[Interruption to treatment with combined lopinavir/ritonavir therapy in HIV positive patients]. / Interrupción del tratamiento con la terapia combinada lopinavir/ritonavir en pacientes VIH+.

OBJECTIVE: To describe the extent of interruptions to treatment with therapies which include the combination of lopinavir-ritonavir within the SNS (Spanish National Health System), as well as identify the causes of these interruptions and analyse the factors associated with the same. METHOD: Retrospective cohort of 197 seropositive patients, who began treatment with lopinavir-ritonavir between January 2000 and October 2002. The patients attended the outpatient pharmaceutical care unit and were followed-up until December 2002. Interruptions and their causes were identified and the factors associated with the interruption were analysed using proportional hazard models. RESULTS: The mean follow-up period was 263 days and 38.6% of patients interrupted therapy. The most common causes of interruption were intolerance (30.3%), non-compliance (21.1%) and therapy failure (5.26%). The mean treatment period was 487 days (95% CI: 432 to 542) and 50% of patients who interrupted treatment did so within the first 4 months. No associations were found between patient or treatment characteristics and the risk of interruption. CONCLUSIONS: The percentage of interruptions was lower than those in other observational studies, but greater than those in clinical trials. The significance of the causes of interruption was similar and no factor associated with the risk of interruption was found.

[Compliance of hormone replacement therapy in menopausal women]. / Cumplimiento del tratamiento hormonal sustitutivo en mujeres menopáusicas.

BACKGROUND: The effectiveness of a given treatment is only achieved with a due compliance. Our objective was to know the compliance degree of hormone replacement therapy (HRT) in menopausal women. METHOD: A descriptive observational study was carried out in three hospitals in the Valencia Community (Spain). We included menopausal patients who were visited in a menopause unit from 1989 to 1999 and who were administered HRT. We analyzed age, age at menopause, type of menopause, age at starting HRT, education level, prescription reason, treatment duration, information level, side effects, and causes leading to withdrawal. RESULTS: The study was performed in 363 women. There were 75% probabilities that women fulfilled the therapy for 5 years. The median of fulfillment was 11 years. Those women who had side effects were more prone to withdraw the treatment. By contrast, women who experienced benefits were less prone to withdraw it. Risk of withdrawal was also lower in cases of postsurgery menopause and in women who were younger than 55 years when they started HRT. CONCLUSIONS: In our study, the compliance level was high and it was determined either by treatment benefits or side effects, type of menopause and age at starting HRT.

[The mortality of a retrospective cohort of workers in a Spanish iron and steel plant. The methodological problems in defining the cohort]. / Mortalidad de una cohorte retrospectiva de trabajadores de una siderúrgica española. Problemas metodológicos en la definición de la cohorte.

The work environment of an iron foundry involved a large number of exposures related to several health problems, mainly lung cancer. "Altos Hornos del Mediterráneo (AHM)" fron Sagunto is an iron industry that stopped its foundry plant production in 1984. The present paper shows the methodological problems merged during the reconstruction of AHM workers' cohort. From personnel files a male cohort was defined for 7,018 males who worked at least one year and started work between 1950 and 1970, following them through 1991. The cause of death was obtained from de Civil register, Life insurance and reference hospitals. By means of experts the work areas were rated in three exposure levels. 6% of cohort members were lost during the follow-up. 2786 deaths were reported and 88% causes of death were retrieved. The enterprise data files let us to reconstruct the cohort, but the availability of a National Death Index, as there is in other countries would have made easier the job and would have improved the data quality.

[Modification of the vaccination technique with DTP in nursing infants after 1 intervention]. / Modificación de la técnica vacunal con DTP en el lactante tras una intervención.

