Prescription of oral antidiabetics in Mexico. A cross-sectional study.

In 2016 diabetes was declared an epidemic and a health emergency in Mexico. As the rationale of the treatment is to achieve target glycemia levels, the appropriateness of the medications used is important. The aim of this study is to learn the pattern of antidiabetic drug prescription and factors associated with inappropriate prescription in Mexico. A retrospective cross-sectional drug utilization study has been conducted. A randomly selected sample was carefully examined. Out of 3600 clinical records of patients diagnosed with type 2 diabetes mellitus (T2DM), 196 records were revised. As far as control is concerned, 36.7% had their glycemia values in the recommended range. A combination of different antidiabetics was the most common pattern observed (60.7%); the most frequent was that of the association of metformin with whatever oral antidiabetics. Prescriptions were considered as inappropriate in 149 cases (76.0%); younger age and lack of nutritional assessment was significantly related to inappropriate prescription. A trend to use more drugs for treating T2DM has been consistently observed. Despite using so many drugs, most of the patients are not controlled. Avoiding inappropriate prescription by following current guidelines may contribute to a better control and, in turn, decrease morbidity and mortality for this cause.

Time evolution of cytokine profiles associated with mortality in COVID-19 hospitalized patients.

Background: High cytokine levels have been associated with severe COVID-19 disease. Although many cytokine studies have been performed, not many of them include combinatorial analysis of cytokine profiles through time. In this study we investigate the association of certain cytokine profiles and its evolution, and mortality in SARS-CoV2 infection in hospitalized patients. Methods: Serum concentration of 45 cytokines was determined in 28 controls at day of admission and in 108 patients with COVID-19 disease at first, third and sixth day of admission. A principal component analysis (PCA) was performed to characterize cytokine profiles through time associated with mortality and survival in hospitalized patients. Results: At day of admission non-survivors present significantly higher levels of IL-1α and VEGFA (PC3) but not through follow up. However, the combination of HGF, MCP-1, IL-18, eotaxine, and SCF (PC2) are significantly higher in non-survivors at all three time-points presenting an increased trend in this group through time. On the other hand, BDNF, IL-12 and IL-15 (PC1) are significantly reduced in non-survivors at all time points with a decreasing trend through time, though a protective factor. The combined mortality prediction accuracy of PC3 at day 1 and PC1 and PC2 at day 6 is 89.00% (p<0.001). Conclusions: Hypercytokinemia is a hallmark of COVID-19 but relevant differences between survivors and non-survivors can be early observed. Combinatorial analysis of serum cytokines and chemokines can contribute to mortality risk assessment and optimize therapeutic strategies. Three clusters of cytokines have been identified as independent markers or risk factors of COVID mortality.

Association of CNR1 and INSIG2 polymorphisms with antipsychotics-induced weight gain: a prospective nested case-control study.

Weight gain is a frequent and severe adverse reaction in patients taking antipsychotics. The objective was to further investigate in a natural setting influential risk factors associated with clinically significant weight gain. An observational follow-up study was conducted. Patients when initiating treatment with whatever antipsychotic were included; a structured questionnaire was applied at baseline, 3 and 6 months later; a blood sample was obtained. In a nested case-control approach, patients with an increase ≥ 7% of their initial weight were considered as cases, the remaining, as controls. The results showed that, out of 185 patients, 137 completed the 6-month follow-up (cases, 38; controls, 99). Weight gain gradually and significantly increased in cases (baseline, 65.0 kg; 6 months, 74.0 kg) but not in controls (65.6 kg and 65.8 kg, respectively). Age (adjusted OR = 0.97, 95% CI = 0.96-0.99, p = 0.004), olanzapine (adjusted OR = 2.98, 95% CI = 1.13-7.80, p = 0.027) and quetiapine (adjusted OR = 0.25, 95% = 0.07-0.92, p = 0.037) significantly associated with weight gain. An association was also found for the CNR1 (rs1049353) and INSIG2 (rs7566605) polymorphisms. In conclusion, an increased risk of antipsychotics-induced weight gain was observed for younger age and olanzapine, and a relative lower risk for quetiapine. A potential role of CNR1 rs1049353 and INSIG2 rs7566605 polymorphisms is suggested.

A cross-sectional study of psychotropic drug use in the elderly: Consuming patterns, risk factors and potentially inappropriate use.

