Trends in the prevalences of congenital anomalies and age at motherhood in a Southern European region: a population-based study.

OBJECTIVES: To estimate the prevalences of the main groups of congenital anomalies and to assess their trend over time. DESIGN: Population-based study of prevalences. SETTING: The Basque Country, Spain. PARTICIPANTS: All births and all congenital anomalies diagnosed prenatally, at birth or during the first year of age, in all hospitals of the country, from 1999 to 2008. MAIN OUTCOMES MEASURES: Total diagnosed prevalences and prevalences at birth of all chromosomal and non-chromosomal anomalies, Down's syndrome, anomalies of the nervous system, urinary, limbs, digestive system and congenital heart defects. RESULTS: Mean age (SD) of women at childbirth and the proportion of them over 35 years of age shifted from 32.1 (4.5) years, with 18.3% in 1999-2001, to 32.3 (4.7) years, with 23.9% in 2006-2008. Between 1999 and 2008, 991 cases of chromosomal anomalies and 3090 of non-chromosomal anomalies were diagnosed, which yields, respectively, total prevalences of 5.2‰ and of 16.2‰. Among chromosomal anomalies, Down's syndrome is the most frequent (2.9‰). With marginal statistical significance, the results point at an increasing trend in total diagnosed chromosomal anomalies, but a decreasing one in prevalences at birth. Among non-chromosomal congenital anomalies, congenital heart defects are the most frequent (5.2‰) one. Rates of all non-chromosomal, urinary and limb anomalies grew during the study period, whereas those of congenital heart defects and anomalies of the digestive system did not change significantly. CONCLUSIONS: In the Basque Country, rates of chromosomal anomalies are higher than the overall estimated prevalence in European countries, and continue to increase slightly, which may be related to the rise in maternal age. Rates of non-chromosomal anomalies are within the European frequent range of values, and the increases observed need to be checked in the following years.

Pasos hacia la institucionalización de la evaluación del impacto en salud en España: la percepción de los profesionales de salud pública / Steps towards the institutionalization of health impact assessment in Spain: perception of public health professionals

Fundamento. La actual reforma normativa de la salud pública en España ha previsto la inclusión de la Evaluación del Impacto en Salud (EIS). El objetivo de este estudio es describir la visión de los profesionales de salud pública y planificación sobre la utilidad y aplicabilidad de la EIS en su trabajo diario y con ello reflexionar sobre la mejor manera de institucionalizarla. Metodología. Se han desarrollado 3 talleres de formación en EIS dirigidos a profesionales de las diferentes ramas de la salud pública. Se ofreció un cuestionario para cumplimentar por las personas asistentes. Resultados. El 41% de las personas asistentes contestaron al cuestionario. Entre quienes respondieron, el 92%consideró que el modelo de los determinantes sociales de la salud resulta de gran utilidad en el ámbito de la salud pública. Las principales vías identificadas para introducirla EIS fueron: la obligatoriedad normativa (85%),la integración en otras herramientas de evaluación ya existentes (65%) y la sistematización de esta metodología(40%). En relación a la aplicabilidad de la EIS, se propusieron estrategias específicas para su introducción en las diferentes ramas de la salud pública. Conclusiones. La institucionalización exitosa de la EIS requerirá de la opinión y colaboración del personal técnico. Se constata la aprobación generalizada de esta herramienta para su utilización en la administración. Para garantizar la viabilidad de su implementación, será necesario sensibilizar a los profesionales sobre el modelo de los determinantes sociales de la salud, y recoger sus demandas y sugerencias(AU)

