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Objectives: How brain damage after stroke is related to specific clinical manifestation and recovery is incompletely understood. We studied cognitive reserve (CR) in stroke patients by two types of measurements: (i) objectively verifiable static proxies (i.e., education, occupational attainment), and (ii) subjective, dynamic proxies based on patient testimony in response to a questionnaire. We hypothesized that one or both of these types of CR measurements might correlate positively with patient cognitive performance during the post-acute and chronic phases of recovery. Method: Thirty-four stroke patients underwent neuropsychological assessment at 2, 6 and 24 months after stroke onset. In chronic stage at 24+ months, self-rating assessments of cognitive performance in daily life and social integration were obtained. CR before and after stroke was estimated using static proxies and dynamic proxies were obtained using the Cognitive Reserve Scale (CRS-Pre-stroke, CRS-Post-stroke). Results: CRS-Pre-stroke and CRS-Post-stroke showed significant mean differences. Dynamic proxies showed positive correlation with self-assessment of attention, metacognition, and functional ability in chronic stage. In contrast, significant correlations between static proxies and cognitive recovery were not found. Conclusions: Dynamic proxies of CR were positively correlated with patients’ perception of their functional abilities in daily life. To best guide cognitive prognosis and treatment, we propose that dynamic proxies of CR should be included in neuropsychological assessments of patients with brain damage.
This is a retrospective cohort study based on data from five nursing homes which aims to appraise how physical and cognitive characteristics of nursing home residents were associated with the use of restraints, and to provide information on their prevalence in Spain. The goal was to assess, in a visual way, the possible interactions between the nursing homes residents’ characteristics and their association with the use of restraints. Motivation, risk factors, characteristics of the residents analysed by validated rating systems that assess mobility, level of dependence, cognitive condition and nutritional status, and their association with the use of restraints, were described by means of linear and non-linear multivariate approaches in the form of self-organised maps. Findings showed that the prevalence of restraints was high when compared to other developed countries. The visual analysis reinforced the knowledge that a greater impairment was associated with the use of restraints and vice versa. However, the residents’ characteristics were not always associated with the use of restraints. Subjective factors seem to play a relevant role in decision-making, so it is important to assess risk factors continuously and determine the actual need for the use of restraints from an individual perspective by basing the criteria on specific objectives, and on consistent, reproducible and reliable methods. Initiatives to minimise these subjective factors should be promoted. Likewise, a clear definition of physical restraints should be offered at each centre. In addition, effective legislation that clearly states the need, alternatives and motivation for the use of restraints is needed.
Earlier activities on health technology assessment (HTA) started in Spain around 1984, with the creation of a National Advisory Board on HTA, and the development of national and regional HTA organizations in the early 1990s. In 2012, the Spanish Health Ministry established the Spanish Network for Health Technology Assessment of the National Health System (RedETS); funded at national level and including all public HTA organizations at national and regional levels. RedETSis focused on the assessment of nondrug health technologies to inform the revision (approval and funding or disinvestment) of the Benefit Portfolio of the Spanish NHS. In parallel with European Network for Health Technology Assessment (EUnetHTA), RedETS has been setting-up and sharing common procedures and methodological guidelines to ensure effective cooperation and mutual recognition of the scientific and technical production in HTA. The output of RedETS is fifty to sixty annual reports, including the production of full HTA reports, Clinical Practice Guidelines, methodological guidance reports, relative effectiveness assessments, tools to support shared decision making between patients and healthcare professionals, and monitoring studies. The HTA assessments requested by the Regional Health Authorities are the biggest component of the annual RedETS working plan. These assessment needs are identified according to a yearly process and prioritized by a Commission composed of representatives from all Spanish regions with the aid of the PRITEC tool. The objectives of this study are to report and update the normative and organizational state of HTA in Spain; describing noteworthy advances witnessed over the past 10 years, as well as discussing existing challenges.