OBJECTIVES: The aims of the present study were: (1) to describe psychotropic drug consumption patterns in an outpatient population aged 65 years and older; (2) to determine the impact of a number of demographic and clinical factors on psychotropic consumption; and (3) to determine the ratio of potentially inappropriate psychotropic agents prescribed to the above population. METHODS: Cross-sectional, observational study of outpatients aged 65 years and older. Data on sociodemographic and clinical variables were collected. Psychotropic drugs were classified into three categories: anxiolytics-hypnotics, antidepressants, and antipsychotics. To determine the risk factors for psychotropic drug use among these patients, a multivariate logistic regression model was developed and subsequently validated using bootstrap resampling techniques. To identify the psychotropic drugs to be avoided, a review of treatments received by the patients was performed based on the 2015 version of the Beers criteria. RESULTS: The study included 225 outpatients of whom 30.7% were on psychotropic drugs for chronic treatment. The highest likelihood of psychotropic utilisation corresponded to the following profile: female, living in a nursing home, having two or more prescribing physicians, and having received six or more different diagnoses. According to Beers criteria, 51 patients (22.7% of the sample and 73.9% of patients on psychotropic drugs) had been prescribed at least one potentially inappropriate psychotropic drug. CONCLUSION: Elderly patients commonly use psychotropic medications and are the most vulnerable to the adverse effects of these drugs. It is necessary to re-evaluate the pertinence and accuracy of these medical prescriptions.

Cerebral Oxygen Saturation and Negative Postoperative Behavioral Changes in Pediatric Surgery: A Prospective Observational Study.

OBJECTIVE: To evaluate if an intraoperative cerebral regional oxygen saturation (crSO2) decrease, less pronounced than 20% below baseline (the current threshold believed to be associated with cognitive dysfunction in adults), is associated with negative postoperative behavioral changes (NPOBC) in the pediatric population after noncardiac surgeries. STUDY DESIGN: A prospective observational study was conducted with 198 children aged 2-12 years old scheduled for noncardiac procedures under general anesthesia. Intraoperatively, crSO2 was monitored with a cerebral oximeter. On postoperative day 7, the Post-Hospital Behavior Questionnaire was used to diagnose NPOBC. RESULTS: The incidence of NPOBC was 38.8%. Logistic regression analysis revealed that with every 1% reduction of crSO2 from the baseline value, the odds of developing NPOBC were 1.199 higher. Likewise, preoperative anxiety (OR 2.832, P = .006), duration of surgery (OR 1.026, P < .0001), and being between the ages of 2 and 3 years (OR 2.604, P = .048) were associated with NPOBC incidence. The multivariable logistic regression model receiver operating characteristic curve showed an area under the curve (95% CI) = 0.820 (0.759-0.881). CONCLUSIONS: During noncardiac surgeries in the pediatric population, an intraoperative decrease in crSO2 less pronounced than 20% from the baseline value is associated with negative postoperative behavior changes on postoperative day 7. The long-term implications remain to be determined, but this supports attention to crSO2 during noncardiac surgeries.

Postoperative kidney oxygen saturation as a novel marker for acute kidney injury after adult cardiac surgery.

OBJECTIVE: Acute kidney injury is a severe complication and one of the stronger risk factors for death in patients undergoing cardiac surgery. The relationship between postoperative brain oxygen saturation and kidney oxygen saturation with acute kidney injury in adults undergoing cardiac surgery has not been determined. We designed a single-center prospective study to determine if the continuous monitoring of postoperative brain oxygen saturation and kidney oxygen saturation could predict postoperative acute kidney injury. METHODS: We conducted a prospective open cohort study from January to September 2017. The primary outcome was postoperative acute kidney injury using the Kidney Disease: Improving Global Outcomes criteria. Brain oxygen saturation and kidney oxygen saturation, the metrics of which were area measurements (%-min), were recorded during the surgery and the first 48 hours after the cardiac procedure. Receiver operating characteristic curve analysis was used to evaluate the predictive power of kidney oxygen saturation for acute kidney injury. RESULTS: A total of 121 consecutive patients were enrolled. Thirty-five patients (28.9%) developed acute kidney injury. Brain oxygen saturation showed no statistical difference in both groups; however, kidney oxygen saturation was related to acute kidney injury (P = .001). Receiver operating characteristic curve analysis showed that kidney oxygen saturation could predict the risk of acute kidney injury. Kidney oxygen saturation less than 65% (area under the curve-receiver operating characteristic, 0.679 ± 0.054, 95% confidence interval, 0.573-0.785, P = .002) and 20% decrease from baseline (area under the curve-receiver operating characteristic, 0.639 ± 0.059, 95% confidence interval, 0.523-0.755, P = .019) showed the better performance, respectively. CONCLUSIONS: Postoperative kidney oxygen saturation is related to the development of cardiac surgery-associated acute kidney injury. Continuous kidney saturation monitoring might be a promising, noninvasive tool for predicting acute kidney injury during the postoperative period for adult patients after cardiac surgery.