Background. The current normative reform of public health policy in Spain envisages the inclusion of Health Impact Assessment (HIA). This study contributes the vision of public health and planning professionals on the usefulness and applicability of HIA in their daily work and thus reflects on how best to institutionalize it. Methodology. Three training workshop were carried out with public health professionals. Participants were specialists in different branches: epidemiological surveillance, environmental health, food safety and health promotion. In this HIA workshop, a questionnaire was given to the attendees to be completed. Results. Forty-one percent of the people attending answered the questionnaire; 92% of the staff considered that the model of social determinants of health is useful in the field of public health. The principal routes for introducing HIA were: mandatory rules (85%), integration into other existing assessment tools (65%) and the systematization of this methodology (40%). Concerning the applicability of HIA, specific strategies are proposed for its introduction into the different branches of public health. Conclusions. The successful institutionalization of HIA will require the opinion and collaboration of the technical personnel. A widespread approval of this tool for its utilization in the administration was verified. To guarantee the viability of its implementation, it will be necessary to raise the awareness of professionals about the model of the social determinants of health, as well as to attend to their demands and suggestions(AU)

[Steps towards the institutionalization of health impact assessment in Spain: perception of public health professionals]. / Pasos hacia la institucionalización de la evaluación del impacto en salud en España: la percepción de los y las profesionales de salud pública.

BACKGROUND: The current normative reform of public health policy in Spain envisages the inclusion of Health Impact Assessment (HIA). This study contributes the vision of public health and planning professionals on the usefulness and applicability of HIA in their daily work and thus reflects on how best to institutionalize it. METHODOLOGY: Three training workshop were carried out with public health professionals. Participants were specialists in different branches: epidemiological surveillance, environmental health, food safety and health promotion. In this HIA workshop, a questionnaire was given to the attendees to be completed. RESULTS: Forty-one percent of the people attending answered the questionnaire; 92% of the staff considered that the model of social determinants of health is useful in the field of public health. The principal routes for introducing HIA were: mandatory rules (85%), integration into other existing assessment tools (65%) and the systematization of this methodology (40%). Concerning the applicability of HIA, specific strategies ere proposed for its introduction into the different branches of public health. CONCLUSIONS: The successful institutionalization of HIA will require the opinion and collaboration of the technical personnel. A widespread approval of this tool for its utilization in the administration was verified. To guarantee the viability of its implementation, it will be necessary to raise the awareness of professionals about the model of the social determinants of health, as well as to attend to their demands and suggestions.

Mortality in small geographical areas and proximity to air polluting industries in the Basque Country (Spain).

OBJECTIVES: To study the association between proximity to air polluting industrial facilities and mortality in the Basque Country (Spain) in the 1996-2003 period. METHODS: A cross-sectional ecological study with 1465 census sections (CS) as units of analysis with a mean population of 1257 inhabitants. Association of CS mortality with proximity of industries of the European Pollutant Emission Register was studied by type of industrial activity and adjusted for social deprivation. Two distance thresholds (1 km and 2 km) were used as proxies for exposure in a 'near versus far' analysis. Causes of mortality studied were: all causes; tracheal, bronchial, and lung cancer; haematological tumours; ischaemic heart disease; cerebrovascular diseases; chronic diseases of the lower respiratory tract; and breast cancer (in women). Poisson's generalised linear mixed models (GLMM) with two random effects (heterogeneity and structured spatial variability) were used in a fully Bayesian environment. RESULTS: Men living in sections within 1 km from energy production industries had greater mortality from tracheal, bronchial, and lung cancer [CI(90%) 6% to 53%] as compared with people living further. Women had greater mortality from ischaemic heart disease [CI(90%) 1% to 17%] and respiratory illness [CI(90%) 1% to 24%] within 2 km from metal-processing industries. On the contrary, within the 1 km buffer from mineral industries, mortality was lower for all causes [CI(90%) -20% to -6%] and for ischaemic heart disease [CI(90%) -40% to -10%] in women, and from respiratory diseases in men [CI(90%) -39% to -4%], while it was greater for breast cancer in women [CI(90%) 2% to 28%] within the 2 km buffer. CONCLUSIONS: Analysis of mortality by census sections is a helpful exploratory tool for investigating environmental risk factors and directing actions to sites and risk factors with a greater impact on health. Further epidemiological and environmental investigations around metal-processing and energy-producing plants are required.

