Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Spread of a SARS-CoV-2 variant through Europe in the summer of 2020

[EN] Following its emergence in late 2019, the spread of SARS-CoV-21,2 has been tracked by phylogenetic analysis of viral genome sequences in unprecedented detail3,4,5. Although the virus spread globally in early 2020 before borders closed, intercontinental travel has since been greatly reduced. However, travel within Europe resumed in the summer of 2020. Here we report on a SARS-CoV-2 variant, 20E (EU1), that was identified in Spain in early summer 2020 and subsequently spread across Europe. We find no evidence that this variant has increased transmissibility, but instead demonstrate how rising incidence in Spain, resumption of travel, and lack of effective screening and containment may explain the variant’s success. Despite travel restrictions, we estimate that 20E (EU1) was introduced hundreds of times to European countries by summertime travellers, which is likely to have undermined local efforts to minimize infection with SARS-CoV-2. Our results illustrate how a variant can rapidly become dominant even in the absence of a substantial transmission advantage in favourable epidemiological settings. Genomic surveillance is critical for understanding how travel can affect transmission of SARS-CoV-2, and thus for informing future containment strategies as travel resumes.S

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

CIBERER : Spanish national network for research on rare diseases: A highly productive collaborative initiative

Altres ajuts: Instituto de Salud Carlos III (ISCIII); Ministerio de Ciencia e Innovación.CIBER (Center for Biomedical Network Research; Centro de Investigación Biomédica En Red) is a public national consortium created in 2006 under the umbrella of the Spanish National Institute of Health Carlos III (ISCIII). This innovative research structure comprises 11 different specific areas dedicated to the main public health priorities in the National Health System. CIBERER, the thematic area of CIBER focused on rare diseases (RDs) currently consists of 75 research groups belonging to universities, research centers, and hospitals of the entire country. CIBERER's mission is to be a center prioritizing and favoring collaboration and cooperation between biomedical and clinical research groups, with special emphasis on the aspects of genetic, molecular, biochemical, and cellular research of RDs. This research is the basis for providing new tools for the diagnosis and therapy of low-prevalence diseases, in line with the International Rare Diseases Research Consortium (IRDiRC) objectives, thus favoring translational research between the scientific environment of the laboratory and the clinical setting of health centers. In this article, we intend to review CIBERER's 15-year journey and summarize the main results obtained in terms of internationalization, scientific production, contributions toward the discovery of new therapies and novel genes associated to diseases, cooperation with patients' associations and many other topics related to RD research

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p &lt; 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

Resiliencia, asertividad y consumo de alcohol en adolescentes.

El objetivo del presente estudio fue determinar la relación que existe entre la resiliencia, la asertividad y el consumo de alcohol en adolescentes estudiantes de una secundaría de la ciudad de Aguascalientes. Para ello se diseñó un estudio transversal correlacional en una muestra de 333 adolescentes. Se aplicaron dos instrumentos: resiliencia y asertividad, además de una cédula de datos sociodemográficos. Se contó con la autorización de padres de familia, participantes y autoridades de la escuela. En los resultados obtenidos predominó el género masculino (52.3 %), y la edad promedio fue de 13.17 (DE=.96) años. Asimismo, se encontró una diferencia significativa entre las variables resiliencia y consumo de alcohol (p<.001), ya que los adolescentes que no consumen alcohol mostraron promedios más altos (M=57.14, DE=15.91) que aquellos que sí lo consumen (M=48.94, DE=17.30). En conclusión, los resultados confirman que existe una relación entre las variables resiliencia y consumo de alcohol

Relación entre asertividad sexual y autoeficacia para prevenir el VIH/SIDA en jóvenes universitarios del área de la salud

