BI scores, and a higher use of benzodiazepines and diuretics and less use of non-benzodiazepines hypnotics compared with the younger patients.

Influence of the antioxidant content of saliva on dental caries in an at-risk community.

OBJECTIVE: This study aims to evaluate the relationship between the total antioxidant capacity of saliva and the presence of dental caries in deciduous and permanent teeth, in a group of Saharan children. METHODS: The dental examination was carried out in accordance with the recommendations of the World Health Organization (WHO). The total antioxidant capacity of the saliva was determined by colorimetry. RESULTS: The total antioxidant capacity (TAC) of the saliva of patients with caries in deciduous teeth was 2.89 1/IC50 greater than among those without. We observed a statistically significant linear regression between the number of deciduous teeth affected by caries and the total antioxidant capacity of the saliva: y = 0.24 + 0.53 x TAC saliva (t = 2.93; p = 0.004) (95% CI of b: 0.018-0.088). CONCLUSIONS: Our results show that the amount of caries in deciduous teeth is in direct proportion to the observed TAC of saliva, and that the presence of caries in deciduous teeth is associated with caries in permanent teeth.

[Circumstances associated to falls resulting in hip fracture in community-dwelling subjects older than 94 years old]. / Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes mayores de 94 años no institucionalizados.

OBJECTIVE: To evaluate the circumstances associated with falls resulting in hip fracture in the 95 years of age or older community-dwelling patients. MATERIAL AND METHODS: A prospective, observational study, was conducted in 6 hospitals in the Barcelona area on the characteristics associated with falls resulting in hip fracture in 30 patients aged > 94 years old. Location, time and the risk factor for the fall (classified as intrinsic, extrinsic or combined) were evaluated. RESULTS: Mean number of falls in the previous year was 1.6, 5 (16.7%) of the patients reporting having fallen two or more times. Falls usually occurred while at home, a high percentage (46.7%) of which occurred during the night. When the differences were evaluated by sex, there was a high percentage of uncorrected auditory loss in men and high number of chronic drugs and psychotropic drugs in women. CONCLUSIONS: Most falls causing hip fracture in community-dwelling very elderly subjects occur at home. Nearly half of the falls occur during the night.

[Characteristics of falls producing hip fracture in an elderly population. Differences according to age and gender]. / Circunstancias asociadas a las caídas responsables de fractura de fémur en pacientes ancianos. Diferencias por grupo de edad y género.

BACKGROUND: The majority of hip fractures are produced because of a fall. We examined the characteristics associated with falls causing hip fracture in elderly patients. MATERIAL AND METHODS: Characteristics of falls owing to hip fracture were analyzed in 410 consecutive patients admitted in 6 hospitals during the 2004. We evaluated the location, time and the possible cause of fall: intrinsic risk factor, extrinsic or combined. RESULTS: We evaluated 316 women (77%) and 94 men, mean age 81.9 years. Previous to the hip fracture, the mean BI was 77.5. The mean value of falls during the last year was 1.9. Previously to the fall that caused hip fracture, we found that 24% of the patients had fallen repeatedly (more than two falls). Usually falls were at home (68%) and during daytime (80%). In 45% of patients an intrinsic risk factor was considered the most likely cause, in 33% an extrinsic risk factor and in 22% a combination. CONCLUSIONS: The majority of falls owing to hip fracture in elderly people happen in daytime, at home and due to intrinsic risk factors. Efforts to identify elderly people at risk of fall should be stressed in order to establish preventive measures.

[Quality of medical diagnosis in sick leave certificates for non-occupational diseases and injuries]. / Calidad del diagnóstico médico en la certificación de la incapacidad temporal por enfermedad común y accidente no laboral.