A polypharmacy risk prediction model for elderly patients based on sociodemographic and clinical factors.

OBJECTIVE: Elderly people take increasing amounts of medication. The aim of our study was to determine the effects of different sociodemographic and clinical factors on polypharmacy and to develop a risk prediction model in outpatients aged 65 years and older. MATERIALS AND METHODS: Cross-sectional, observational, descriptive study of outpatients aged 65 years and older scheduled for a specialist visit. Data on sociodemographic (age, sex, place of residence, and institutionalization) as well as on clinical variables (number of prescribing physicians and number of diagnoses) were collected. Polypharmacy was defined as the uninterrupted use of more than 5 medications within the last 3 months. To determine the risk factors for polypharmacy among these patients, a multivariate logistic regression model was developed and subsequently validated using bootstrap resampling techniques. The model was assessed for its discrimination accuracy using the area under the curve (ROC AUC). RESULTS: A total of 225 outpatients were included for development of the model. Polypharmacy was found in 46.7% of patients. The determinants that best predicted polypharmacy included: age, institutionalization, number of prescribing physicians, and number of diagnoses. The ROC AUC was 0.85. CONCLUSION: The predictive model developed in this study, which consists of 4 readily obtainable variables, may be a useful tool for identifying and monitoring elderly patients at risk for polypharmacy.
.

Impact of an ultraviolet air sterilizer on cardiac surgery patients, a randomized clinical trial / Impacto de un esterilizador ultravioleta en pacientes de cirugía cardíaca: ensayo clínico aleatorizado

Background: Numerous studies have evaluated the use of ultraviolet-C devices for terminal disinfection in hospitals, however, to date there is little information about the device's final impact on patients. We investigated the effect of an ultraviolet air sterilizer (UVAS) on the clinical outcomes of cardiac surgery patients. Materials and methods: This random, prospective and non-interventional study included 1097 adult patients undergoing elective cardiac surgery: 522 stayed in an ICU room with UVAS (Medixair®) and 575 patients ICU room without UVAS and were used as a control. The primary outcome measure was to evaluate the effect of a UVAS on the overall prevalence of nosocomial infections in postoperative cardiac patients in ICUs. Results: No significant differences in ventilator-associated pneumonia (4.6% vs. 5.0%, p=0.77) and total infection (14.0% vs. 15.5%, p=0.45) rates were detected in patients with and without the UVAS. The length of stay in the intensive care unit and at the hospital was similar in both groups, UVAS (4.6 (8.2) days and 18.3 (5.5) days) and without UVAS (4.6 (7.3) days and 19.2 (18.6) days). The 30-day in-hospital mortality rate was 5.3%, no significant differences between groups were observed (p=0.053). Conclusion: Novel ultraviolet-C technology has not been shown to significantly reduce nosocomial infections or mortality rates in cardiac surgery patients

Introducción: Numerosos estudios han evaluado el uso de dispositivos ultravioleta C para la desinfección terminal en hospitales; sin embargo, hasta la fecha existen pocos datos sobre el impacto en los pacientes. Hemos evaluado el efecto de un esterilizador de aire ultravioleta (UVAS) sobre las variables clínicas de los pacientes operados de cirugía cardíaca. Materiales y métodos: Este estudio prospectivo, aleatorizado no intervencional incluyó 1.097 pacientes adultos intervenidos de cirugía cardíaca electiva: 522 ingresaron en una habitación de UCI con UVAS (Medixair®) y 575 pacientes en habitación de UCI sin UVAS se utilizaron como control. La variable principal medida fue el efecto del UVAS sobre la prevalencia global de infecciones en el postoperatorio de cirugía cardíaca en UCI. Resultados: No hubo diferencias significativas en la neumonía asociada a ventilación mecánica (4,6% vs. 5,0%, p=0,77) e índices totales de infección (14,0% vs. 15,5%, p=0,45) detectados en pacientes con y sin UVAS. La duración del ingreso en UCI y en el hospital fue similar en ambos grupos, UVAS (4,6 [8,2] días y 18,3 [5,5] días) y sin UVAS (4,6 [7,3] días y 19,2 [18,6] días). La mortalidad a 30 días hospitalaria fue del 5,3%, sin diferencias significativas entre los grupos (p=0,053). Conclusión: La nueva tecnología ultravioleta C no ha demostrado disminuir las infecciones nosocomiales ni la mortalidad en pacientes de cirugía cardíaca

Impact of an ultraviolet air sterilizer on cardiac surgery patients, a randomized clinical trial.

