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In recent years, the GRADE system has been adopted internationally to make judgments about evidence and/or recommendations. Recently, the Spanish Network of HTA (RedETS) has promoted among its members the use of the GRADE system, especially the “Evidence to Decision” tool (EtD) where a multidisciplinary panel is involved. The objective is to describe the methodological approach with the first AQuAS experience using this methodology in HTA, focused on inclusion/exclusion of these technologies in the Spanish National Health Service (NHS) portfolio.
The standard EtD tool was used for clinical and financial decisions. Four multidisciplinary panels were constituted by relevant professionals in clinical practice and, where possible, patients. The four panels discussed on the following four interventions: in two cases, AQuAS prepared preliminary recommendations and participants provided feedback, while in the other two cases, experts received the evidence review and were asked to formulate recommendations. These recommendations were voted on and, in the case of disagreement, adapted and then voted on for a second time. Finally, any discrepancies were noted in the report. Evaluated interventions were: maxillofacial 3D-reconstruction, cataract surgery equipment, non-invasive surgery in obesity and pharmacological treatment in secondary fracture prevention.
Especially when more than one evaluative question was addressed in the HTA report the EtD and the consensus results required discussion. Consensus was fast but not immediate. Meeting length depended on the number of HTA questions and the amount of original disagreement in the recommendations. The nuances on how to write recommendations also affected the panel duration. All panels were successful in formulating the final recommendations.
Standardizing methodologies increased the homogeneity across HTA reports. The GRADE system is a feasible and useful tool because it favors transparency and rigor in drawing up recommendations on the inclusion/exclusion of technologies in the NHS portfolio. The EtD framework complements GRADE tables, which display the relevant evidence in a way that can be used by multidisciplinary groups to reach a consensual recommendation.
Although all participants received a short training video, more experience in the use of these methodologies might shorten the duration of the process and facilitate reaching consensus. Some considerations on how to overcome the difficulties and complexity of this methodological approach are discussed.
Pulses such as peas, beans or lentils are one of the most complete foods at the nutritional level; however, they are one of the most often neglected foods in the diets of university students. Entrance to university translates into a major lifestyle change for many young people, and the habits acquired or cemented at this time will remain into adulthood. The objective of this study is to analyse the association between personal/sociodemographic factors, dietary intake of other food groups and the consumption of pulses in first-year university students. This cross-sectional study is part of the UniHcos project, a multicentre study of multipurpose prospective cohorts in eleven Spanish universities. Data from 9862 university students were collected through an online self-questionnaire completed by all students who met the selection criteria and agreed to participate in the project during the 2011–2018 academic years. Of students, 75·8 % presented an inadequate (≤2 times/week) consumption of pulses. Living outside the family home in either a student residence (OR 0·76; 95 % CI 0·69, 0·84) or rental (OR 0·81; 95 % CI 0·70, 0·95) decreased the compliance with recommendations on the consumption of pulses. Low consumption of pulses is seemingly not restricted to a specific profile or dietary pattern among university students, and no specific focus group for intervention can be identified. Policies promoting the consumption of pulses among the university population as a whole are necessary to increase compliance rates with the dietary recommendations.
The objective was to evaluate maternal Mediterranean diet (MD) pattern adherence during pregnancy and its association with small for gestational age (SGA) and preterm birth. A secondary objective of the current study was to describe the sociodemographic, lifestyle and obstetric profile of the mothers studied as well as the most relevant paternal and newborn characteristics.
The current study is a two-phase retrospective population-based study of maternal dietary habits during pregnancy and their effect on newborn size and prematurity. The descriptive first phase examined maternal dietary habits during pregnancy along with the maternal sociodemographic, lifestyle and obstetric profile in a cross-sectional period study. In the second phase, newborn outcomes were evaluated in a nested case–control study. Adherence to MD during pregnancy was measured with the Spanish version of Kidmed index.
Obstetrics ward of the La Fe Hospital in Valencia.
All mother–child pairs admitted after delivery during a 12-month period starting from January 2018 were assessed for eligibility. A total of 1118 provided complete outcome data after signing informed consent.