OBJECTIVE: To evaluate the quality of medical diagnosis in the sick leave certificate. DESIGN: Retrospective, observational study. SETTING: Castelldefels Primary Care Centre, Barcelona, Spain. MEASUREMENTS AND INTERVENTIONS: 205 sick leave episodes of patients reported as non-occupational diseases and injuries were analyzed. The diagnosis of the sick leave certificate was checked against the clinical report carried out by the same physician who made out the sick leave certificate. To assess the quality of medical diagnosis, sensitivity, positive predictive value and the percentage of positive agreement were calculated. The variability of these indicators was also assessed according to the duration of the sick leave episode. RESULTS: Simple agreement between the diagnoses of the sick leave certificate and the clinical report was 92%. The sensitivity of the sick leave certificate in relation to the clinical report by diagnostic group ranged from 75% to 97%; positive predictive value, from 81% to 100%; and the percentage of positive agreement, from 86% to 97%. Short-term sick leave episodes (< or =15 days) had lower values than long-term sick leave (>15 days). CONCLUSIONS: Our findings confirm that the quality of diagnosis on the sick leave certificate is high. The availability of more medical information about the reasons for the sick leave episode does not modify the quality of the diagnosis substantially.

Reported occupational respiratory diseases in Catalonia.

OBJECTIVES: A voluntary surveillance system was implemented in Catalonia (Spain) to ascertain the feasibility, incidence, and characteristics of occupational respiratory diseases and compare them with those of the compulsory official system. METHODS: In 2002, in collaboration with the Occupational and Thoracic Societies of Catalonia, occupational and chest physicians and other specialists were invited to report, on a bimonthly basis, newly diagnosed cases of occupational respiratory diseases. Information requested on each case included diagnosis, age, sex, place of residence, occupation, suspected agent, and physician's opinion on the likelihood that the condition was work related. Compulsory official system data derived from statistics on work related diseases for possible disability benefits declared by insurance companies, which are responsible for declaring these diseases to the Autonomous Government of Catalonia. RESULTS: Of 142 physicians seeing patients with occupational respiratory diseases approached, 102 (74%) participated. Three hundred and fifty nine cases were reported, of which asthma (48.5%), asbestos related diseases (14.5%), and acute inhalations (12.8%) were the most common. Physicians rated 63% of suspected cases as highly likely, 28% as likely, and 8% as low likelihood. The most frequent suspected agents reported for asthma were isocyanates (15.5%), persulphates (12.1%), and cleaning products (8.6%). Mesothelioma (5.9%) was the most frequent diagnosis among asbestos related diseases. The number of acute inhalations reported was high, with metal industries (26%), cleaning services (22%), and chemical industries (13%) being the most frequently involved. The frequency of occupational respiratory diseases recorded by this voluntary surveillance system was four times higher than that reported by the compulsory official system. CONCLUSIONS: The compulsory scheme for reporting occupational lung diseases is seriously underreporting in Catalonia. A surveillance programme based on voluntary reporting by physicians may provide better understanding of the incidence and characteristics of these diseases. Persulphates and cleaning products, besides isocyanates, were the most reported causes of occupational asthma. Metal industries and cleaning services were the occupations most frequently involved in acute inhalations with a remarkably high incidence in our register.

Calidad del diagnóstico médico en la certificación de la incapacidad temporal por enfermedad común / Quality of medical diagnosis in sick leave certificates for non-occupational diseases and injuries

Objetivo. Evaluar la calidad del diagnóstico que consta en el parte de alta de la incapacidad temporal (IT). Diseño. Estudio observacional, retrospectivo. Emplazamiento. Centro de atención primaria de Castelldefels (Barcelona). Participantes. Un total de 205 episodios de IT por enfermedad común o accidente no laboral entre los pacientes atendidos. Mediciones principales. El diagnóstico del parte de alta se comprobó con el informe clínico que cumplimentaba el mismo médico que prescribió el alta. Para valorar la calidad del diagnóstico se calcularon la sensibilidad, el valor predictivo positivo y el porcentaje de concordancia positiva. También se valoró la variabilidad de estos índices según la duración del episodio de baja. Resultados. La concordancia simple entre el diagnóstico del parte de alta y el del informe clínico para toda la muestra fue del 92%. La sensibilidad del parte respecto al informe por grupo diagnóstico variaba entre un 75-97%, el valor predictivo positivo en el 81-100% y el porcentaje de concordancia positiva oscilaba en el 86-97%. Los episodios de corta duración (¾ 15 días) tuvieron valores menores que los episodios de larga duración (> 15 días). Conclusiones. Los resultados corroboran que la calidad del diagnóstico del parte de alta es elevada, sin que la disponibilidad de mayor información sobre los motivos de baja modifique sustancialmente la calidad del diagnóstico