To translate, culturally adapt, and psychometrically evaluate the Spanish version of the “Scale for End-of Life Caregiving Appraisal” (SEOLCAS).
Observational cross-sectional study. Convenience sample of 201 informal end-of-life caregivers recruited in a southern Spanish hospital. The reliability of the questionnaire was assessed through its internal consistency (Cronbach's α) and temporal stability (Pearson's correlation coefficient [r] between test-retest). The content validity index of the items and the scale was calculated. Criterion validity was explored through performing a linear regression analysis to evaluate the SEOLCAS’ predictive validity. Exploratory factor analysis was used to examine its construct validity.
The SEOLCAS’ reliability was very high (Cronbach's α = 0.92). Its content validity was excellent (all items’ content validity index = 0.8–1; scale's validity index = 0.88). Evidence of the SEOLCAS’ criterion validity showed that the participants’ scores on the SEOLCAS explained approximately 79.3% of the between-subject variation of their results on the Zarit Burden Interview. Exploratory factor analysis provided evidence of the SEOLCAS’ construct validity. This analysis revealed that two factors (“internal contingencies” and “external contingencies”) explained 53.77% of the total variance found and reflected the stoic Hispanic attitude toward adversity.
Significance of results
The Spanish version of the SEOLCAS has shown to be an easily applicable, valid, reliable, and culturally appropriate tool to measure the impact of end-of-life care provision on Hispanic informal caregivers. This tool offers healthcare professionals the opportunity to easily explore Hispanic informal end-of-life caregivers’ experiences and discover the type of support they may need (instrumental or emotional) even when there are communicational and organizational constraints.
The aim of this study was to identify the main Enterobacteriaceae species responsible for early gas blowing during curdling and the first week of ripening in raw goats’ milk cheese. Two batches of raw goats’ milk cheese were selected. One of them showed early blowing within the first 24 h of cheese ripening while the other showed no alteration. Although initial levels of Enterobacteriaceae were similar in defective and non-defective cheese, their dynamics (growth and disappearance rates of the species detected) were different. Klebsiella oxytoca and Enterobacter cloacae were the main species in the defective curd, whereas Buttiauxela spp. was predominant in normal curd. Hafnia alvei was the prevailing isolated species for both normal and defective cheese throughout the ripening process. The highest gas production was rendered by K. oxytoca and H. alvei, mainly isolated from curd and cheese. However, other species relevant in milk or curd, like Pantoea ssp. or Buttiauxela spp. were considered as low gas producers. The analysis of digitalized images of cheese showed that most of the cheese eyes were formed before the first week of ripening, although this process continued during maturation.
According to the species found in the defective and non-defective cheese, their proportions at different ripening stages, their ability to produce gas and eye formation, K. oxytoca might be considered the most likely responsible for early blowing in raw goats’ milk cheeses; while H. alvei increased the eyes number in the later stages of the ripening period.
To compare the epidemiology, clinical characteristics, and mortality of patients with bloodstream infections (BSI) caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) versus ESBL-producing Klebsiella pneumoniae (ESBL-KP) and to examine the differences in clinical characteristics and outcome between BSIs caused by isolates with CTX-M versus other ESBL genotypes
As part of the INCREMENT project, 33 tertiary hospitals in 12 countries retrospectively collected data on adult patients diagnosed with ESBL-EC BSI or ESBL-KP BSI between 2004 and 2013. Risk factors for ESBL-EC versus ESBL-KP BSI and for 30-day mortality were examined by bivariate analysis followed by multivariable logistic regression.
The study included 909 patients: 687 with ESBL-EC BSI and 222 with ESBL-KP BSI. ESBL genotype by polymerase chain reaction amplification of 286 isolates was available. ESBL-KP BSI was associated with intensive care unit admission, cardiovascular and neurological comorbidities, length of stay to bacteremia >14 days from admission, and a nonurinary source. Overall, 30-day mortality was significantly higher in patients with ESBL-KP BSI than ESBL-EC BSI (33.7% vs 17.4%; odds ratio, 1.64; P=.016). CTX-M was the most prevalent ESBL subtype identified (218 of 286 polymerase chain reaction-tested isolates, 76%). No differences in clinical characteristics or in mortality between CTX-M and non–CTX-M ESBLs were detected.