14·5 % met the criteria of poor adherence (PA); 34·8 %, medium adherence (MA); and 50·7 %, optimal adherence (OA). Medium adherence to MD was associated in the adjusted scenarios with a higher risk of giving birth to a preterm newborn. No association was found between MD adherence and SGA.
Early intervention programmes geared towards pregnant women, where women were aided in reaching OA to MD, might reduce the risk of preterm newborn.
The increasing prevalence of overweight and obesity has developed into an epidemic public health problem worldwide. In this regard, in the last years several investigations have suggested that water intake and water balance could have important implications for both weight management and body composition. The aim of this study was to analyse the association between fluid intake, water balance and body composition in a sample of healthy young adults from Spain.
Material and methods
A total of 358 healthy subjects (121 males; 237 females) aged 18–39 years participated in the current study. The validated questionnaire entitled “The hydration status questionnaire” was used to assess fluid intake, elimination, and water balance. Anthropometric measurements (height, weight and waist circumference) were performed according to the recommendations of the International Standards for Anthropometric Assessment (ISAK). The estimates of total body water (TBW), fat mass (FM) and fat free mass (FFM) were acquired by bioelectrical bioimpedance analysis. Physical activity was estimated through the Short form of the International Physical Activity Questionnaire (IPAQ-SF). Differences in anthropometric and body composition variables were assessed through the ANOVA test and considered significant at p < 0.05.
Fluid intake was correlated with body water content in females (r = 0.180, p = 0.006) and males (r = 0.266, p = 0.003). An inverse association between water consumption per weight (ml/kg) with body weight (females (f): r = -0.318, p = 0.000; males (m): r = -0.220, p = 0.015), body fat mass (f: r = -0.320, p = 0.000; m: r = -0.200, p = 0.028), and waist circumference (f: r = -0.237, p = 0.000; m: r = -0.215, p = 0.018) was found. Finally, significant differences in body water content in females according to water balance were observed (p = 0.04).
Higher fluid intake seems to be related with a better body composition, therefore the improvement of water intake and water balance could be useful in weight management and in the prevention of overweight and obesity in healthy young adults.
Age-related hearing loss (ARHL) is a sensory impairment, with a dramatic increase in its incidence, which is caused by genetic and environmental factors such as noise and ototoxic drugs. Recent studies correlated ARHL to elevated plasma homocysteine (Hcy) by folate deficiency, suggesting that reduction of Hcy levels by folate supplementation could potentially ameliorate ARHL.
Hyperhomocysteinemia (HHcy), a status that contributes to ARHL, may also arise from malfunction of Hcy remethylation by betaine homocysteine S-methyltransferases (BHMTs) and methionine synthase in the methionine cycle. The expression and/or activity of these enzymes may be altered by ototoxic drugs, including paracetamol (APAP).
To determine the effect of APAP in cochlear morphology and function of control and Bhmt-/- mice, and to analyze putative preventive effects of folic acid (FA) supplementation.
Materials and Methods
Two-month-old Bhmt-/- mice (n = 47), with greater dependence on folate metabolism for Hcy remethylation, and Bhmt + / + mice (n = 42) were fed control or FA supplemented diets for 30 days. The last day APAP (250 mg/kg) or placebo were injected intraperitoneally.
Hearing was evaluated by recording auditory brainstem responses (ABR) at the beginning of the experiment and after treatments. Picrosirius red staining was used for evaluation of the cochlear lateral wall cytoarchitecture. Plasma and hepatic metabolite levels were determined by HPLC or on Spinlab 100® autoanalyzer.
Loss of Bhmt expression induced HHcy, but an impact on hearing acuity was not observed. Acute APAP administration did not induce ABR threshold shifts. However, following ototoxic treatment, changes of 5–17% in the areas of the stria vascularis and spiral ligament were detected between Bhmt-/- mice under different dietary treatments; cochlear structures of Bhmt-/- mice receiving APAP plus FA supplementation resemble those of the control group. APAP increases susceptibility to ototoxic damage in the presence of HHcy.
BHMT plays a central role in cochlear methionine metabolism. FA supplementation modulates Hcy levels, contributing to a proper remethylation status that prevents ARHL.
To assess weight status and eating habits of undergraduate university students in relation to gender and examine the relationships between weight status, physical activity and eating habits.
Cross-sectional study conducted between October 2016 and May 2017.