The objective of this research is to determine the relationship between sexual assertiveness and self-efficacy for preventing HIV/AIDS in students of the Academic Unit of Nursing N° 2, at the Autonomous University of Guerrero. Cross-sectional, descriptive and correlational study method was used. Was attended by 400 students by simple random sampling, who answered a card with data personal, school, and work, sexual assertiveness scale and one of self-efficacy for preventing HIV/AIDS. Was authorized by the educational institution and the participants informed consent/assent. In the analysis of the data is obtained statistics descriptive and inferential. Out of the profile demographic of participants, 50% are women and the rest men, of which 84.8% are unmarried, 33.8% is the third semester, 31.0% working and studying at the same time, and 65.8% study Bachelor's degree. With respect to the level of sexual assertiveness, 39.5% achieved a high average level and 39.0% a high average level of self-efficacy for preventing HIV/AIDS. Also, there was a significant relationship between these variables (r =. 406; p<0.01), which noted that to higher level of sexual assertiveness no higher level of self-efficacy for preventing HIV/AIDS. In conclusion, the results allowed to determine that to higher level of sexual assertiveness have higher level of self-efficacy for prevention of HIV/AIDS, which serves as a base for designing targeted interventions in this study population.O objetivo desta pesquisa é determinar a relação entre assertividade sexual e auto-eficácia na prevenção de HIV / AIDS entre os jovens universitários unidade de enfermagem Academic No. 2, na Universidade Autónoma de Guerrero. Para este efeito, o método da transversal, foi utilizado estudo descritivo e de correlação. 400 estudantes universitários participaram por amostragem aleatória simples, que respondeu com uma cedula de dados pessoais, escolares e de trabalho, uma escala de assertividade sexual e auto-eficácia na prevenção de HIV / AIDS. Ele teve o apoio da escola e de consentimento / assentimento informado participantes. Na análise dos dados foram obtidos estatística descritiva e inferencial. Quanto ao perfil sóciodemográfico dos participantes, 50% são mulheres e os homens de descanso, dos quais 84,8% são solteiros, 33,8% está no terceiro semestre, 31,0% trabalham e estudam ao mesmo tempo, e 65,8% estudando um grau. Quanto ao nível de assertividade sexual, 39,5% alcançaram um elevado nível médio e 39,0% maior nível médio de auto-eficácia para prevenir o HIV / AIDS. Houve também uma relação significativa entre estas variáveis (r = 406 ;. P <0,01), o que prova que um maior nível de assertividade sexual não é maior nível de auto-eficácia para prevenir o HIV / AIDS. Em conclusão, os resultados permitiram determinar que um maior nível de assertividade sexual não é maior nível de auto-eficácia na prevenção de HIV / AIDS, que serve como base para a concepção de intervenções específicas na população estudada.El objetivo de este trabajo de investigación es determinar la relación entre asertividad sexual y autoeficacia para prevenir el VIH/SIDA en jóvenes universitarios de la Unidad Académica de Enfermería N° 2, en la Universidad Autónoma de Guerrero. Para ello se utilizó el método de estudio transversal, descriptivo y correlacional. Participaron 400 jóvenes universitarios por muestreo aleatorio simple, quienes respondieron una cédula con datos personales, escolares y laborales, una escala de asertividad sexual y una de autoeficacia para prevenir el VIH/SIDA. Se contó con la autorización de la institución educativa y el consentimiento/asentimiento informado de los participantes. En el análisis de los datos se obtuvo estadística descriptiva e inferencial. En cuanto al perfil sociodemográfico de los participantes, 50 % son mujeres y el resto hombres, de los cuales 84.8 % está soltero, 33.8 % cursa el tercer semestre, 31.0% trabaja y estudia al mismo tiempo, y 65.8 % estudia la licenciatura. Con respecto al nivel de asertividad sexual, 39.5 % alcanzó un nivel promedio alto y 39.0 % un nivel promedio alto de autoeficacia para prevenir el VIH/SIDA. Asimismo, hubo una relación significativa entre estas variables (r=. 406; p<0,01), lo que comprueba que a mayor nivel de asertividad sexual hay mayor nivel de autoeficacia para prevenir el VIH/SIDA. En conclusión, los resultados permitieron determinar que a mayor nivel de asertividad sexual hay mayor nivel de autoeficacia para prevenir el VIH/SIDA, lo cual sirve de base para diseñar intervenciones específicas en esta población de estudio

