[Evolution of the serotypes causing invasive pneumococcal disease along 2008-2022 in a Level 2 Public Hospital of the Madrid Region, in relation to their inclusion in different conjugate vaccines]. / Evolución de los serotipos causantes de enfermedad neumocócica invasiva aislados durante 2008-2022 en un Hospital Público Madrileño de nivel dos, en relación con su inclusión en diferentes vacunas conjugadas.

OBJECTIVE: The use of conjugate vaccines against Streptococcus pneumoniae originates changes in the invasive pneumococcal disease (IPD). The aim of this study was to in vestigate the evolution of S. pneumoniae serotypes isolated in the Hospital Universitario de Getafe between 2008 and 2022. METHODS: 313 of S. pneumoniae strains were studied. Serotyping was carried out by latex agglutination (Pneumotest-latex) and the Quellung reaction. In addition, the minimal inhibitory concentration (MIC) was determined against penicillin, erythromycin and levofloxacin by the concentration gradient method (E-test) according the EUCAST breakpoints. RESULTS: The most frequent serotypes throughout the study period were 8, 3, 19A, 1, 11A and 22F corresponding to 46.6% of the isolates. Along 2008-2012 the serotypes 3, 1, 19A, 7F, 6C and 11A represented altogether 53.6% of the isolates. Between 2013 and 2017 the serotypes 3, 8, 12F, 19A, 22F and 19F grouped 51% of the isolates. During 2018-2022 the serotypes 8, 3, 11A, 15A, 4 and 6C included the 55.5% of the cases. In total 5 strains (1.6%) were penicillin resistant, 64 (20.4%) erythromycin resistant and 11 (3.5%) levofloxacin resistant. The MIC50 and MIC90 levels maintained stables along the time. CONCLUSIONS: The conjugate vaccines use with different serotype coverage conditioned a decrease of the vaccine-included and an increase of non-covered. Despite these changes, the global antimicrobial susceptibility patterns to erythromycin and levofloxacin maintained relatively stables. The resistance a penicillin was low, not finding this type of resistant strains in the last study period.

Approach to COVID-19 pandemic management in Madrid. Chronic of a year.

After more than a year of pandemic, the international medical community has changed the perception of fear to one of respect for SARS-COV-2. This has been the consequence of the integral study of all the dimensions of the disease, from viral recombinant capacity to transmissibility, diagnosis, care and prevention. This document summarizes the main strategic lines of study and approach to the pandemic in Madrid.

[SARS-CoV-2 variants, a still unfinished story]. / Variantes de SARS-CoV-2, una historia todavía inacabada.

Mutations in the SARS-CoV-2 genome can affect the gene encoding the Spike (S) antigen, which interacts with the host cell specific receptor, selecting mutant variants with changes in their infective capacity, pathogenic potential and resistance to neutralizing antibodies. The nomenclature to design the variants uses a colloquial form referred to the country or place of detection, a code from the "Pangolin" database and one from the "Nextstrain" page. New variants that have spread include the British B.1.1.7 (20I/501Y.V1), the South African B.1.351 (20H/501.V2), the Brazilian P.1 (20J/501Y.V3), the Californians B.1.427 B.1.429 (20C/S:452R) and the most recent, the Indian B.1.617 (VUI-21APR-01).The gold standard for the identification of the variants is whole genome sequencing. However, real-time PCR techniques have already been developed for the detection of specific mutations that can facilitate their presumptive identification.The impact of these variants on global vaccination programs has raised concern. It is generally thought that, since the response evoked by the vaccine against the S antigen is directed at the entire protein and the mutations only affect specific regions, the escape effect of the vaccine antibodies will be limited. Among the future strategies proposed for immuno-protection, the increase in the number of doses, the alternation of vaccines and the development of specific vaccines against different variants has been suggested.

Community-wide measles outbreak in the Region of Madrid, Spain, 10 years after the implementation of the Elimination Plan, 2011-2012.