Health impact assessment of an urban regeneration project: opportunities and challenges in the context of a southern European city.

BACKGROUND: Social values and the political context have an influence on the use and spread of health impact assessment (HIA). In Spain, there is little experience in HIA but some regional governments are already introducing it. The aim of this article is to describe the health impacts of a local regeneration project to improve accessibility in a neighbourhood of Bilbao (Spain), and discuss the main difficulties, opportunities and challenges of the process, considering the specificities of the social and political context. METHODS: A concurrent and prospective assessment, based on a broad model of health, was carried out following the Merseyside guidelines. A literature review, community profiling and qualitative data collection were undertaken. Profound involvement of members of the community and key informants was judged as essential in the HIA process. RESULTS: The overall expected effect of the new lifts, roads, park and the rainwater collection system was positive. Uncertain or negative impacts were identified in some of those areas, and also concerning the burying of four high-voltage power lines. Historical and current characteristics of the community were highly influential on the way local people perceived the project and its impacts. Likewise, the way in which processes of planning and implementation were developing also played an important role. CONCLUSION: The spread of HIA in southern European countries will depend on the progressive introduction of values underlying HIA, as well as on the promotion of intersectoral work, a better knowledge of the social model of health and community's participation in policy making.

Socioeconomic inequalities in lung cancer mortality in 16 European populations.

OBJECTIVES: This paper aims to describe socioeconomic inequalities in lung cancer mortality in Europe and to get further insight into socioeconomic inequalities in lung cancer mortality in different European populations by relating these to socioeconomic inequalities in overall mortality and smoking within the same or reference populations. Particular attention is paid to inequalities in Eastern European and Baltic countries. METHODS: Data were obtained from mortality registers, population censuses and health interview surveys in 16 European populations. Educational inequalities in lung cancer and total mortality were assessed by direct standardization and calculation of two indices of inequality: the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). SIIs were used to calculate the contribution of inequalities in lung cancer mortality to inequalities in total mortality. Indices of inequality in lung cancer mortality in the age group 40-59 years were compared with indices of inequalities in smoking taking into account a time lag of 20 years. RESULTS: The pattern of inequalities in Eastern European and Baltic countries is more or less similar as the one observed in the Northern countries. Among men educational inequalities are largest in the Eastern European and Baltic countries. Among women they are largest in Northern European countries. Whereas among Southern European women lung cancer mortality rates are still higher among the high educated, we observe a negative association between smoking and education among young female adults. The contribution of lung cancer mortality inequalities to total mortality inequalities is in most male populations more than 10%. Important smoking inequalities are observed among young adults in all populations. In Sweden, Hungary and the Czech Republic smoking inequalities among young adult women are larger than lung cancer mortality inequalities among women aged 20 years older. CONCLUSIONS: Important socioeconomic inequalities exist in lung cancer mortality in Europe. They are consistent with the geographical spread of the smoking epidemic. In the next decades socioeconomic inequalities in lung cancer mortality are likely to persist and even increase among women. In Southern European countries we may expect a reversal from a positive to a negative association between socioeconomic status and lung cancer mortality. Continuous efforts are necessary to tackle socioeconomic inequalities in lung cancer mortality in all European countries.

Educational differences in cancer mortality among women and men: a gender pattern that differs across Europe.