BACKGROUND: Numerous studies have evaluated the use of ultraviolet-C devices for terminal disinfection in hospitals, however, to date there is little information about the device's final impact on patients. We investigated the effect of an ultraviolet air sterilizer (UVAS) on the clinical outcomes of cardiac surgery patients. MATERIALS AND METHODS: This random, prospective and non-interventional study included 1097 adult patients undergoing elective cardiac surgery: 522 stayed in an ICU room with UVAS (Medixair®) and 575 patients ICU room without UVAS and were used as a control. The primary outcome measure was to evaluate the effect of a UVAS on the overall prevalence of nosocomial infections in postoperative cardiac patients in ICUs. RESULTS: No significant differences in ventilator-associated pneumonia (4.6% vs. 5.0%, p=0.77) and total infection (14.0% vs. 15.5%, p=0.45) rates were detected in patients with and without the UVAS. The length of stay in the intensive care unit and at the hospital was similar in both groups, UVAS (4.6 (8.2) days and 18.3 (5.5) days) and without UVAS (4.6 (7.3) days and 19.2 (18.6) days). The 30-day in-hospital mortality rate was 5.3%, no significant differences between groups were observed (p=0.053). CONCLUSION: Novel ultraviolet-C technology has not been shown to significantly reduce nosocomial infections or mortality rates in cardiac surgery patients.

Procalcitonin and white blood cells, combined predictors of infection in cardiac surgery patients.

BACKGROUND: Sepsis is strongly associated with an increased risk of postoperative mortality, longer length of hospital stay, and elevated health care costs. Early clinical symptoms overlap with those of systemic inflammatory response syndrome, a response that commonly occurs after cardiac surgery with cardiopulmonary bypass. Since a combination of biomarkers has been demonstrated to improve the prediction of postoperative infection, the objective of the present study was to test whether the combination of C-reactive protein (CRP), white blood cells (WBC), and procalcitonin (PCT) is able to predict postoperative infection in a large cohort of cardiac surgery patients. MATERIAL AND METHODS: Case-control study involving 423 patients who underwent cardiac surgery with cardiopulmonary bypass. Patients were retrospectively classified into two groups based on whether they developed severe sepsis or septic shock during the postoperative period. Blood samples for biological measurements (PCT, CRP, and WBC) were drawn on the first day in the intensive care unit, then once daily in the morning until the 10th postoperative day. RESULTS: CRP median values were similar in both groups. WBC and PCT median values were significantly higher in patients with infection than without during the first 10 postoperative days. With elevation cutoffs ≤3 times (OR: 4.058; 95% CI: 2.206-7.463; P = 0.001) and ≥4 times (OR: 10.274, 95% CI: 3.690-28.604; P < 0.001), the median value for PCT (1.7 ng/mL) and/or WBC (13,000 cells/mm3) on the second postoperative day was significantly associated with the development of infection. CONCLUSIONS: The goal of this study was to use a large cohort of cardiac surgery patients to ensure that the results were representative of this population. The combination of PCT and WBC levels over the first three postoperative days was able to predict postoperative infection within the 30 d following cardiac surgery.

Roadside opioid testing of drivers using oral fluid: the case of a country with a zero tolerance law, Spain.

BACKGROUND: Opioids can impair psychomotor performance, and driving under the influence of opioids is associated with an increased risk of accidents. The goals of this study were i) to determine the prevalence of opioids (heroin, morphine, codeine, methadone and tramadol) in Spanish drivers and ii) to explore the presence of opioids, more specifically whether they are used alone or in combination with other drugs. METHODS: The 2008/9 DRUID database regarding Spain was used, which provided information on 3302 drivers. All drivers included in the study provided a saliva sample and mass-chromatographic analyses were carried out in all cases. To determine the prevalence, the sample was weighted according to traffic intensity. In the case of opioid use combinations, the sample was not weighted. The detection limit for each substance was considered a positive result. RESULTS: The prevalence of opioids in Spanish drivers was 1.8% (95% CI, 1.4-2.3). Polydrug detection was common (56.2%): of these, in two out of three cases, two opioids were detected and cocaine was also detected in 86% of the cases. The concentration (median [Q1-Q3] ng/ml) of the substances was low: methadone 1.71 [0.10-15.30], codeine 40.55 [2.10-120.77], 6-acetylmorphine 5.71 [1.53-84.05], and morphine 37.40 [2.84-200.00]. Morphine was always detected with 6-acetylmorphine (heroin use). CONCLUSIONS: Driving under the influence of opioids is relatively infrequent, but polydrug use is common. Our study shows that 6 out of 10 drivers with methadone in their OF (likely in methadone maintenance programs) are using other substances. This should be taken into account by health professionals in order to properly inform patients about the added risks of mixing substances when driving.