OBJECTIVES: To evaluate alterations in techniques of DTP vaccination of nursing children after a two-year intervention and analyse the reasons for reluctance to change the norms. DESIGN: A longitudinal and prospective study, with intervention before and after. Evaluation through two anonymous questionnaires of staff in charge of the vaccinations: a general survey for each centre and an individual one for each nurse. SETTING: Primary care. PARTICIPANTS: The professionals in charge of vaccinations of nursing children in the 13 health centres and clinics in areas 11 and 12 of the Valencian Community in 1993. INTERVENTION: Informative meetings with paediatricians and nurses to pass on the recommendations of experts on vaccination techniques, supported by written information to the person in charge of vaccinations at each centre. MEASUREMENTS AND MAIN RESULTS: Out of the 13 centres 12 returned the general survey in 1993 and 11 in 1995. The individual questionnaire was returned by 49 nurses. From the 12 centres injecting in the gluteus in 1993, 5 changed to the thigh and all now use 25 mm-long needles. The reasons for not changing the site of the injection were basically the greater number of side-effects and that the paediatricians did not consider it necessary. CONCLUSIONS: Vaccination techniques are usually altered after the intervention, though still not sufficiently.

[Improvement in the quality of the interclinic referral note in regard to the information given]. / Mejora de la calidad de la hoja de interconsulta a través de la información.

OBJECTIVE: To quantify the improvement in compliance with filling out the interclinical note after both general practitioners and specialists were informed of the compliance level found in an earlier study. DESIGN: An intervention before-and-after study. Unit of analysis: interclinical note in the primary care clinical record. SETTING: Health Areas 11 and 12 in the Community of Valencia, November 1993 and 1994. Field work was developed on the premises of the two specialist centres of these areas. PARTICIPANTS: Two samples, of 708 and 326 interclinical notes, were used. These were stratified in function of the number of consultations during the first six months of each of the study years, by centre and speciality. INTERVENTION: All primary care and specialist professionals were informed of the level of compliance with the interclinical note in the first part of the study. MAIN RESULTS: The primary care section improved significantly in: personal history, data on physical examination, suspected diagnosis, reason for consultation. The section on specialists improved significantly in the identification of the specialist, diagnosis, treatment, action to take. CONCLUSIONS: Information given to professionals improved their filling out of the interclinical note, basically on variables to do with the pathological process. It should be routine to feed back information to the professionals concerned.

[An analysis of prior antibiotic treatment on the impact of meningococcal disease in children of the Valencian Community. The Study Group of Invasive Diseases]. / Análisis del tratamiento antibiótico previo sobre el impacto de la enfermedad meningocócica en niños de la comunidad Valenciana. El Grupo de Estudio de Enfermedades Invasoras.

OBJECTIVE: The objective of this study was to describe the effect of antibiotics given prior to hospitalization of children with meningococcal disease and to assess their relationship with disease outcome and microbiological isolation. PATIENTS AND METHODS: A prospective surveillance system in all hospitals of the Community of Valencia was implemented. All cases of children less than 15 years of age with clinically suspected invasive disease and: 1) N. meningitidis isolated in a normally sterile body fluid; 2) positive capsular antigens in blood or CSF and a positive Gram stain; and 3) clinical diagnosis of an invasive N. meningitidis disease. RESULTS: In a two-year period 157 cases were reported. In 143 cases, data about antibiotic prescription prior to hospitalization was known. Of these, 24.5% had received antibiotics and none had received parenteral penicillin or cephalosporins. Oral antibiotics decreased bacterial isolation (p < 0.001) and did not modify outcome (p = 0.66). CONCLUSIONS: Oral antibiotics, not recommended for N. meningitidis diseases, did not modify prognosis, but decreased bacterial isolation, and therefore worsened clinical handling of the cases and epidemiological studies.

[The use of drugs as a risk factor for poorly controlled arterial hypertension]. / Uso de medicamentos como factor de riesgo de hipertensión arterial mal controlada.

OBJECTIVE: To describe use of medication simultaneously with antihypertensive drugs that can cause inadequate pharmacological control of hypertension (HTA). DESIGN: A descriptive observational retrospective study. SETTING: Four urban health care center, Valencia. PARTICIPANTS: 389 patients with hypertension and chronic treatment card opened (TLT). MEASUREMENTS AND MAIN RESULTS: Were collected from de TLT and from the health history (HS) the number and type of drugs used against the hypertension and drugs with hypertensive effects, and number of potential interactions, type and duration of simultaneous treatment. 32.39% of the study subjects used drugs with potential hypertensive effects. The mean of interactions found were 1.75; 145 drugs were responsible of the 220 potential interactions found, 66.89% were non-steroids anti-inflammatory drugs (AINEs) and 23.45% antacids; 6.43% of the patients used another drug that increases by itself blood pressure; 96% of them were glucocorticoids. Jointly administration of drugs with potential antihypertensive effect occurs in 63.18% among drugs chronically prescribed. In a 28.45% the concurrent treatment was kept longer than 9 months. CONCLUSIONS: The third part of the hypertensive patients with pharmacological treatment, during a year-long period, used any moment, some drug with potential hypertensive effect. The third part of them this simultaneous treatment was kept for more than 9 months. It is necessary to take into account the use of other drugs simultaneously with antihypertensive drugs.