We used longitudinal mortality data sets for the 1990s to compare socioeconomic inequalities in total cancer mortality between women and men aged 30-74 in 12 different European populations (Madrid, Basque region, Barcelona, Slovenia, Turin, Switzerland, France, Belgium, Denmark, Norway, Sweden, Finland) and to investigate which cancer sites explain the differences found. We measured socioeconomic status using educational level and computed relative indices of inequality (RII). We observed large variations within Europe for educational differences in total cancer mortality among men and women. Three patterns were observed: Denmark, Norway and Sweden (significant RII around 1.3-1.4 among both men and women); France, Switzerland, Belgium and Finland (significant RII around 1.7-1.8 among men and around 1.2 among women); Spanish populations, Slovenia and Turin (significant RII from 1.29 to 1.88 among men; no differences among women except in the Basque region, where RII is significantly lower than 1). Lung, upper aerodigestive tract and breast cancers explained most of the variations between gender and populations in the magnitude of inequalities in total cancer mortality. Given time trends in cancer mortality, the gap in the magnitude of socioeconomic inequalities in cancer mortality between gender and between European populations will probably decrease in the future.

Socio-economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain.

AIMS: To establish the relationship between socio-economic status and the prevalence of known Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications. METHODS: In 2000, a cross-sectional survey was conducted among 61 general practitioners (GPs) who studied 65 651 people older than 24 years. Of those, 2985 known Type 2 diabetic patients were registered. The main outcome measures were: diabetes prevalence, major cardiovascular risk factors, chronic diabetic complications and primary care services utilization in Type 2 diabetic patients. Socio-economic status was based on area-based socio-economic measures. RESULTS: The prevalence of known Type 2 diabetes was higher in patients of lower socio-economic status (OR: 2.17, 95% CI: 1.77-2.28), especially among women (OR: 2.28, 95% CI: 1.91-2.73). In Type 2 diabetes patients, obesity, sedentary lifestyle, and abnormal levels of low-density lipoprotein (LDL) cholesterol and HbA(1c) were more prevalent among those from lower socio-economic status. Macroangiopathy was inversely associated with socio-economic status after adjustment for clinical and demographic variables. Patients of lower socio-economic status more frequently visited primary care services than those of higher status. CONCLUSIONS: This study shows an association between deprivation and Type 2 diabetes prevalence, cardiovascular risk factors and chronic diabetic complications in Type 2 diabetes patients. Despite a greater use of health services by less wealthy patients, they showed worse glycaemic control and more chronic complications. Besides clinical variables, socio-economic status and environmental information need to be considered in the assessment of risk profile of diabetic patients by health professionals and by health service planners.

Comparison of a cardiorespiratory device versus polysomnography for diagnosis of sleep apnoea.

This study assessed the accuracy of a cardiorespiratory monitoring device versus polysomnography for the diagnosis of suspected sleep apnoea/hypoponea syndrome (SAS). A total of 86 patients (89% male, mean age 52 yrs) that had been referred to a sleep laboratory with a clinical diagnosis of SAS underwent cardiorespiratory polygraphy in an unattended mode using an ambulatory device (MERLIN). Analysis was carried out both automatically and manually. Conventional overnight full-channel polysomnography was performed simultaneously. Valid polygraphical recordings were obtained from 79 patients. The mean+/-SD apnoea/hypopnoea index (AHI) was 34.4+/-29.2. The results obtained with manual scoring were superior to automatic scoring for all AHI thresholds. For an AHI of > or = 5, which is diagnostic SAS, the optimum cut-off value for the manual respiratory event index was 6.7 and the cardiorespiratory monitoring device had 97.1% sensitivity and 90.9% specificity. Correct classification according to the different cut-off points obtained via polysomnography and the corresponding cut-off points in the MERLIN manual index were confirmed in 90-96% of patients. The MERLIN device is a useful diagnostic approach for the initial assessment of adult patients with clinical suspicion of sleep apnoea/hypopnoea syndrome. Manual scoring is clearly better than automatic scoring in terms of agreement with the apnoea/hypopnoea index and to discern patients with sleep apnoea/hypopnoea syndrome.

Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.