Young adults in Midwest Brazil.
Undergraduate university students (n 2163) majoring in health care.
Among 2163 students, 69·3 % were female, 65·4 % were aged 20–29 years, 66·8% consumed alcohol and 44·2% did not achieve more than 150 min of physical activity per week. We found significant differences in the consumption of beans (P < 0·04) and full-fat milk (P < 0·01) between women and men. Women also had more sedentary lifestyles (P < 0·01) and showed higher prevalence of overweight (33·8 %) and obesity (5·0 %) than men. Students who did not engage in physical activity were more overweight (P = 0·03), consumed more soft drinks (P < 0·01) and meat with excess fat (P = 0·01). There was a positive association between weight status and fruit (P = 0·02), salad (P < 0·01), greens/vegetables (P < 0·01) and beans (P < 0·01) intake.
The low level of physical activity and unhealthy eating patterns reported by the study participants were inconsistent with the national recommendations for a healthy active lifestyle for adults and may contribute to the increasing rate of overweight and obesity in this population. A joint effort between universities and all relevant government agencies is needed to develop and promote school- and community-based interventions.
In the past decades the community-based participatory research method known as PhotoVoice has gained relevance, but there are few published studies on its application in the field of health technology assessment (HTA) and clinical practice guidelines (CPGs). The aim of this presentation was to describe a PhotoVoice project linked to a CPG on major depression in children and adolescents.
The design of the study was adapted to the main objective, which was to enhance the understanding of major depression and improve clinical practice with the contributions of clinicians, methodologists, and patients. Seven adolescents and ten of their family members participated in the study through PhotoVoice sessions and focus groups. The audio recordings of all sessions were transcribed verbatim and coded, and a thematic analysis was undertaken.
Six themes emerged: (i) a lack of understanding and information about depression in childhood and adolescence; (ii) the importance of support groups; (iii) the need to favor early care and access to services; (iv) the adaptation of therapeutic strategies tailored to individual needs; (v) the sensitivity of professionals; and (vi) fostering interaction between the health and education systems. Photographic exhibitions were planned to share the main results. These exhibitions were promoted to increase public awareness and reduce stigmatization, and to reach clinicians and policy makers. From a methodological point of view, the use of PhotoVoice in this study helped to effectively incorporate the lived experiences, concerns, and preferences of patients and their relatives into the CPG. The study also confirmed the value of photographs and participatory methods. The main limitations and strengths of the study, as well as suggestions for future research, are also outlined.
PhotoVoice is a flexible, effective, and innovative method of obtaining information about patients’ perspectives and experiences, and it offers the added value of being able to reach the main stakeholders, including policymakers and the public.
The specificities of non-pharmaceuticals can require adapting classical health technology assessment (HTA) methodologies and developing additional regional approaches to support decision-making processes. However, little information exists regarding the explicit approaches used in different countries. The aim of this work is to provide an overview of the role and activities of the Galician HTA agency (avalia-t, Spain) regarding assessment, appraisal and continued evaluation across the whole life cycle of non-pharmaceutical technologies.
In depth review and analysis of the activities undertaken by avalia-t during the past five years to support the introduction and appropriate use of non-pharmaceutical health care technologies at the regional level.
A multidisciplinary Commission judges the added value of new non-pharmaceuticals and establishes the indications and conditions for use. HTAs, which are mandatory for all relevant technologies, rely on the best available evidence on safety and effectiveness but also provide fit for purpose contextualized information based on organizational data and administrative registers. Interaction with multidisciplinary stakeholders is commonly needed to complement the evidence base (ad hoc working groups, face to face discussions), and post-launch studies can be implemented to analyze the utilization and results in real world practice. Performance indicators and other HTA based products can also be required to ensure the quality of health care (e.g., appropriate use indications, quality indicators, evidence based patient information). In addition, technical and scientific advice/support can be provided at different decision levels of the health organization to promote the quality of care and appropriate use of technologies (e.g., regional mental health program, suicide management strategy, bariatric surgery surveillance registry).
Rigorous, comprehensive and systematic processes for supporting non-pharmaceutical technology adoption and implementation are required. Although it is acknowledged that core information does not differ substantially within countries, contextualized information is recognized as essential for establishing the conditions for use at the regional level.