[Pertinence of analysis requests in primary care]. / Pertinencia de las peticiones analíticas en atención primaria.

OBJECTIVE: To find the relevance of analytic tests requested by the Primary Care doctor. DESIGN: A descriptive crossover study. Relevance was decided by the definition of criteria through consensus techniques. SETTING: Three urban Health Centres in Area 4 of the City of Valencia. PARTICIPANTS: All the requests for analysis made by 31 general practitioners over four days were included in the study. MEASUREMENTS AND MAIN RESULTS: Relevance was evaluated by four assessors. The reliability of the method used was calculated through the simple concordance index (0.708-0.842) and the Kappa index (0.421-0.661). 355 path analyses were examined. Three of the assessors found between 60 and 63% of the requests relevant; the fourth found 48% relevant. The most frequent reason for irrelevance was that the request did not fit the requisite procedure. CONCLUSIONS: Relevance of requests for analytic tests could be improved. The present study is a starting-point, which allows us to deduce that an improvement in tests' relevance could be achieved with greater circulation of information on agreed diagnostic and follow-up procedures.

[The coverage of vaccines systematically administered and of a vaccine against Haemophilus influenzae type b prior to its inclusion in the vaccinal calendar in the Valencian Community]. / Cobertura de las vacunas administradas sistemáticamente y de la vacuna frente a Haemophilus influenzae tipo b previa a su incorporación al calendario vacunal en la Comunidad Valenciana.

OBJECTIVE: The objective of this study was to estimate the vaccine coverage among children two years of age in the Community of Valencia, Spain, in 1997. PATIENTS AND METHODS: Cluster sampling was used to assess vaccine coverage. Clusters were villages randomized according to their population < 5 years of age. At least 7 children of each of the 30 selected clusters were randomly selected from the database of newborn metabolic screening. Parents were contacted and vaccine registration cards requested by mail. RESULTS: Four hundred forty subjects were selected. Eight percent of the families had moved and were not contacted. Sixty-nine percent participated in the study. Coverage for three doses of DTP was 97.8% and 87.6% for four doses. MMR vaccine coverage was 96.6% and three doses of hepatitis B had been given in 95.1%. H. influenzae type b (Hib) vaccine coverage was 57%. In 70% of the studied cases of non-participants, vaccine coverage was known through vaccination centers and was very similar to that of the participants. CONCLUSIONS: Vaccine coverage in the Community of Valencia is high for the scheduled vaccines. Although Hib is not a scheduled vaccination, its coverage was 57%.

[Evaluation of the quality of inter-clinic documents. Does their proper filling out by the family doctor affect the reply obtained from the specialist?]. / Evaluación de la calidad del documento de interconsulta. 'Influye la adecuada cumplimentación del médico de familia en la respuesta que obtiene del especialista?