The prevalence and related clinical features of obstructive sleep apnea-hypopnea (OSAH) in the general population were estimated in a two-phase cross-sectional study. The first phase, completed by 2,148 subjects (76.9%), included a home survey, blood pressure, and a portable respiratory recording, whereas in the second, subjects with suspected OSAH (n = 442) and a subgroup of those with normal results (n = 305) were invited to undergo polysomnography (555 accepted). Habitual snoring was found in 35% of the population and breathing pauses in 6%. Both features occurred more frequently in men, showed a trend to increase with age, and were significantly associated with OSAH. Daytime hypersomnolence occurred in 18% of the subjects and was not associated with OSAH. An apnea-hypopnea index (AHI) > or = 10 was found in 19% of men and 15% of women. The prevalence of OSAH (AHI > or = 5) increased with age in both sexes, with an odds ratio (OR) of 2.2 for each 10-yr increase. AHI was associated with hypertension after adjusting for age, sex, body mass index, neck circumference, alcohol use, and smoking habit. This study adds evidence for a link between OSAH and hypertension.

Changes in social inequalities in health in the Basque Country.

STUDY OBJECTIVE: To determine the extent of the inequalities in self reported health between socioeconomic groups and its changes over time in the Basque Country (Spain). DESIGN: Cross sectional data on the association between occupation, education and income and three health indicators was obtained from the Basque Health Surveys of 1986 and 1992. Representative population samples were analysed. In 1986 the number of respondents was 24 657 and in 1992, 13 277. SETTING: Basque Country, Spain. MAIN OUTCOME MEASURES: The effect of socioeconomic position on health and the magnitude of social inequalities in health were quantified using the odds ratios based on logistic regression analysis, and the Relative Index of Inequality. RESULTS: As was expected, social inequalities in self reported health existed in both surveys, but the social gradient was greater in 1992. Social differences varied according to gender and health indicator. According to education an increase in social inequalities was observed consistently in all the health indicators except long term conditions in women. A consistent increase in inequalities in limiting longstanding illness was also observed according to all socioeconomic indicators. CONCLUSIONS: These results agree to a large extent with those of previous studies in other countries. In this context the unequal distribution of material circumstances and working conditions between socioeconomic groups seem to play a major part in health inequalities. The worsening of the labour market during this period and the onset of a new economic recession may explain the increase in social inequalities over time.

Diagnostic accuracy of a portable recording device (MESAM IV) in suspected obstructive sleep apnoea.

This study evaluated the accuracy of a portable recording device (MESAM IV) in identifying obstructive sleep apnoea (OSA). The MESAM IV system measures arterial oxygen saturation (Sa,O2), heart rate, snoring sounds and body position, and allows both automatic and manual scoring of the recordings. Nocturnal polysomnography and MESAM IV recordings were performed simultaneously in 150 patients with suspected OSA, and were analysed blindly by a different observer. Patients with an apnoea-hypopnoea index (AHI) greater than or equal to 10 were diagnosed as having OSA. In the evaluation of the discriminatory ability of MESAM IV scores, the cut-off point was set to minimize first the exclusion of truly diseased patients (i.e. false-negative interpretations), and then confirmation of nondiseased subjects (i.e. false-positives). When used as an exclusion test, the portable device reached a sensitivity of 0.98 and a specificity of 0.78; as a confirmation test, these values were 0.69 and 0.97, respectively. These results were achieved with manual scoring, which was superior to automatic scoring. Manual scoring was also better than automatic scoring when OSA was defined according to other threshold values (> or = 5, 15 and 20) for the AHI. The combination of MESAM IV manual scores could reduce the need for diagnostic polysomnography in three quarters of the patients clinically suspected of having obstructive sleep apnoea, substantially reducing costs associated with diagnostic procedures.

[The evolution of mortality from ischemic heart disease in Basque Country 1975-1990]. / La evolución de la mortalidad por cardiopatía isquémica en el País Vasco, 1975-1990.