Impact of ventilator-associated pneumonia on mortality and epidemiological features of patients with secondary peritonitis.

BACKGROUND: Despite the significant impact of nosocomial infections on the morbidity and mortality of patients staying in the intensive care unit (ICU), no study over the past 20 years has focused specifically on VAP following secondary peritonitis. The objective of the present study was to determine in-hospital mortality and epidemiological features attributed to ventilator-associated pneumonia (VAP) following secondary peritonitis. METHODS: Prospective observational study involved 418 consecutive patients admitted in the ICU. Univariate and multivariate analyses were performed to identify risk factors associated with mortality and development of VAP. RESULTS: The incidence of VAP following secondary peritonitis was 9.6 %. Risk factors associated with the development of VAP were hospital-acquired peritonitis, requiring >48 h of mechanical ventilation, and SOFA score. The onset of VAP was late in majority of patients. VAP was developed about 16.8 days after the initiation of the peritonitis. Etiological microorganisms responsible for the peritonitis were different than for VAP. The 90-day in-hospital mortality rate was 47.5 % of VAP patients. Independent factors associated with 30- to 90-day in-hospital mortality were VAP and SOFA. CONCLUSIONS: In light of the impact on morbidity and mortality in the ICU, more attention should be given to the concurrent features among VAP and secondary peritonitis.

Procalcitonin cannot be used as a biomarker of infection in heart surgery patients with acute kidney injury.

PURPOSE: We intended to assess how acute kidney injuy impacts on procalcitonin levels in cardiac surgery patients, with or without infection, and whether procalcitonin might be used as a biomarker of infection in acute kidney injuy. MATERIAL AND METHODS: A case-control study was designed which included patients that had had cardiac surgery between January 2011 and January 2015. Every patient developing severe sepsis or septic shock (n = 122; 5.5%) was enrolled. In addition, consecutive cardiac surgery patients during 2013 developing systemic inflammatory response syndrome (n = 318) were enrolled. Those recruited 440 patients were divided into 2 groups, according to renal function. RESULTS: Median procalcitonin levels were significantly higher during the 10 postoperative days in the acute kidney injury patients. Regression analysis showed that postoperatory day, creatinine, white blood cells and infection were significantly (P < .0001) associated to serum procalcitonin level. In patients with creatinine ≥2, median procalcitonin levels were similar in infected and non-infected patients. Only when creatinine was less than 2 mg/L, the median procalcitonin levels were significantly higher in patients with infection, as compared to those with no infection. CONCLUSIONS: In acute kidney injuy patients, high procalcitonin levels are a marker of acute kidney injuy but will not be able to differentiate infected from non-infected patients.

Carpal Tunnel Syndrome Associated with Oral Bisphosphonates. A Population-Based Cohort Study.

BACKGROUND: Bisphosphonates are widely used to prevent osteoporotic fractures. Some severe musculoskeletal reactions have been described with this medication; among them, some cases of carpal tunnel syndrome. Thus, the aim of this study was to explore whether bisphosphonates may be associated with this syndrome. METHODS: A cohort study was conducted to compare exposed to unexposed women; the exposed group was that composed of women having received at least one prescription of an oral bisphosphonate. For the purpose, we used information from The Health Improvement Network (THIN) database. The outcome of interest was defined as those women diagnosed with carpal tunnel syndrome. A survival analysis was performed; the Cox proportional hazard model was used to calculate hazard ratios and 95% confidence intervals, and to adjust for identified confounding variables. RESULTS: Out of a sample of 59,475 women older than 51 years, 19,825 were treated with bisphosphonates during the period studied. No differences in age distribution or mean follow-up time were observed between the two groups in comparison. Overall, there were 572 women diagnosed with carpal tunnel syndrome, 242 (1.2%) in the group exposed to bisphosphonates, and 330 (0.8%) in the unexposed. An adjusted hazard ratio of developing carpal tunnel syndrome of 1.38 (95%CI, 1.15-1.64) was found for women exposed to bisphosphonates; no significant changes in the hazard ratios were found when considering different levels of bisphosphonate exposure. CONCLUSIONS: An increased risk of carpal tunnel syndrome is associated with the use of bisphosphonates in postmenopausal women.