Clinical characteristics and risk of mortality differ significantly between ESBL-EC and ESBL-KP BSI. Therefore, all ESBL-producing Enterobacteriaceae should not be considered a homogeneous group. No differences in outcomes between genotypes were detected.
Early awareness and alert systems (EAAS) try to anticipate the impact of new technologies in the healthcare systems. Spain, which has a decentralized health system with public provision and universal health coverage, has been a pioneer in establishing EAAS activities. From 2006 a network of regional agencies coordinated EAAS activities. Taking into account the individual agencies scarce resources and in order to improve efficiency, this collaboration decided to distribute tasks when identifying and early assessment of new and emerging health technologies. The aim was to inform the common benefit package of the Spanish public health system.
Four out of eight Spanish Health Technology Assessment (HTA) agencies had EAAS in Spain (AETS-Carlos III Institute; AETSA-Andalusia; Avalia-t-Galicia; Osteba-Basque Country). Each agency has taken care of different sources for the identification of new and emerging non-drug health technologies: industry and innovator contacts, health expert networks, mass media and EAAS databases. Members of the network used the same filtration criteria to reach the final list. The system will run in parallel to a biannual identification process in major databases.
In 2016, the network identified and filtered sixty-three technologies: ten by mass media; five by health experts; thirty-five other EAAS and thirteen by direct contact with industry and innovators. Main represented specialties were: endocrinology (seven); gynecology and obstetrics (six); cardiology and cardiac surgery (five); emergency medicine (four); dermatology (three) and pneumology (three). Technologies were grouped by specialty in order to inform the different commissions that discuss inclusion in the Spanish Benefit Package. Specialty monographs will be published to inform stakeholders.
The approach is feasible, and increases the capacity of individual agencies to address the needs of the national and regional systems by improving their efficiency. There is a need to previously define the methods and the criteria that will be used for the identification and filtration.
The Spanish Network of Agencies for Health Technology Assessment (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. In this work, guided by the necessity of implementing a Quality Management System, we present the process to achieve this objective.
As an initial step, a review was carried out based on a structured search strategy in the main electronic databases Medline and EMBASE, and a manual search in websites of national and international agencies (March 2016) in order to collate previous knowledge and experiences. Through the information included in this review, a proposal to create a quality, self-evaluating tool is necessary.
In total, 800 references were found and finally 6 studies were included in the review (1-3). All had a similar structure. Some lists of good practices, classified in dimensions related to different quality aspects in Health Technology Assessment (HTA) organizations, were found. Also some information about questions for evaluating quality standards was indicated. Taking all this information, a proposal of sixty-six standard titles was put forward. These standards were then grouped into twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process and IV Resources.
Based on the systematic review, we developed a proposal for a self-evaluating tool and this is the baseline for a common Quality Management System for the Spanish Network of HTA Agencies. The quality management process will require the development of a handbook by each member of REDETS that will be based on agreed quality standards.
The Spanish National Network (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. The necessity of considering a Quality Management System has been detected and, consequently, a common tool for all the members needs to be developed. We describe in this study the process to achieve that goal.
Based on both a review of previous literature and the proposal for a self-evaluating tool, a group of experts from each agency through consensus have developed a tool for self-evaluation in Health Technology Assessment (HTA) agencies. Through the structure described in the handbook of the Andalusian Agency for Healthcare Quality (ACSA), each standard should have a statement or proposal that needs to also include evidence or good practices, and the corresponding evaluation questions. In separate workgroups, the definition of these proposals, evidence and evaluation questions were developed. One face-to-face meeting and two meetings via teleconference were necessary to achieve a final document with all the quality standards.