OBJECTIVE: To analyse the filling out of the inter-clinic form (IF) at a centre with special fields of care (CS) and to assess whether its proper filling out in primary care (PC) affects the reply from specialist care. DESIGN: Cross-sectional, descriptive study. SETTING: Primary health care area in the Community of Valencia. PARTICIPANTS: Randomised sample of IFs of patients referred for the first time from PC to specialists. MAIN MEASUREMENTS: Evaluation criteria were grouped in two: those IFs were considered acceptable (IFCA) in which the family doctor included the reason for consultation or his/her diagnostic impression, as well at least one of the following: anamnesis, personal background, physical examination, further tests or current medication. The remaining IFs were considered inadequately filled out (IFCI). RESULTS: The sample analysed for the IF audit of the CS was 392 people. The result of the audit in the specialist clinics was that 243 IFs were blank (62.0%); the specialist doctor was identified in 19% of cases; the diagnosis was given in 23.5%; treatment, in 21%, and the follow-up plan, in 20%. In the PC evaluation, there were no blank IFs; anamnesis was recorded in 41.8%; reason for consultation in 73%; suspected diagnosis in 58.2%, and treatment in 11.5%. The sample to analyse the differences in the filling of the form in specialist care according to the quality of the PC filling out was 529 IFs. 56.3% of the IFs were considered acceptable. No statistically significant differences were found in the filling of any of the criteria of evaluation by the specialist doctor between the IFs from PC of acceptable and inadequate quality, except on the question of specifying treatment. CONCLUSIONS: We found no relationship between the quality of the IF from PC and the reply from specialist care. Currently, the filling out of IFs continues to be deficient.

[Helicobacter pylori: 6-day triple therapy in duodenal ulcer]. / Helicobacter pylori: triple terapia de 6 días en el ulcus duodenal.

OBJECTIVES: To find the effectiveness of short-term eradication treatment of Helicobacter pylori in the duodenal ulcer. DESIGN: Intervention study, open controlled, randomised with parallel groups. SETTING: Three Health Centres in the city of Valencia. PATIENTS: Patients with a duodenal ulcer diagnosis and a Helicobacter pylori infection who attended the Primary Care physician. INTERVENTION: The study group (48 patients) was treated for six days with the triple therapy: Amoxycillin, Clarithromycin and Omeprazole. The control group (40 patients) was treated with Omeprazole for six weeks. MEASUREMENTS AND MAIN RESULTS: The observance period lasted a year, after which the Elisa test was conducted. Eradication was successful for 65% of those treated with the triple therapy, but for only 30% of those treated with monotherapy. The consumption of medication for the ulcer during the year of observance was almost three times greater in the group treated with monotherapy than in the triple-therapy group. CONCLUSIONS: Eradicative triple therapy was shown to be more effective and efficient than monotherapy. It is feasible to use it in Primary Care. Eradicative triple therapy is not advisable within six days: a longer treatment period should be employed with this recommendable therapy.

[An episode of the prevention of cardiovascular risk factors by age and sex in the Community of Valencia]. / Episodio de prevención de factores de riesgo cardiovascular por edad y sexo en la Comunidad Valenciana.

OBJECTIVE: To typify the episodes of early detection of cardiovascular risk factors (CRF) and to calculate their frequency by age and sex groups. DESIGN: An observational, prospective and multi-centred study. SETTING: Twenty health centres distributed in the three provinces of the Community of Valencia. PATIENTS: Episodes of prevention of CRF in users of both sexes aged between 18 and 64 who, in the three years prior to the study, had undergone no CRF early diagnosis protocol. They were included by means of consecutive proposal with informed consent. MEASUREMENTS AND RESULTS: The diagnostic protocol of the Plan for Prevention of Cardiovascular Diseases (PPCVD) was applied. The variables analysed were: age, sex, number and duration of consultations, CRF diagnosed previously, and CRF diagnosed at the intervention. 632 episodes were analysed, with a mean 1.44 (CI: 1.39-1.49) consultations per episode and a mean duration of 10 minutes 53 seconds. At the start of the study 60.3% of the population did not have CRF, but after the intervention only 17.2% had no CRF diagnosed. CRF frequency after the intervention was: diabetes 4.5% (CI: 3.2-12.2), alcohol consumption 5.5% (CI: 2.2-13.1), hypertension 14.9% (CI: 7.7-22.2), obesity 30.8% (CI: 24.3-37.3), tobacco habit 33.2% (CI: 26.8-39.6), lipaemia 42.5% (CI: 36.6-48.5), and sedentary life-style 54.9% (CI: 49.6-60.2). CONCLUSIONS: CRF diagnosed most often after the intervention were: sedentary life-style, tobacco habit and obesity; and the least commonly diagnosed was alcohol consumption. The application of the PPCVD protocol was most effective in the youngest age-groups and women. The "episode" as a unit of analysis is a useful and feasible instrument for investigating the procedures and results of primary care preventive activities.