Objective. To evaluate the quality of medical diagnosis in the sick leave certificate. Design. Retrospective, observational study. Setting. Castelldefels Primary Care Centre, Barcelona, Spain. Measurements and interventions. 205 sick leave episodes of patients reported as non-occupational diseases and injuries were analyzed. The diagnosis of the sick leave certificate was checked against the clinical report carried out by the same physician who made out the sick leave certificate. To assess the quality of medical diagnosis, sensitivity, positive predictive value and the percentage of positive agreement were calculated. The variability of these indicators was also assessed according to the duration of the sick leave episode. Results. Simple agreement between the diagnoses of the sick leave certificate and the clinical report was 92%. The sensitivity of the sick leave certificate in relation to the clinical report by diagnostic group ranged from 75% to 97%; positive predictive value, from 81% to 100%; and the percentage of positive agreement, from 86% to 97%. Short-term sick leave episodes (¾15 days) had lower values than long-term sick leave (>15 days). Conclusions. Our findings confirm that the quality of diagnosis on the sick leave certificate is high. The availability of more medical information about the reasons for the sick leave episode does not modify the quality of the diagnosis substantially

Anestesia multimodal infantil: analgesia epidural / Pediatric multimodal anesthesia: epidural analgesia

La aplicación de fármacos anestésicos y analgésicos por punción epidural lumbar constituye en la actualidad una técnica escasamente usada en enfermos pediátricos, aunque las aportaciones en este campo ponen de manifiesto su elevada eficacia clínica. El objetivo del presente trabajo es sintetizar, en base a la literatura médica de referencia y la experiencia personal de los autores, la metodología correcta de aplicación de la técnica en enfermos pediátricos sometidos a intervención quirúrgica, así como exponer sistemáticamente el cuadro de complicaciones susceptibles de aparecer en este tipo de pacientes (AU)

Aplicación de los estudios de casos y controles en la investigación de los accidentes de trabajo / Application of case-control studies to research occupational accidents

Objetivos: Valorar la asociación entre la actividad económica y la forma del accidente de trabajo (AT) mediante una estrategia de casos y controles. Material y métodos: Se estudiaron todos los AT graves y una muestra representativa del 13 por ciento de los AT leves con baja ocurridos entre 1991 y 1993 en las empresas de los municipios de la Dirección d'Atenció Primaria del Baix Llobregat-Litoral. La asociación entre actividad económica y la forma de AT se examinó por medio de múltiples estudios de casos y controles, donde los casos correspondieron a un tipo específico de forma de AT (p. ej., caídas) y los controles al resto de formas de AT. La odds de casos se comparaba para cada grupo de actividades económicas (p. ej., industria química) con el resto de actividades económicas. Para los accidentes graves, las asociaciones estadísticamente significativas se ajustaron según edad, género, antigüedad, categoría y tamaño de la empresa a través de una regresión logística no condicional. Resultados: Entre los AT leves se observó un riesgo de sobresfuerzo en la industria manufacturera (odds ratio [OR] = 1,3; IC del 95 por ciento: 1,02-1,67) y en la industria química (OR = 1,83; IC del 95 por ciento: 1,43-2,33). Asimismo, se encontró un mayor riesgo de AT por atropellamiento en el sector del transporte (OR = 5,57; IC del 95 por ciento: 2,5-12,12). Para los AT graves se observó un mayor riesgo de atrapamientos entre objetos y máquinas en la industria manufacturera (OR = 3,96; IC del 95 por ciento: 1,62-9,61), el cual se incrementa en 2,5 veces en las empresas de más de 50 trabajadores; igualmente, se encontró un incremento del riesgo de caídas de personas en la construcción (OR = 2,57; IC del 95 por ciento: 1,24-5,3) que se reduce un 50 por ciento en los trabajadores con más de un año de antigüedad. Conclusiones: A pesar de las limitaciones, relativas a la pérdida de precisión y al sesgo que puede introducir el criterio usado para seleccionar los controles, los resultados son útiles para priorizar actividades preventivas y para evaluar otras ya iniciadas. La estrategia de análisis propuesta incrementa la eficiencia del sistema de información basado en la notificación de los AT (AU)