From a proposed structure of sixty-six standards, the titles, definitions, statements and evidence as well as good practices and evaluation questions were established in workgroups with consensus among all of the members (1 - 3). The final version of the self-assessment tool was composed of sixty-eight standards, grouped in twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process, and IV Resources.
Quality management requires an evaluation tool and this version, based on a systematic review and consensus, is a useful and practical instrument for developing a handbook by each member of REDETS. An online version of the tool is in process of development.
To evaluate the performance of waist-to-height ratio (WHtR) in predicting
cardiometabolic outcomes and compare cut-off points for Brazilian
Cross-sectional study. WHtR areas under the curve (AUC) were compared with
those for BMI, waist circumference (WC) and waist-to-hip ratio (WHR). The
outcomes of interest were hypertension, diabetes, hypertriacylglycerolaemia
and presence of at least two components of metabolic syndrome (≥2
MetS). Cut-offs for WHtR were compared and validity measures were estimated
for each point.
Teaching and research institutions in six Brazilian state capitals,
Women (n 5026) and men (n 4238) aged
35–54 years who participated in the Brazilian Longitudinal Study of
Adult Health (ELSA-Brasil) at baseline.
WHtR age-adjusted AUC ranged from 0·68 to 0·72 in men and
0·69 to 0·75 in women, with smaller AUC for
hypertriacylglycerolaemia and the largest for ≥2 MetS. WHtR performed
better than BMI for practically all outcomes; better than WHR for
hypertension in both sexes; and displayed larger AUC than WC in predicting
diabetes mellitus. It also offered better discriminatory power for ≥2
MetS in men; and was better than WC, but not WHR, in women. Optimal cut-off
points of WHtR were 0·55 (women) and 0·54 (men), but they
presented high false-negative rate compared with 0·50.
We recommend using WHtR (which performed similarly to, or better than, other
available indices of adiposity) as an anthropometric index with good
discriminatory power for cardiometabolic outcomes in Brazilian adults,
indicating the already referenced limit of WHtR≥0·50.
This study aims to explain the victory of Hugo Chávez and his party in the 2000 Venezuelan elections, to analyze the factors that made this victory possible, and to examine the consequences for future developments in the Venezuelan political system. The decay of traditional party loyalties without the emergence of new parties deeply rooted in society (dealignment without realignment); underdevelopment; and an institutional setting dominated by a president elected by a plurality electoral system have opened the door to personality-centered politics and weak parties, which are the main features of the current political situation. Compared to the 1993 and 1998 elections, the 2000 elections once again confirm an increase in personality politics and the decay of parties as instruments for articulating interests, representation, and governance. As a consequence, this article argues, instability is likely to remain a feature of Venezuela's party system for some time.
The 1946 election for Venezuela's National Constituent Assembly marked the beginning of democratic electoral processes and the modern party system in that country. Although interrupted by ten years of dictatorship (1948-1958), nine national elections for president and parliament have been held since 1946. In conjunction with these elections, the Venezuelan party system has passed through four stages: a predominant party system (1945-1948), a limited multiparty system (1958-1973), an attenuated two-party system (1973-1993), and recently, the return to a limited multiparty system (1993-) (Sartori 1976).
This work studied the effect of plasma treatment on the wettability of composite materials constituted of polyethylene glycol (PEG) and polyhydroxybutyrate (PHB) processed through the spin-coating and electrospinning techniques. For this purpose different polymeric solutions of PEG:PHB with proportions of 100:0, 80:20, 50:50, 20:80, and 0:100 were prepared. It found that the hydrophobicity of the as-prepared composite films processed by electrospinning was higher than those processed by spin-coating, using the same proportions of PEG:PHB. The electrospun samples with higher content of PHB (20:80 and 0:100) showed a surface morphology constituted by fibers of 1.7-1.9 μm in size. On the other hand, the electrospun samples processed with a lower content of PHB (100:0, 80:20, 50:50) did not form fibers and exhibited a rough surface. The subsequent plasma treatment with argon plasma of the electrospun samples produced a decrease in the contact angle, even in the samples with surface roughness. These contact angle values were similar to those obtained by spin-coating, or even lower, as in the case of the sample with PEG:PHB content of 20:80 in which the dip-coated film, the as-prepared membrane, and the plasma-treated membrane showed contact angles of 49°, 77.4°, and 0° (superhydrophilic) respectively.