[The evolution of health and relationship habits of an adolescent cohort of Puerto de Sagunto (1995-1996)]. / Evolución de hábitos de salud y de relación de una cohorte de adolescentes de Puerto de Sagunto (1995-1996). Grupo de Trabajo TBC-3. Valencia.

OBJECTIVE: To know the prevalence of tobacco consumption, alcohol and marihuana as well as the habits of relationship, in an adolescents cohort of 3rd of Obligatory Secondary Teaching (ESO), that accede for the first time to one of the four secondary school of Puerto de Sagunto and the evolution of these habits after a year of follow-up. DESIGN: Transverse observational study with data withdrawal in two moments. Site. In the four secondary school of Puerto de Sagunto (Valencia). PATIENT AND OTHERS PARTICIPANTS: Adolescent of 3rd of ESO that accede for the first time to the four secondary school of Puerto de Sagunto in the course 95-96. INTERVENTIONS: A self-fully validated habits poll of health and of relationship was given to the pupils of 3rd of ESO (n = 573), and a year after was given the same poll, to the pupils already in 4th of ESO (n = 395). MEASUREMENTS AND RESULTS: On health habits, were found meaningful statistic differences in various variables: in tobacco consumption several times to the month passes of the 30% to the 40%, in alcohol consumption more than proven passes of the 35% to the 52%, in have you intoxicated the response never passes of the 67% to the 57%, in the paragraph of marihuana consumption, the response never passes of the 82% to the 72%. On the habits of relationship were found significant statistic differences with respect to number of nocturnal exists during the week that goes from 1.07 to 1.33, the return hour before 10 passes of the 23% to the 8%, as well as the type of associations to those which belong, sports club passes of the 38% to the 46%. In the paragraph of relationship to their teachers, the response good passes of the 89% to the 93%. CONCLUSIONS: The step of 14 to 15 years supposes in this population an increase in alcohol consumption, tobacco and marihuana, they go out more days at night and return later to house, are associated more in sports clubs and have better relationships to their teachers. The knowledge of these habits permits the intervention with preventive programs, that attempt to change attitudes toward these toxic habits and to promote the healthiest.

[School failure in a cohort of adolescents]. / Fracaso escolar en una cohorte de adolescentes.

OBJECTIVE: To evaluate a cohort of adolescents as to whether their personal characteristics and/or determined habits of health and social relations bore any relation to the state of their studies two years later. DESIGN: A prospective study following a cohort of adolescents. PARTICIPANTS AND SETTING: Third-year ESO (aged c. 14) adolescents from the four state secondary schools in Puerto de Sagunto. INTERVENTIONS: Once the cohort (n = 551) was defined, in November 1995 the students themselves filled in a questionnaire on health and relationship habits. Two years afterwards they were located through school registers and classified as good if they were in the appropriate year, repeat if they were repeating a year and disappeared if they had left school. These last two categories were both considered school failures (SF). MEASUREMENTS AND RESULTS: 222 students were classed as SF (40%). 118 of these (21.4%) had left and 104 (18.9%) were repeating a year. There were statistically significant differences in the following characteristics measured at the start of the study: greater SF among boys than girls (46.4%/35.6%): the disappeared had a higher average age than the good students (14.98/14.17), higher average number of siblings (2.73/2.26), and higher average of nights they went out during the week (1.65/0.84). Mean family income was lower in the repeat group (1926087/2475436 pesetas); the money students received weekly was higher in both SF groups (over 900/641 pesetas). Students whose fathers have university degrees made up only 7.4% of SF; and no student whose mother had a university degree was SF. 17.5% of those who said they spent their free time with their family were SF, whereas 53% of those who devoted their free time basically to enjoying themselves were SF. On drug consumption, those who replied they never smoked had 27.2% SF, never consumed alcohol 25.8% SF, never took marihuana 35.3% SF, and never consumed other drugs 39.5% SF. Students who said their relationships with family and teachers was bad had 70% and 62.2% of SF, respectively. 70% of those who felt depressed were SF. CONCLUSIONS: This study confirms that a favourable family atmosphere is important in preventing school failure. It also makes clear that young people's social relationships and health habits are closely associated to their being a standard student or a school failure.