BACKGROUND: Given the importance of ischemic cardiopathy (IC) as a cause of death in industrialized countries, the trend of mortality by IC in people from 30 to 69 years of age residing in the Basque Country between 1975-1990 were studied. Furthermore, the evolution of the mortality by cardiac diseases and by other causes which may compete with IC in the certification or coding of the cause of death was studied. METHODS: The rate of mortality standardized by age by the direct methods were estimated from data from the Natural Movement of Population. The trend was graphically studied and quantified by means of the percentage difference between the rates. RESULTS: Mortality by IC decreased between 1975-1990 by 37% in men and 46% in women with a mean annual percentage decrease of 2.8% and 2.9%, respectively. Mortality by cardiac disease decreased 34% in men and 52% in women. CONCLUSIONS: Mortality by ischemic cardiopathy in the Basque Country has significantly decreased in both sexes. This decrease is not explicable by possible changes over the years in the practises of certification or coding of the cause of death.

Role of endoscopic variceal sclerotherapy in the long-term management of variceal bleeding: a meta-analysis.

Seven randomized clinical trials evaluating the effect of repeated endoscopic variceal sclerotherapy on the long-term survival of patients with variceal hemorrhage have been published in the English-language literature. In four trials, the sclerotherapy-treated patients showed an improved long-term survival (follow-up periods longer than a year) when compared with patients in the medical regimen group, whereas in the other three trials, the long-term survival did not differ between the compared groups. Sample sizes in these "negative" trials were too small to detect a true moderate effect for serial sclerotherapy. To resolve this controversy, we combined the findings from all trials using a meta-analysis and determined the overall effect of repeated endoscopic variceal sclerotherapy on the survival of patients who had previously bled from esophageal varices. An overall risk difference of -0.15 (95% confidence limits, -0.21 to -0.08; p less than 0.0005) was estimated, indicating that sclerotherapy reduced the number of deaths by 25%. The estimated overall risk difference remained negative even when all patients in the sclerotherapy group with an unknown survival status were pessimistically considered dead at the end of the follow-up period. The results of this quantitative synthesis suggest that patients with bleeding esophageal varices benefit from the inclusion of repeated sclerotherapy in their long-term management regimen.

A framework for evaluating and conducting prognostic studies: an application to cirrhosis of the liver.

A framework for evaluating and conducting prognostic studies is proposed. Recently published studies on prognosis of cirrhosis of the liver are evaluated according to the proposed framework. It was found that appropriate statistical techniques were often used to analyze the results of prognostic studies of cirrhosis of the liver. On the other hand, the studies performed poorly with regards to study design, the determination of the usefulness of the data, the validity of the collected information, and the analytic strategy. It is hoped that the criteria suggested in this paper will improve the planning and the reporting of prognostic studies.

Clinical and statistical validity of conventional prognostic factors in predicting short-term survival among cirrhotics.

The objective of this study was to assess the prognostic validity of Child-Turcotte classification with regard to short-term (1-year) survival. The Child-Turcotte classification, as modified by Pugh et al., was recorded on admission in 177 cirrhotic patients. The variables that comprise the Pugh modification are ascites, encephalopathy, serum albumin, serum bilirubin and prothrombin time. Using multiple logistic regression, we evaluated the contribution of different models to the likelihood of survival, defining different ways to use the Pugh score. The Pugh score categorized in three strata (5 to 6, 7 to 9 and 10 to 15) captured less variance in the survival than the Pugh score counted from 5 to 15. This, in turn, captured less variance than a model in which the parameters of the Pugh score were analyzed according to their original units. The prediction rule based on the last model was tested in another sample of cirrhotics. The "original unit" model was studied in both training and testing samples, using receiver-operating characteristic curves to evaluate its clinical validity (sensitivity and specificity). The prediction rule based on the "original units" Pugh score allowed for a good discrimination of patients who lived and those who died. (At the point of maximum discrimination, sensitivity and specificity reached a mean of 80%). Validity of the prediction rule was confirmed by the testing sample. The qualities of simplicity, availability, low cost and good discriminating power for a life or death outcome make the Pugh score a very useful method to estimate prognosis in patients with cirrhosis.