We describe a community-wide outbreak of measles due to a D4 genotype virus that took place in the Region of Madrid, Spain, between February 2011 and August 2012, along with the control measures adopted. The following variables were collected: date of birth, sex, symptoms, complications, hospital admission, laboratory test results, link with another cases, home address, places of work or study, travel during the incubation period, ethnic group, and Mumps-Measles-Rubella (MMR) vaccination status. Incidences were calculated by 100,000 inhabitants. A total of 789 cases were identified. Of all cases, 36.0% belonged to Roma community, among which 68.7% were 16 months to 19 y old. Non-Roma cases were predominantly patients from 6 to 15 months (28.1%) and 20 to 39 y (52.3%). Most cases were unvaccinated. We found out that 3.0% of cases were healthcare workers. The first vaccination dose was brought forward to 12 months, active recruitment of unvaccinated children from 12 months to 4 y of age was performed and the vaccination of healthcare workers and of members of the Roma community was reinforced. High vaccination coverage must be reached with 2 doses of MMR vaccine, aimed at specific groups, such as young adults, Roma population and healthcare workers.

Simplification to dual therapy (atazanavir/ritonavir + lamivudine) versus standard triple therapy [atazanavir/ritonavir + two nucleos(t)ides] in virologically stable patients on antiretroviral therapy: 96 week results from an open-label, non-inferiority, randomized clinical trial (SALT study).

OBJECTIVES: We evaluated whether maintenance therapy with atazanavir/ritonavir plus lamivudine (ATV/r + 3TC) was non-inferior to ATV/r plus two nucleosides (ATV/r + 2NUCs) at 96 weeks of follow-up. METHODS: SALT is a multicentre, open-label, non-inferiority clinical trial in HIV-1-infected virologically suppressed patients. Hepatitis B virus surface antigen-negative subjects with no previous treatment failure/resistance mutations and HIV-1-RNA <50 copies/mL for ≥6 months were randomized (1 : 1) to ATV/r + 3TC or ATV/r + 2NUCs. The primary endpoint was HIV-1-RNA <50 copies/mL in the PP population. Non-inferiority was demonstrated if the lower bound of the 95% CI for the difference was not below -12%. RESULTS: Some 286 patients were analysed. At week 96, 74.4% had HIV-1-RNA <50 copies/mL in the ATV/r + 3TC arm versus 73.9% in the ATV/r + 2NUCs arm (95% CI for the difference, -9.9%-11.0%). In both groups, similar values were observed for patients with confirmed virological failure in ATV/r + 3TC versus ATV/r + 2NUCs (9 versus 5), death (1 versus 0), discontinuation due to ART-related toxicity (7 versus 11), withdrawal from the study (7 versus 9) and loss to follow-up (6 versus 6). One patient taking ATV/r + 2NUCs developed resistance mutations (M184V and L63P). Similar values were obtained for change in mean CD4 count [19 versus 18 cells/mm3 (95% CI for the difference, -49.3-50.7), grade 3-4 adverse events (70.7% versus 70.2%) and changes in the global deficit score, -0.3 (95% CI, -0.5 to -0.1) for ATV/r + 3TC, versus -0.2 (95% CI, -0.4 to -0.1) for ATV/r + 2NUCs]. CONCLUSIONS: The long-term results of switching to ATV/r + 3TC show that this strategy is effective, safe and non-inferior to ATV + 2NUCs in virologically suppressed HIV-infected patients.

Seroprevalence of measles and rubella virus antibodies in the population of the Community of Madrid, 2008-2009.

The seroprevalence (SP) of measles and rubella virus antibodies is presented by age groups obtained in the IV Serosurvey of the Region of Madrid (2008-2009). The target population is composed of residents with ages ranging between 2 and 60 years in the Region of Madrid. A two-stage cluster sample is used. The SP of measles virus antibodies is 97.8% (CI 95%: 97.3-98.2). The highest SP is observed in the 2-5 year and 41-60 year age groups. The point estimate does not reach 95% in the 16-20 and 21-30 year age groups. The SP of rubella virus antibodies is 97.2% (CI 95%: 96.5-97.7). The SP is over 95% in all of the age groups. In immigrant women between the ages of 16 and 49, the SP is 95.9% (CI 95%: 93.7-97.4). The identification of groups susceptible to the measles virus in young adults could lead to outbreaks as a result of importing the virus. The circulation of the rubella virus is possible among immigrant women aged between 16 and 49 years, which could lead to the appearance of SRC cases. Epidemiological surveillance will allow the impact on the measles and rubella elimination plan to be determined in the future.