Predicting cardiac surgery-associated acute kidney injury: The CRATE score.

PURPOSE: Acute kidney injury (AKI) is a frequent complication after cardiac surgery and is associated with increased mortality. The aim was to design a nondialytic AKI score in patients with previously normal renal function undergoing cardiac surgery. METHODS: Data were collected on 909 patients who underwent cardiac surgery with cardiopulmonary bypass between 2012 and 2014. A total of 810 patients fulfilled the inclusion criteria. Patients were classified as having AKI based on the RIFLE criteria. Postoperative AKI occurred in 137 patients (16.9%). Several parameters were recorded preoperatively, intraoperatively, and at intensive care unit admission, looking for a univariate and multivariate association with AKI risk. A second data set of 741 patients, from 2 different hospitals, was recorded as a validation cohort. RESULTS: Four independent risk factors were included in the CRATE score: creatinine (odds ratio [OR], 9.66; 95% confidence interval [CI], 4.77-19.56; P < .001), EuroSCORE (OR, 1.40; CI, 1.29-1.52; P < .001), lactate (OR, 1.03; CI, 1.01-1.04; P < .001), and cardiopulmonary bypass time (OR, 1.01; CI, 1.01-1.02; P < .001). The accuracy of the model was good, with an area under the curve of 0.89 (CI, 0.85-0.92). The CRATE score retained good discrimination in validation cohort, with an area under the curve of 0.81 (95% CI, 0.78-0.85). CONCLUSIONS: CRATE score is an accurate and easy to calculate risk score that uses affordable and widely available variables in the routine care surgical patients.

The relationship between observed signs of impairment and THC concentration in oral fluid.

BACKGROUND: Studies have shown that cannabis intake increases the risk of traffic accidents. Controlled experiments support these findings and have shown a positive dose-effect relationship. METHODS: In this retrospective cross-sectional study of data from a roadside survey, we investigated whether a police officer's judgment regarding signs of impairment is related to the concentration of delta-9-tetrahydrocannabinol (THC) in the oral fluid (OF). We investigated 2,632 cases from a representative sample of 3,302 Spanish drivers: 253 drivers positive for THC only, 32 positive for THC and ethanol, 201 with only ethanol detected in their breath, and 2,146 drivers who tested negative for ethanol in breath and drugs in OF. Recorded data comprised breath alcohol concentrations, THC concentrations in the OF, and the 31 observed signs of impairment. Subject groups were compared using the chi-square test, and logistic regression was used to examine the risk of being categorized as exhibiting signs of impairment. RESULTS: A relationship was found between the OF THC concentration and some observed signs of impairment. Eye signs were noticeable from a THC concentration >3.0 ng/ml in OF, and >25 ng/ml was related to behavior, facial expression, and speech signs. Alcohol and THC contribute to impairment independently and, when taken simultaneously, the effects are comparable to the sum of the effects when consumed separately. CONCLUSIONS: The observation of signs of impairment due to cannabis occurs in an OF concentration-related manner but, as a clinical test, OF has low sensitivity and specificity in a random roadside survey.

The Spanish pictogram on medicines and driving: The population's comprehension of and attitudes towards its use on medication packaging.

The Spanish pictogram on medicines and driving is legally binding since 2011. We have evaluated patients' comprehension, change in driving frequency and the perceived usefulness, information, comprehensibility, and simplicity of this pictogram on 1385 Spaniards users of the National Health Service (pharmacies, primary care and hospital centres). Most, 85.7%, correctly related the symbol with the possible effects of the medicine on driving and the 83.9% of the drivers would reduce the frequency with which they drive when prescribed a medicine with such pictogram. The pictogram was found, in a 10-point Likert, useful (8.3±1.7), informative (7.7±1.9), comprehensible (7.8±1.9) and simple (7.8±1.9). The Spanish pictogram on medicines and driving is understood by the great majority of those interviewed; is well considered by the users of the National Health Service; and offers good prospects for reinforce the awareness of health care professionals and patients on the effects of medicines on driving.