To prospectively assess the associations between lean fish, fatty fish and total fish intakes and risk of stroke in the Spanish cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Spain).
Fish intake was estimated from a validated dietary questionnaire. Cox proportional hazards regression models were used to assess the association between the intakes of lean fish, fatty fish and total fish and stroke risk. Models were run separately for men and women.
Five Spanish regions (Asturias, San Sebastian, Navarra, Granada and Murcia).
Individuals (n 41 020; 15 490 men and 25 530 women) aged 20–69 years, recruited from 1992 to 1996 and followed-up until December 2008 (December 2006 in the case of Asturias). Only participants with definite incident stroke were considered as cases.
During a mean follow-up of 13·8 years, 674 strokes were identified and subsequently validated by record linkage with hospital discharge databases, primary-care records and regional mortality registries, comprising 531 ischaemic, seventy-nine haemorrhagic, forty-two subarachnoid and twenty-two unspecific strokes. After multiple adjustments, no significant associations were observed between lean fish, fatty fish and total fish consumption and the risk of stroke in men or women. In men, results revealed a non-significant trend towards an inverse association between lean fish (hazard ratio=0·84; 95 % CI 0·55, 1·29, Ptrend=0·06) and total fish consumption (hazard ratio=0·77; 95 % CI 0·51, 1·16, Ptrend=0·06) and risk of total stroke.
In the EPIC-Spain cohort, no association was found between lean fish, fatty fish and total fish consumption and risk of stroke.
Although dating violence takes place within the context of a couple, there are few studies exploring how the prevalence data change when violence is reported by one partner or both, and to what extent partners agree about the existence of violence. The aim of this study is therefore to analyze and compare the reports about the prevalence of violence obtained from participants and their partners, together with interpartner agreement concerning victimization and perpetration of threats, physical, verbal-emotional and sexual violence. A total of 105 young heterosexual couples answered a questionnaire about victimization and the perpetration of violence in their relationship during the previous year. The results indicated that prevalence rates varied, depending on who reported the violence -the man, the woman or the couple- perhaps because interpartner agreement was low, except for the occurrence of verbal-emotional violence and the absence of physical violence. These findings suggest the need to develop more systematic research, especially through the use of reports from both members of the couple.
Pattern analysis has emerged as a tool to depict the role of multiple nutrients/foods in relation to health outcomes. The present study aimed at extracting nutrient patterns with respect to breast cancer (BC) aetiology.
Nutrient patterns were derived with treelet transform (TT) and related to BC risk. TT was applied to twenty-three log-transformed nutrient densities from dietary questionnaires. Hazard ratios (HR) and 95 % confidence intervals computed using Cox proportional hazards models quantified the association between quintiles of nutrient pattern scores and risk of overall BC, and by hormonal receptor and menopausal status. Principal component analysis was applied for comparison.
The European Prospective Investigation into Cancer and Nutrition (EPIC).
Women (n 334 850) from the EPIC study.
The first TT component (TC1) highlighted a pattern rich in nutrients found in animal foods loading on cholesterol, protein, retinol, vitamins B12 and D, while the second TT component (TC2) reflected a diet rich in β-carotene, riboflavin, thiamin, vitamins C and B6, fibre, Fe, Ca, K, Mg, P and folate. While TC1 was not associated with BC risk, TC2 was inversely associated with BC risk overall (HRQ5 v. Q1=0·89, 95 % CI 0·83, 0·95, Ptrend<0·01) and showed a significantly lower risk in oestrogen receptor-positive (HRQ5 v. Q1=0·89, 95 % CI 0·81, 0·98, Ptrend=0·02) and progesterone receptor-positive tumours (HRQ5 v. Q1=0·87, 95 % CI 0·77, 0·98, Ptrend<0·01).