Effectiveness of 23-valent pneumococcal polysaccharide vaccine in adults aged 60 years and over in the Region of Madrid, Spain, 2008-2011.

Invasive pneumococcal disease (IPD) is a notifiable disease in the Region of Madrid. The 23-valent pneumococcal polysaccharide vaccine (PPV23) is recommended for children and adults aged two years or over with a high risk of disease, and for all adults aged 60 and over. We describe the evolution of IPD incidence from 2008 to 2011 in people aged 60 years and over and PPV23 vaccine effectiveness (VE). VE is estimated using both the screening method and indirect cohort method. The incidence of IPD varied from 20.0 in 2008 to 15.2 per 100,000 inhabitants in 2011 (RR: 0.8; 95% CI: 0.6­0.9). Adjusted VE estimated with the screening method was 68.2% (95% CI: 56.2­76.9). VE with the Broome method was 44.5% (95% CI: 23.8­59.6) for all PPV23 serotypes, and 64.4% (95% CI: 45.2­76.8) for PPV23 serotypes not included in conjugate vaccines. VE was lower in patients aged 80 years and older (25.5%; 95% CI:-23.2 to 55.0) and those with highrisk medical conditions (31.7%; 95% CI: -2.2 to -54.4). Adjusted VE was 44.5% (95% CI: 19.4-61.8) within 5 years of vaccination and 32.5% (95% CI: -5.6 to 56.9) after 5 years. These results are compatible with current recommendations for PPV23.

Risk factors and clinical significance of invasive infections caused by levofloxacin-resistant Streptococcus pneumoniae.

PURPOSE: Fluoroquinolones are recommended for the treatment of pneumonia. The recognition of risk factors for invasive levofloxacin-resistant Streptococcus pneumoniae is important for the design of treatment. METHODS: A retrospective review of cases of invasive pneumococcal infections in adults was undertaken. Epidemiologic data, predisposing factors, clinical variables, and outcome were recorded from previously established protocols. Antimicrobial susceptibility was determined by disk diffusion and the Etest method. Serotyping was performed by latex agglutination and Quellung reaction. RESULTS: Twenty patients with infection caused by levofloxacin-resistant pneumococci [minimum inhibitory concentration (MIC) ≥2 µg/ml] were compared with 102 patients harboring levofloxacin-susceptible strains; 80% of levofloxacin-resistant pneumococci were resistant to ≥3 antibiotics but susceptible to penicillin. Most levofloxacin-resistant strains (80%) belonged to serotype 8. In comparison, only 8% of levofloxacin-susceptible pneumococci belonged to serotype 8. In the multivariate analysis, residence in public shelters [odds ratio (OR) 26.13; p 0.002], previous hospitalization (OR 61.77; p < 0.001), human immunodeficiency virus (HIV) infection (OR 28.14; p = 0.009), and heavy smoking (OR 14.41; p = 0.016) were associated with an increased risk of infection by levofloxacin-resistant pneumococci. Mortality caused by levofloxacin-resistant and levofloxacin-susceptible pneumococci was 35 and 14%, respectively. Among HIV-positive individuals infected with levofloxacin-resistant pneumococci 44% died, but only 12.5% of HIV-positive patients with levofloxacin-susceptible strains died. CONCLUSIONS: We observed the emergence of serotype 8 as the main cause of invasive disease caused by levofloxacin-resistant S. pneumoniae. HIV-positive patients seem to be prone to infection caused by multidrug-resistant serotype 8 and have a high mortality rate.

[Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection]. / Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada.

BACKGROUND: Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. PATIENTS AND METHODS: Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. RESULTS: A total of 98 patients with a mean baseline CD4 count of 122 x 10(6)/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. CONCLUSIONS: In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI.

Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada / Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection

Introducción. Comparación de la eficacia y seguridad de cuatro pautas de terapia antirretroviral de gran actividad (TARGA) incluyendo dos análogos de nucleósidos (AN) y un inhibidor de proteasa (IP) en pacientes con el virus de la inmunodeficiencia humana (VIH) con infección avanzada y naive a antirretrovirales. Pacientes y método. Ensayo clínico, multicéntrico, randomizado y abierto en diez hospitales comunitarios de Castilla-La Mancha y Madrid. La pauta 1 contenía zidovudina (ZDV), lamivudina (3TC) e indinavir (IDV); la pauta 2 incluía ZDV, 3TC y ritonavir (RTV); la pauta 3 era didanosina (DDI), estavudina (D4T) e IDV, y la pauta 4 incluía DDI, D4T y RTV. Se ha valorado como variable principal de respuesta el descenso de la carga viral del VIH (CV), y como variables secundarias: el aumento del número de linfocitos CD4, el porcentaje de progresión de la enfermedad, las reacciones adversas y la adherencia. Las determinaciones se realizaron en la visita basal y a las 6, 12, 24, 36 y 48 semanas. Resultados. Se incluyeron 98 pacientes con una media de CD4 basal de 122 x 106/l (rango de 5-340) y una carga viral basal de 5,1 log copias/ml. A las 48 semanas, en el análisis de los pacientes en tratamiento se observó un incremento medio de los CD4 y una disminución de la carga viral sin diferencia significativa entre las 4 pautas (103 células/2,62 log en la pauta 1, 169 células/ 2,86 log en la pauta 2, 171 células/2,56 log en la pauta 3 y 141 células/1,71 log en la pauta 4). Interrumpieron el tratamiento por reacciones adversas: el 24% en la pauta 1, el 48% en la pauta 2, el 26% en la pauta 3 y el 32% en la pauta 4, sin diferencias significativas. Analizando por grupos de IP el 41% de los pacientes con RTV y el 25% de los pacientes con IDV suspendieron el tratamiento por efectos adversos. Se produjo retirada del tratamiento por progresión de la enfermedad en el 7% de los pacientes con RTV y en el 9% de los pacientes con IDV. Conclusiones. En los pacientes VIH positivos con infección avanzada la eficacia entre cuatro pautas de TARGA es similar, pero existe una tendencia a precisar mayor retirada por efectos adversos en los grupos de RTV que en los de IDV, los dos usados como IP único

Background. Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. Patients and methods. Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. Results. A total of 98 patients with a mean baseline CD4 count of 122 x 106/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. Conclusions. In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI

[Prescription of drugs in family medicine: on the trail of efficiency]. / Prescripción de medicamentos en medicina de familia: tras las pistas de la eficiencia.

OBJECTIVE: To analyse the effect of various factors on the efficiency of drug prescription by general practitioners (GPs). DESIGN: Descriptive, cross-sectional study. SETTING: Primary care in Murcia, Cartagena, and Lorca, in which 535 GPs work in the care of 921,281 people. Murcia Region (Spain).Participants. Prescriptions issued by the 288 GPs who were working constantly and continuously in May-June 1998 and who were away from work for no longer than 10% of the time (53.8%). MAIN MEASUREMENTS: We measured their efficiency with two general indicators--potential saving (PS) and prescription of generics (PG)--and 3 specific indicators: efficiency of prescription of omeprazole (EO), enalapril (EE), and ranitidine (ER). We analysed their relationship with structural-organisational factors and with the population attended, the doctor and his/her action. Bivariate and multivariate analyses (logistic regression) were used. RESULTS: There was an association with programmed consultation (PC); a weak inverse relationship with age of doctor, years qualified, pensioners allocated, case load and inter-consultations conducted; and a direct correlation with the length of the consultation. PG was related to rural environment, being non-permanent, specialist in family medicine, belonging to a primary care team. In the multivariate analysis PC was related to all the indicators: PS (OR=1.96), PG (OR=2.10), EO (OR=2.63), ER (OR=2.84), EE (OR=2.06); and the inter-consultations conducted with general efficiency of PS (OR=1.70), PG (OR=1.91). Rural environment was the worst for PS (OR=2.43). CONCLUSIONS: The main factors related to the efficiency of GPs prescription can be changed. The most important is the existence of PC. A lot of inter-consultations and working in a rural environment means worse general efficiency.