Decision making regarding national population-based prenatal and newborn screening policies is recognized to be highly challenging. This paper aims to describe the formalized collaboration that has been established between the Spanish National Public Health Screening Advisory Committee (PHSAC) and the Spanish Network of Health Technology Assessment (HTA) agencies to support the development of evidence- and consensus-based recommendations to support this process.
In-depth description and analysis of the strategic and methodological processes that have been implemented within the Spanish National Health System prenatal and newborn screening frameworks, with special emphasis on the role, actions, and responsibilities of HTA agencies.
The role of HTA agencies is threefold: (i) support the PHSAC by providing evidence on safety, effectiveness and cost/effectiveness of the screening tests/strategies, as well as contextualized information regarding costs, organizational, social, legal and ethical issues; (ii) collaborate with the PHSAC in the development of formal evidence- and consensus-based recommendations for defining population screening programs, when required; (iii) analyze real-world data that is generated by piloted programs. This paper will provide real-life examples of how these processes were implemented in practice, with a special focus on the development of the non-invasive prenatal testing (NIPT) policy. Recommendations for NIPT were developed by a multidisciplinary group based on the European network for Health Technology Assessment (EUnetHTA) rapid assessment report and the predictive models that were built using national statistics and other contextualized data.
The current work represents an innovative approach for prenatal and newborn screening policymaking, which are commonly difficult to evaluate due to the low quality of evidence and the confounding public health issues. The paper raises awareness regarding the importance of joint collaborations in areas where evidence is commonly insufficient for decision making.
To assess the daily intake of polychlorinated biphenyls not similar to dioxins (NDL-PCB) derived from fish consumption in Spain and compare it with tolerance limits in order to establish a safe threshold so that the nutritional benefits derived from fish consumption may be optimized.
Analysis of NDL-PCB in fish samples and ecological study of the estimated intake of NDL-PCB from fish consumption in different Spanish population groups.
National representative sample of the Spanish population.
The intake of NDL-PCB was estimated in two different scenarios: upper bound (UB) and lower bound (LB). Estimating intake using the average concentration of NDL-PCB found in the fish samples, the intake for ‘other children’ is estimated as: 1·80 (UB) and 5·33 (LB) ng/kg per d at the 50th percentile (P50); 7·39 (UB) and 21·94 (LB) ng/kg per d at the 95th percentile (P95) of fish consumption. Estimated NDL-PCB intake shoots up in the toddler group, reaching values of 30·43 (UB) and 90·37 (LB) ng/kg per d at P95. Estimated intake values are lower than those previously estimated in Europe, something expected since in previous studies intake was estimated through total diet. In adults, our estimated values are 1·59 (UB) and 4·72 (LB) ng/kg per d at P50; 4·95 (UB) and 14·72 (LB) ng/kg per d at P95.
NDL-PCB concentration in fish is under the tolerance limits in most samples. However, daily intake in consumers of large quantities of fish should be monitored and special attention should be given to the youngest age groups due to their special vulnerability and higher exposure.
Tsangpoite, ideally Ca5(PO4)2(SiO4), the hexagonal polymorph of silicocarnotite, and matyhite, ideally Ca9(Ca0.5□0.5)Fe(PO4)7, the Fe-analogue of Ca-merrillite, were identified from the D'Orbigny angrite meteorite by electron probe microanalysis, electron microscopy and micro-Raman spectroscopy. On the basis of electron diffraction, the symmetry of tsangpoite was shown to be hexagonal, P63/m or P63, with a = 9.489(4) Å, c = 6.991(6) Å, V = 545.1(6) Å3 and Z = 2 for 12 oxygen atoms per formula unit, and that of matyhite was shown to be trigonal, R3c, with a = 10.456 (7) Å, c = 37.408(34) Å, V = 3541.6 (4.8) Å3 and Z = 6 for 28 oxygen atoms per formula unit. On the basis of their constant association with the grain-boundary assemblage: Fe sulfide + ulvöspinel + Al–Ti-bearing hedenbergite + fayalite–kirschsteinite intergrowth, the formation of tsangpoite and matyhite, along with kuratite (the Fe-analogue of rhönite), can be readily rationalised as crystallisation from residue magmas at the final stage of the D'Orbigny meteorite formation. Alternatively, the close petrographic relations between tsangpoite/matyhite and the resorbed Fe sulfide rimmed by fayalite + kirschsteinite symplectite, such as the nucleation of tsangpoite in association with magnetite ± other phases within Fe sulfide and the common outward growth of needle-like tsangpoite or plate-like matyhite from the fayalite–kirschsteinite symplectic rim of Fe sulfide into hedenbergite, infer that these new minerals and the grain-boundary assemblage might represent metasomatic products resulting from reactions between an intruding metasomatic agent and the porous olivine–plagioclase plate + fayalite-kirschsteinite overgrowth + augite + Fe sulfide aggregates. Still further thermochemical and kinetics evidence is required to clarify the exact formation mechanisms/conditions of the euhedral tsangpoite, matyhite and kuratite at the grain boundary of the D'Orbigny angrite.