La evaluación de riesgos laborales en la planificación de la prevención: una perspectiva epidemiológica / Evaluation of occupational risk in prevention planning: an epidemiological perspective

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El edificio enfermo

Se define como edificio enfermo aquel en el que la calidad del aire interior es deficiente por la presencia de contaminantes químicos y biológicos que proceden tanto del exterior como del propio edificio o de sus ocupantes. Numerosos estudios han puesto de relieve enfermedades específicas relacionadas con estos contaminantes, como la fiebre de los humidificadores, la alveolitis alérgica extrínseca o el asma. También se ha descrito una serie de síntomas inespecíficos, como cefaleas, prurito, conjuntivitis, tos o sequedad de boca asociados a la permanencia en estos edificios. Se denomina síndrome del edificio enfermo cuando estos trastornos inespecíficos, que se agravan cuando hay una mayor reutilización del aire interior, afectan a una proporción superior al 20 por ciento de sus ocupantes. Para realizar un control eficaz de la calidad del aire interior es necesario primero identificar las condiciones ambientales y los agentes contaminantes, en la medida de lo posible cuantificarlos y finalmente controlarlos. Las medidas correctoras se centran sobre los focos contaminantes (exteriores e interiores) y en el mantenimiento de los sistemas de ventilación y climatización. Desde la atención primaria, los problemas de salud debidos al edificio enfermo se pueden abordar de forma individual, facilitando información específica sobre su origen y su posible control (consejo médico), derivando el caso a la mutua o al servicio de prevención de la empresa y, si ello no es posible, instaurando las pautas asistenciales que el cuadro clínico requiera. Esta estrategia se puede complementar con un enfoque comunitario que, identificando un conjunto de casos, facilite la adopción de medidas de prevención colectiva (AU)

El papel de las condiciones de trabajo en la incidencia de la incapacidad temporal por contingencias comunes. Resultados de un estudio piloto / The potential occupational origin of short non occupational sick-leave spells. Findings from a pilot study

Objetivos: evaluar el diseño, el cuestionario y la logística de un estudio prospectivo sobre el posible origen laboral de la Incapacidad Temporal (IT) por enfermedad común o accidente no laboral. Evaluar los criterios utilizados por los expertos para valorar el papel de las condiciones de trabajo en su inicio. Métodos: el estudio se realizó en una muestra (n = 50) de la población activa asegurada residente en el municipio de Castelldefels y atendida por el Centro de Atención Primaria (CAP). La recogida de datos se realizó utilizando tres fuentes de información: el comunicado médico de alta, el informe clínico del alta y un cuestionario laboral estandarizado para obtener información sobre la exposición ocupacional. Dos expertos valoraron, por separado y para cada episodio, su posible origen ocupacional. Resultados: las altas prescritas fueron 74 (tasa de respuesta 67,6 por ciento). La muestra estudiada fue de 46 trabajadores (54 por ciento hombres) al no obtenerse el informe clínico de 4 episodios. La edad media fue de 37 años (18-61). Para 17 trabajadores (37 por ciento) había relación entre el problema de salud motivo de la baja y su trabajo. Los expertos consideraron que había relación en nueve casos (19,6 por ciento). El análisis de concordancia (índice Kappa) entre expertos fue de 0,63 y al comparar la opinión de éstos con la percepción de los trabajadores, la sensibilidad de la prueba fue de 88,9 por ciento y el valor predictivo positivo de 47,1 por ciento. Conclusión: el cuestionario laboral resultó ser comprensible e idóneo. La cumplimentación del informe clínico no supuso sobrecarga excesiva para el médico. Los evaluadores consideraron suficiente la información facilitada. La duración de la entrevista fue breve (entre 8 y 13 minutos), confirmándose la idoneidad del momento de su realización. Los resultados, aunque preliminares, apoyan la hipótesis inicial del trabajo: una proporción significativa de IT calificadas como enfermedad no relacionada con el trabajo están relacionadas con las condiciones de trabajo, y además es posible desarrollar una metodología que permita su cuantificación (AU)