Utilización de antihipertensivosen Atención Primaria / Antihypertensive drug use in Primary Health Care

Objetivo. Analizar el uso de antihipertensivos en Atención Primaria en el período comprendido entre 1999 y 2001 y valorar la introducción de los antagonistas de los receptores de la angiotensina II (ARA-II).Métodos. Estudio observacional retrospectivo. Se seleccionaron todas las prescripciones de antihipertensivos mediante recetas de la Seguridad Social en la gerencia de Atención Primaria de Murcia. Las fuentes de datos fueron las cintas de facturación mensual de recetas de la Seguridad Social, nomenclator digitalis de noviembre de 2001, bases de datos de médicos y población con tarjeta sanitaria. Los resultados se expresan en dosis diaria definida (DDD) por 1.000 habitantes y día (DHD).Resultados. El consumo de antihipertensivos se incrementó de 161,7 DHD en 1999 a 183,22 en 2001 (13,3 por ciento).Las prescripciones de antihipertensivos supusieron el 11,67 por ciento del total de recetas. Los fármacos más utilizados fueron los inhibidores de la enzima de conversión de la angiotensina (IECA) (28 por ciento de las DHD totales) y los de mayor crecimiento los ARA-II (incremento del 108 por ciento).Aunque en 2001 los IECA duplicaron a los ARA-II en DHD, el consumo por precio de venta al público (PVP) fue prácticamente el mismo. El uso de diuréticos y betabloqueantes fue del 12,3 por ciento y 8,8 por ciento, respectivamente, en DHD. El fármaco más consumido en todo el período fue enalapril, seguido a distancia por amlodipino, captopril, atenolol y valsartán en 2001.Conclusiones. Los antihipertensivos mantienen una tendencia ascendente de consumo determinada por el incremento de ARA-II. Los IECA continúan siendo los más prescritos y los diuréticos y betabloqueantes probablemente estén infrautilizados. El incremento de ARA-II ha originado un cambio cualitativo en la terapéutica antihipertensiva: se ha detenido la tendencia ascendente de los IECA y se ha incrementado el coste del tratamiento. (AU)

[Effectiveness of a personalized information system on the quality of family doctors' medical prescription]. / Efectividad de un sistema de información personalizada sobre la calidad de prescripción de medicamentos en médicos de familia.

OBJECTIVES: To evaluate the effectiveness of a system of personalised prescription information (PPI) to improve prescription habits of family doctors (FD); to examine how useful PPI is in maintaining these habits, and to analyse its influence through factors of the doctor and his/her environment. DESIGN: Cross-sectional, descriptive pilot study to analyse conditioning factors and possible confusion; quasi-experimental intervention study to assess the effectiveness of PPI, with two groups (experimental and control) and 4 determinations (before the PPI and after: short, medium and long-term).Setting. Family doctors in the Murcia Region. SUBJECTS OF STUDY: The prescriptions of all family doctors in the Murcia region which started before PPI and which continued until the end of the study and without absences of over 10% at each measurement.Intervention. The family doctors from the Murcia city area formed the experimental group: they received PPI with specific proposals for improvement. The FDs of Cartagena and Lorca, who did not receive PPI, made up the control group. Statistical analysis. Logistical regression to identify conditioning factors. Z comparison of proportions contrasted with one-tail hypothesis to check the effectiveness of PPI. LIMITATIONS OF THE DESIGN: Non-randomised allocation to groups made comparison difficult: conditioning factors for stratification or adjustment were studied. PRACTICAL APPLICATION: Confirmation of PPI s effectiveness justifies its dissemination. If there is no such confirmation, it will have to be perfected. Isolating the factors conditioning prescription that can be modified helps find ways to improve PPI.

[Evaluating, improving and monitoring generic drug prescription]. / Evaluación, mejora y monitorización de la prescripción de medicamentos genéricos.