TT produces readily interpretable sparse components explaining similar amounts of variation as principal component analysis. Our results suggest that participants with a nutrient pattern high in micronutrients found in vegetables, fruits and cereals had a lower risk of BC.
I find it convenient to talk of a social field of this kind as a network. The image I have is of a set of points some of which are joined by lines. The points of the image are people, or sometimes groups, and the lines indicate which people interact with each other. We can of course think of the whole of social life as generating a network of this kind. (Barnes 1954)
This chapter describes the application of visualization strategies in the context of mixed methods studies. Network visualization is an excellent way to present relational data, and a valuable tool for collecting, exploring, and analyzing data. This chapter focuses mainly on the description of personal networks (Hollstein 2011) with examples of parallel designs. The main contribution for investigating social networks consists in the incorporation of network perceptions and interpretations made by participants in the analysis, which leads to a better understanding of how people are positioned within the social context.
Dietary guidelines are intended to prevent chronic diseases and obesity. The aim of the present study was to develop a diet quality index based on the Spanish Food Pyramid (SFP) and to further explore its association with obesity in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Granada study.
Cross–sectional study. The SFP score considered recommendations given for twelve food groups, and for physical activity and alcohol consumption. Obesity was defined as BMI over 30 kg/m2 and abdominal obesity as waist circumference larger than 102 cm (men) and 88 cm (women). Logistic regression was conducted to estimate odds ratios of obesity by quintiles and by 10-point increment in adherence to the score, controlling for potential confounders.
Participants (n 6717) aged 35–69 years (77 % women).
A 10-point increase in adherence to the SFP score was associated with a 14 % (OR=0·86; 95 % CI 0·79, 0·94) lower odds of obesity in men (P interaction by sex=0·02). The odds of abdominal obesity decreased globally by 12 % (OR=0·88; 95 % CI 0·84, 0·93) per 10-point increase in adherence to this score. The effect of higher adherence to the score on abdominal obesity was stronger in physically inactive men and women (ORper 10-point increase=0·79; 95 % CI 0·68, 0·92 and ORper 10-point increase=0·89; 95 % CI 0·84, 0·95, respectively).
These findings support that the Spanish dietary guidelines might be an effective tool for obesity prevention. However, prospective studies investigating this association are warranted.
Health-beneficial effects of adhering to a healthy Nordic diet index have been suggested. However, it has not been examined to what extent the included dietary components are exclusively related to the Nordic countries or if they are part of other European diets as well, suggesting a broader preventive potential. The present study describes the intake of seven a priori defined healthy food items (apples/pears, berries, cabbages, dark bread, shellfish, fish and root vegetables) across ten countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) and examines their consumption across Europe.
Cross-sectional study. A 24 h dietary recall was administered through a software program containing country-specific recipes. Sex-specific mean food intake was calculated for each centre/country, as well as percentage of overall food groups consumed as healthy Nordic food items. All analyses were weighted by day and season of data collection.
Multi-centre, European study.
Persons (n 36 970) aged 35–74 years, constituting a random sample of 519 978 EPIC participants.
The highest intakes of the included diet components were: cabbages and berries in Central Europe; apples/pears in Southern Europe; dark bread in Norway, Denmark and Greece; fish in Southern and Northern countries; shellfish in Spain; and root vegetables in Northern and Central Europe. Large inter-centre variation, however, existed in some countries.
Dark bread, root vegetables and fish are strongly related to a Nordic dietary tradition. Apples/pears, berries, cabbages, fish, shellfish and root vegetables are broadly consumed in Europe, and may thus be included in regional public health campaigns.