Percepción materna y estado de peso del hijo escolar en una comunidad rural

The maternal perception is the recognition and discrimination of the mother regarding the weight of the child, considering him as a child with overweight, malnourished or healthy; mothers with inadequate perception report that the weight of the child is not a health problem, avoiding the timely identification of nutritional alterations that affect their growth and development. To determine the relationship between the maternal perception and the weight status of the schoolchild in a rural community. Involving 120 dyads (mother-child) by census-type sampling. The scale of children's figures was applied where the mothers selected the image that represented the weight of the child and data of the weight and sociodemographic status of the participants were obtained, with their authorization and that of the school authorities. Descriptive and inferential analysis was obtained. 65% of the mothers were overweight, 32.5% of the children in mild malnutrition. The perception of the mothers regarding the weight status of their child was inadequate in three moments: current 58.3%, ideal 60.8% and future 51.7%. Regarding the relationship between the maternal perception and the weight status of the schoolchild, it was not statistically significant; however, it was observed that overweight or obese mothers have inadequate perception of their child's weight status than normal-weight mothers. The results allow to design and implement strategies for this group that favors the health of the child.A percepção materna é o reconhecimento e a discriminação da mãe em relação ao peso da criança, considerando-o como uma criança com excesso de peso, desnutrida ou saudável; Mães com percepção inadequada relatam que o peso da criança não é um problema de saúde e, consequentemente, evitam a identificação oportuna de alterações nutricionais que afetam seu crescimento e desenvolvimento. O objetivo desta pesquisa foi determinar a relação entre a percepção materna e o status de peso da criança em idade escolar (6 a 10 anos) em uma comunidade rural. Noventa e dois díades participaram (escola materno-infantil) por amostragem do tipo censitário. Foram obtidos dados de escala de crianças, onde mães selecionadas a imagem que descreve o peso dos dados da criança e estaduais e peso sócio-demográfico dos participantes, com as autoridades de permissão e escolares foi aplicado. Com base nisso, foi realizada uma análise descritiva e inferencial, que mostrou que 65% dos progenitores apresentavam sobrepeso e 32,5% dos escolares em desnutrição leve. Além disso, a percepção das mães sobre o peso de seus filhos foi inadequada em três momentos: os atuais 58,3%, os ideais 60,8% e os futuros 51,7%. Em relação à relação entre a percepção materna e o status de peso do escolar, não foi estatisticamente significante; no entanto, observou-se que as mães com sobrepeso ou obesas têm uma percepção inadequada do status de peso da criança, em oposição à mãe com peso normal. Os resultados permitem projetar e implementar estratégias para esse grupo que favoreçam a saúde dos escolares.La percepción materna es el reconocimiento y la discriminación de la madre respecto al peso del hijo, considerándolo como un niño con sobrepeso, con desnutrición o sano; las madres con una percepción inadecuada refieren que el peso del hijo no es un problema de salud y, en consecuencia, evitan la identificación oportuna de alteraciones nutricionales que afectan su crecimiento y desarrollo. El objetivo de esta investigación fue determinar la relación entre la percepción materna y el estado de peso del hijo escolar (6 a 10 años de edad) en una comunidad rural. Participaron 92 diadas (madre-hijo escolar) por muestreo tipo censo. Se aplicó la escala de figuras de niños donde las madres seleccionaron la imagen que representaba el peso del hijo y se obtuvieron datos del estado de peso y sociodemográficos de los participantes, con su autorización y la de las autoridades escolares. A partir de ello se realizó un análisis descriptivo e inferencial, el cual arrojó que 65 % de las progenitoras se encontraron en sobrepeso y 32.5 % de los escolares en desnutrición leve. Además, la percepción de las madres respecto al estado de peso de su hijo fue inadecuada en tres momentos: el actual 58.3 %, el ideal 60.8 % y el futuro 51.7 %. Respecto a la relación entre la percepción materna y el estado de peso del escolar no fue estadísticamente significativa; sin embargo, se apreció que las madres con sobrepeso u obesidad tienen una percepción inadecuada del estado de peso de su hijo contrario a la madre con peso normal. Los resultados permiten diseñar e implementar estrategias para este grupo que favorezca la salud de los escolares

How do women living with HIV experience menopause? Menopausal symptoms, anxiety and depression according to reproductive age in a multicenter cohort

CatedresBackground: To estimate the prevalence and severity of menopausal symptoms and anxiety/depression and to assess the differences according to menopausal status among women living with HIV aged 45-60 years from the cohort of Spanish HIV/AIDS Research Network (CoRIS). Methods: Women were interviewed by phone between September 2017 and December 2018 to determine whether they had experienced menopausal symptoms and anxiety/depression. The Menopause Rating Scale was used to evaluate the prevalence and severity of symptoms related to menopause in three subscales: somatic, psychologic and urogenital; and the 4-item Patient Health Questionnaire was used for anxiety/depression. Logistic regression models were used to estimate odds ratios (ORs) of association between menopausal status, and other potential risk factors, the presence and severity of somatic, psychological and urogenital symptoms and of anxiety/depression. Results: Of 251 women included, 137 (54.6%) were post-, 70 (27.9%) peri- and 44 (17.5%) pre-menopausal, respectively. Median age of onset menopause was 48 years (IQR 45-50). The proportions of pre-, peri- and post-menopausal women who had experienced any menopausal symptoms were 45.5%, 60.0% and 66.4%, respectively. Both peri- and post-menopause were associated with a higher likelihood of having somatic symptoms (aOR 3.01; 95% CI 1.38-6.55 and 2.63; 1.44-4.81, respectively), while post-menopause increased the likelihood of having psychological (2.16; 1.13-4.14) and urogenital symptoms (2.54; 1.42-4.85). By other hand, post-menopausal women had a statistically significant five-fold increase in the likelihood of presenting severe urogenital symptoms than pre-menopausal women (4.90; 1.74-13.84). No significant differences by menopausal status were found for anxiety/depression. Joint/muscle problems, exhaustion and sleeping disorders were the most commonly reported symptoms among all women. Differences in the prevalences of vaginal dryness (p = 0.002), joint/muscle complaints (p = 0.032), and sweating/flush (p = 0.032) were found among the three groups. Conclusions: Women living with HIV experienced a wide variety of menopausal symptoms, some of them initiated before women had any menstrual irregularity. We found a higher likelihood of somatic symptoms in peri- and post-menopausal women, while a higher likelihood of psychological and urogenital symptoms was found in post-menopausal women. Most somatic symptoms were of low or moderate severity, probably due to the good clinical and immunological situation of these women