OBJECTIVE: To evaluate and improve generic drug prescription by family physicians in a regional primary care district with a specially-designed intervention. DESIGN: Uncontrolled study of an intervention, based quality evaluation and improvement methods. We selected an indicator that could be constructed with the available data (monthly reports of prescriptions dispensed through the public national health system) and determined the proportion of prescriptions for generic drugs to the total number of prescriptions dispensed, for those medications that had a generic alternative (percentage of generic prescriptions, PGP). After these data were evaluated, an intervention was implemented to increase generic prescriptions. Prescribing behavior was again evaluated and monitored at the end of the intervention period. Setting. Forty-five primary care teams in the Murcia (Southeast Spain) regional primary care district. PARTICIPANTS: A total of 339 family physicians. Interventions. During 15 months, individual reports of prescribing practices, in which changes over time were graphed, were sent to each participating prescriber. Each semester the physicians received a personal letter and a specially-printed, updated card showing the generic medications available and their pharmaceutical forms. One to three face-to-face clinical outreach sessions were held with each primary care team. Specific prescribing goals for the PGP were set and incentives to attain the goals were included in the terms of the contract for clinical services signed between the regional office of primary care management and each primary care team. MAIN OUTCOME MEASURES: The PGP increased from a pre-intervention rate of 2.7% to a post-intervention rate of 17.63%. Absolute improvement was therefore 14.84%, and relative improvement was 15.27%. Variability was monitored and analyzed with control charts. There was no significant variability within the pre- and post-intervention phases, whereas variability increased significantly (indicating improvement) during the intervention phase. CONCLUSIONS: The increase in PGP showed that prescribing for generic preparations improved. Statistical quality control tests were useful in evaluating and tracking the results of the intervention, and were indispensable for monitoring and promptly detecting opportunities to improve prescribing behavior and take appropriate measures.

Efectividad de un sistema de información personalizada sobre la calidad de prescripción de medicamentos en médicos de familia / Effectiveness of a personalised information system on the quality of family doctors' medical prescription

Objetivo. Evaluar la efectividad de un sistema de información personalizada de prescripción (IPP) en la mejora de los hábitos de prescripción de los médicos de familia (MF); conocer su utilidad para mantener estos hábitos, y analizar su influencia por factores del médico y su entorno. Diseño. Estudio descriptivo, transversal, previo para analizar factores condicionantes y de confusión; estudio de intervención cuasiexperimental para valorar la efectividad del IPP, con 2 grupos (experimental y control) y 4 determinaciones (antes del IPP y después: corto, medio y largo plazo).Emplazamiento. MF de la Región de Murcia. Sujetos de estudio. Prescripciones de todos los MF de la Región de Murcia existentes antes del IPP, que continúan hasta finalizar el estudio y sin ausencias superiores al 10 por ciento en cada medición. Formación de los grupos. Intervención: los MF de la Gerencia de Murcia formarán el grupo experimental; reciben el IPP con propuestas específicas de mejora. Los MF de Cartagena y Lorca no reciben el IPP y constituyen el grupo control. Análisis estadístico. Regresión logística para identificar factores condicionantes. Z de comparación de proporciones con contraste de hipótesis unilateral para comprobar la efectividad del IPP. Limitaciones del diseño. La no asignación aleatoria de los grupos dificulta su comparabilidad: se estudian factores condicionantes para estratificación o ajuste. Aplicabilidad práctica. Confirmar la efectividad del IPP justifica su difusión. No hacerlo obligará a perfeccionarlo. Aislar factores modificables condicionantes de la prescripción ayuda a actuar para mejorar (AU)

Evaluación, mejora y monitorización de la prescripción de medicamentos genéricos / Evaluating, improving and monitoring generic drug prescription

Objetivo. Evaluar y mejorar la prescripción de medicamentos genéricos por los médicos de familia de una gerencia de atención primaria (GAP) mediante un programa de intervención. Diseño. Estudio de intervención no controlado, basado en la metodología de evaluación y mejora de la calidad. Seleccionamos un indicador capaz de ser construido con los datos disponibles (cinta de facturación), eligiendo la proporción de genéricos prescritos sobre el total de envases en que existe alternativa genérica (PPEFG).Evaluamos, diseñamos una intervención para mejorar, reevaluamos y monitorizamos. Emplazamiento. Cuarenta y cinco EAP de la GAP de Murcia. Participantes. Un total de 339 médicos de familia. Intervenciones. Realizadas durante 15 meses, fueron: remisión de informe mensual personalizado mostrando la evolución del PPEFG mediante gráficos de desarrollo; edición y entrega personalizada semestral de una tarjeta con los medicamentos genéricos disponibles y sus presentaciones; realización de 1-3 sesiones/EAP, e inclusión de un objetivo en PPEFG explícito e incentivado en los contratos de gestión. Mediciones y resultados principales. El PPEFG preintervención fue del 2,79 por ciento y el postintervención de un 17,63 por ciento. La mejora absoluta es del 14,84 por ciento y la relativa de un 15,27 por ciento. Se ha monitorizado y analizado la variabilidad mediante gráficos de control. No se detecta variabilidad significativa en las fases pre y postintervención y sí (hacia la mejora) durante la intervención. Conclusiones. Ha mejorado la prescripción de genéricos medida en PPEFG. Las técnicas de control estadístico de la calidad aplicadas son útiles en la evaluación y seguimiento de la intervención e imprescindibles para monitorizar, detectar precozmente oportunidades de mejora y actuar en consecuencia. (AU)