To study the association of meal patterns and timing with central obesity to identify the best dietary strategies to deal with the increasing obesity prevalence.
A cross-sectional study performed on data from a representative sample of the Spanish population. Height and waist circumference were measured using standardized procedures and waist-to-height ratio (WHtR) was calculated. The sample was divided into those without central obesity (WHtR<0·5) and those with central obesity (WHtR≥0·5).
ANIBES (‘Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles in Spain’) Study.
Adults aged 18–64 years (n 1655; 798 men and 857 women).
A higher percentage of people ate more than four meals daily in the group without central obesity and those with central obesity more frequently skipped the mid-afternoon snack than those without. Breakfasts containing >25 % of total energy intake and lunches containing >35 % of total energy intake were associated with increased likelihood of central obesity (OR=1·874, 95 % CI 1·019, 3·448; P<0·05 and OR=1·693, 95 % CI 1·264, 2·268; P<0·001, respectively). On the contrary, mid-morning snacks and mid-afternoon snacks containing >15 % of total energy were associated with decreased likelihood of central obesity (OR=0·477, 95 % CI 0·313, 0·727; P<0·001 and OR=0·650, 95 % CI 0·453, 0·932; P<0·05, respectively). The variety of cereals, wholegrain cereals and dairy was higher in the population without central obesity.
Our results suggest that ‘what and when we eat’ should be considered dietary strategies to reduce central obesity.
The worldwide cultivation of fig (Ficus carica L.) has achieved great economic importance, mainly, due to its important role as a food supplement. This situation has generated great interest in researching its methods of production, processing and conservation. The objective of this research was to evaluate six intensive production systems of fig in hydroponic and greenhouse conditions. The experimental phase started on November 15, 2010 and was completed in September 2011. Production systems were established by varying the number of productive stems between three and eight in each plant, with densities of 1.25 plants m−2. A completely experimental – randomized design was used with five replications, with a pot and a plant as an experimental unit. The results indicate that the highest yielding of fresh fruit was presented by eight productive stems (109.5 t ha−1), this one outperformed the seven productive stems (94.8 t ha−1) in 13.3% and six productive stems (78.6 t ha−1), at 26.8%. The handling of productive stems allowed an increase in the leaf area index, harvest index and fruit yielding. These results suggest that intensive production in hydroponic and greenhouse conditions of fig is an excellent alternative production, allowing to collect up to 20 times of fresh fruit yielding in relation to the plantations in the open field.
The diet and the feeding habits of the common dolphinfish (Coryphaena hippurus) in the Pacific coast of Ecuador was assessed by examining 320 stomachs of individuals ranging from 51 to 149 cm in total length. Fish was the predominant prey group in the diet (Alimentary Index, %AI = 95.39) followed by cephalopods (%AI = 4.13) and crustaceans (%AI = 0.48). Among the 17 prey items that make up the dolphinfish diet, the Exocoetidae family was the most important prey (%AI = 57.13), Dosidicus gigas being the most abundant invertebrate species (%AI = 7.65). Feeding patterns were evaluated using the graphing method of Amundsen, which suggested that this species shows a varying degree of specialization on different prey taxa. Thus, while some species were unimportant and rare (Hippocampus hippocampus, Lagocephalus lagocephalus, Gobiidae and Argonauta sp.), several dolphinfishes showed a high degree of specialization on Scombridae, Pleuroncodes planipes, Portunus xantusii and Opisthonema libertate. Size-related and temporal shifts in dietary composition were investigated by PERMANOVA analysis, which showed wide variations among size classes and periods of capture. The results of this study indicate that the common dolphinfish is an opportunistic feeder, which is capable of consuming a wide variety of schooling epipelagic organisms.