[Mumps in a urban area of the Community of Madrid. Vaccination status, diagnosis and intervention measures]. / Parotiditis en un área urbana de la Comunidad de Madrid. Estado vacunal, diagnóstico y medidas de intervención.

OBJECTIVES: To describe the epidemiological situation of an epidemic of mumps, to calculate the risk of catching the illness depending on the vaccine strain used and to evaluate the diagnostic performance of the serologic determination. DESIGN: Longitudinal observational study. The incidence of mumps between January 1999 and June 2000 was calculated. Case-control study of outbreaks evaluated the risk of catching the disease depending on the vaccine strain. SETTING: Health Area 4 in the Community of Madrid. PARTICIPANTS: Residents and students from schools in the district.Interventions. Epidemiological vigilance. Serologic determination of IgM and titration of IgG. In outbreaks, people exposed were vaccinated after assessment of their vaccine status. MEASUREMENTS AND MAIN RESULTS: The rate of incidence in the first 27 weeks of the year 2000 for the 1-4 year-old age group was 334.7/105, against 12.2 in 1999. In children under 5 vaccinated with the Rubini strain there was a significantly greater risk of suffering illness than in those vaccinated with the Jeryl-Lynn strain (OR, 6.28, 95% CI, 1.43-38.50). The amount of cases confirmed serologically (specific IgM positive) was 22.22%. The mean of the logarithms of the IgG titres was significantly higher (p < 0.001) in IgM-negative patients with epidemiological confirmation (4.05, 95% CI, 3.18-4.28) than in IgM-negative cases without any epidemiological link (2.58; 95% CI, 2.33-2.84). CONCLUSIONS: We emphasise the increase of mumps incidence in the school population (fundamentally in the under-5s), which parallels an increase in outbreaks. The results suggest that the Rubini strain is less efficacious. The possibility of using alternative methods to IgM detection (IgG titration) as a diagnostic tool in a population with high vaccination coverage is posed.

[Cytomegalovirus seroepidemiology in the community of Madrid]. / Seroepidemiología frente a citomegalovirus en la Comunidad de Madrid.

BACKGROUND: Cytomegalovirus (CMV) is frequently asymptomatic. However, it constitutes an important cause of congenital disease and severe pathology in immunodepressed patients, thus representing an important problem in Public Health. The object of this work was to study the prevalence of IgG against CMV (IgG-CMV) in the general population from Madrid. METHODS: It is a transversal study, in which IgG-CMV was assayed in a representative sample of the general population from the Region of Madrid, aged 2 to 60 years (n = 2030). Participants were recruited by a two-stage cluster sample procedure from those attending primary health care centres between October, 1993 and February, 1994. For the statistical analysis the chi 2 and chi 2 lineal trend tests were employed. The percentages of seroprevalence and the specific odds ratios were calculated with confidence intervals of 95%. RESULTS: The overall seroprevalence has been 62.8% (IC95% 60.6-64.9), ranging from 58.4% (IC95% 55.2-61.5) in men to 66.7% (IC95% 63.7-69.5) in women. A significant association between increase of the age and increment of the seroprevalence was observed. The consult to dentistry, the antecedent of surgery, as well as tattooing and acupuncture has been identified as risk factors of acquiring the infection. On the other hand, to have carried out University studies seems to act as a significant factor of protection. CONCLUSIONS: Although the risk factors detected indicates a transmission by blood, the high prevalence suggests the existence of other more common ways. The age-dependent seroprevalence increase confirms an important number of infections in the adult age. However, it cannot be exclude that this increase responds to an effect cohort due to socio-economic improvements similar to the detected for other virus.