Polymer-clay nanocomposites are compounds in which nanoclay particles are distributed in a polymer matrix. Epoxy-clay nanocomposites have become a very interesting topic among researchers in the past two decades because nanoclays have a positive effect on the mechanical, thermal and especially barrier anticorrosive performance of the polymers. In this study, epoxy-montmorillonite organoclay (OMMT) nanocomposite coatings were prepared and deposited on carbon steel substrates. The coatings were prepared through in situ polymerization and by UV-curing technique. The OMMT was added to epoxy resin at loadings between 0 wt.% and 5 wt.%, the particles of OMMT were dispersed using forced agitation-sonication and deposited on carbon steel coupons. The nanocomposite coatings obtained have been characterized by scanning electron microscopy (SEM), spectroscopy Fourier transform infrared (FTIR), X-ray diffraction (XRD), thermogravimetric analysis (TGA), and evaluated their corrosion protection effect on cold rolled carbon steel coupons by performing visual analysis. The X-ray analysis showed that exfoliation occurred for the OMMT in the polymer matrix, the SEM analysis showed that OMMT was homogenous dispersed in the polymer matrix and the coatings were uniform. The FTIR analysis showed the characteristic bands of epoxy resin and OMMT in the composite. The results showed that 1 wt.% OMMT coating exhibit better anticorrosive properties than pure epoxy.
To assess the potential contribution of foods fortified with folic acid (FA) to target population intakes when included as part of a healthy breakfast.
Breakfast models aligned with the Spanish Dietary Guidelines were studied using the recommended, average and 95th percentile of serving sizes consumed by women of childbearing age. Food composition data were obtained from a database including FA analytical data from sixty-eight products and the Spanish food composition tables. Different scenarios were assessed with the inclusion of one, two or three FA-fortified products and with two different fortification levels: ≤33 µg/serving (L1) and ≥70 µg/serving (L4). FA contents provided by the different models for each scenario were compared with the Recommended Nutrient Intake (RNI) for folate and the Upper Level (UL) of intake for FA.
Madrid Region, Spain.
Women aged 16–49 years were considered.
Overall, simulation of ten breakfast models and three scenarios of product inclusion accounted for 20–25 % of total daily energy recommendations for women. Unfortified breakfast models provided on average 4–23 % of the folate RNI. Inclusion of one L4 FA-fortified food contributed 20–60 % of the RNI. Fortified yoghurt and milk had the highest FA contents per serving. Scenarios with two or three fortified products delivered 40–80 % of the RNI. None of the evaluated models exceeded the FA UL.
At existing levels of FA fortification, inclusion of fortified products as part of a regular breakfast meal could positively impact the nutritional quality of women’s diet without involving a risk of excessive FA exposure.
To date, it is unclear whether chemical order (or disorder) is in any way connected to double exchange, electronic phase separation, or charge ordering (CO) in manganites. In this work, we carry out an atomic resolution study of the colossal magnetoresistant manganite La2−2xSr1+2xMn2O7 (LSMO). We combine aberration-corrected electron microscopy and spectroscopy with spectroscopic image simulations, to analyze cation ordering at the atomic scale in real space in a number of LSMO single crystals. We compare three different compositions within the phase diagram: a ferromagnetic metallic material (x=0.36), an insulating, antiferromagnetic charge ordered (AF-CO) compound (x=0.5), which also exhibits orbital ordering, and an additional AF sample (x=0.56). Detailed image simulations are essential to accurately quantify the degree of chemical ordering of these samples. We find a significant degree of long-range chemical ordering in all cases, which increases in the AF-CO range. However, the degree of ordering is never complete nor can it explain the strongly correlated underlying ordering phenomena. Our results show that chemical ordering over distinct crystallographic sites is not needed for electronic ordering phenomena to appear in manganites, and cannot by itself explain the complex electronic behavior of LSMO.