PREVENTIVE MEDICINE (2)

Author: PEREIRÓ BERENGUER INMACULADA.
Year: 2004.
University: VALENCIA [www.uv.es].
Place of defense: FACULTAD DE MEDICINA Y ODONTOLOGÍA.
Place of preparation: FACULTAD DE MEDICINA Y ODONTOLOGÍA.

Summary: The purpose of due describe the epidemiology, prevention and risk factors for invasive disease caused by H. influenzae, N.meningitidis and S.pneumoniae in children under 15 years, diagnosed in all hospitals in the public network in the Community Valencia in a period of three years. We used a prospective epidemiological surveillance system and an active case-control study. In the first year of study the incidence of invasive Hib disease was 15.5 casos/100.000 children under 5 years. During the period 1995-1998 the incidence rate of meningitis was 11.3 / 1000,000 children less than two years with 16.8 cases. What serótipos 19.14 and 6 accounted for 83%. Immunization coverage frete to Hib, prior to joining the calendar vaccine in children two years, was 32.5 in the first year of the study, 44.1 in 1997 and 59.8 in 1998. The effectiveness of vaccination was not systematic of 71% in 1997. After the campaign of immunization against meningitis C vaccine through polysaccharide in 1997, the incidence rate decreased from 5.4 casos/1000.000 children under 15 years old in the year 1997 to 1.4 in 1998. Exposure to snuff, cohabiting and overcrowding are risk factors for invasive disease suffer meningitis and Hib. Having siblings under 15 years old in children under one year and go to kindergarten in under two years represent a risk to suffer from invasive pneumococcal disease.

Author: GUTIERREZ MONTERO CAROLINA.
Year: 2004.
University: AUTÓNOMA DE MADRID [www.uam.es].
Place of defense: UNIVERSIDAD AUTONOMA DE MADRID.
Place of preparation: HOSPITAL UNIVERSITARIO RAMON Y CAJAL.

Summary: According to the work carried out so far, PTO can see drug sensitivity diminished by the presence of three groups mutacionales, K65R, NAMs and the complex multidrug resistance (Q151M and ins69). In recent years we have witnessed an increase in the selection of K65R, but without achieving very high rates, attributed to the increased use of PTO, but the mutation can be selected by other antiretroviral agents as abacavir and didanosine. It has been evaluated in several studies, both in patients naà ¯ ve (patients who had not previously received antiretroviral therapy), and in patients pretreated selection of K65R following administration of PTO and the data show a greater selection, but not significant in the case of patients naà ¯ ve receiving PTO compared to those receiving stavudine (2.7% vs.. 0.7%). In the case of patients pretreated unclear contribution from the rest of drugs and receiving patients had received previously, which included didanosine and abacavir, and that might be influencing the selection of K65R. The development of NAMs after treatment with TDF was also evaluated in several studies. We saw that the virological response was diminished by the presence of these mutations, but needed at least three NAMs to include the M41L and L210W. Importantly, as previous studies showing a selection favorable NAMs face K65R. Something that also seemed to gain importance was not the coexistence of NAMs along with the K65R, apparently because of structural problems in the IT enzyme. The presence of pre NAMs, generally associated with treatment with thymidine analogues, did not develop K65R, that suggested two possible mechanisms of resistance to TDF mid through the NAMs or route of K65R, and did consider whether it was better to the selection of a type of mutation or other. The selection of K65R could therefore be due to PTO, but we could not forget the selection of the same combinations containing didanosine or abacavir. It remains the subject of debate the impact of the K65R following the selection of the same by any of these drugs, namely whether it can be considered a multidrug resistance mutation affecting all nucleoside analogues / nucleotide to a greater or lesser extent, as the NAMs or whether on the contrary it mainly affects PTO, and a moderate decrease of the sensitivity of the rest of the nucleoside analogues / nucleotide. With these data we ask prior to carry out our study with the following objectives: 1-Evaluar mechanisms of resistance to TDF mediated different sets mutacionales (K65R, NAMs and complex multidrug resistance). 2-To assess the frequency, description and epidemiology of K65R in a cohort of patients followed in the search for Infectious Diseases Hospital Ramon y Cajal in Madrid and describe changes in the epidemiology of mutation in the period 1996-primer half of year 2004. 3-To evaluate the involvement of various ITIAN, especially didanosine, abacavir and tenofovir in different combinations, in the selection of K65R. 4-Analyze the impact of changing from the standpoint of virologic response and the genotype / fenotipo-virtual of patients collected in two hospitals Spanish and presenting K65R. The conclusions obtained according to the results found, were as follows: 1. The K65R is rare. In our study represents only 1% of the resistance mutations to nucleoside analogues / nucleotide. Only about 2% of all genotypes registered since 1996 8 up and a81 he first semester of the year 2004 had the mutation. 2. The K65R mutation is not associated with other major resistance mutations in the gene for reverse transcriptase (RT), except with the M184V mutations and alterations in some positions polymorphic. Particularly striking is the antagonism between the selection of K65R and NAMs. 3. Tenofovir has a significantly greater ability to select the K65R that abacavir or didanosine. We have not found evidence that the mutation can be selected by a thymidine analogue (AZT or D4T). 4. The combination of three nucleoside analogues / nucleotide, which are present tenofovir, abacavir and didanosine, followed by those in which two of them are present, the combinations are at higher risk for the selection of K65R. 5. We have not found differences in the selection of K65R between regimes that are present in the tenofovir, or abacavir, didanosine and including a ITINAN or a PI. 6. Our data confirm the protective role of thymidine analogues (AZT and / or D4T) in the selection of K65R when they are present in those combinations which also include tenofovir, or abacavir, didanosine. 7. Studies Fenotipo-Virtual of isolates with the K65R showed only a modest decrease in the sensitivity to didanosine, or tenofovir abacavir. 8. In most patients who have been selected K65R gives a good virological response with conventional combinations with a PI or ITINAN despite the inclusion in the same didanosine, tenofovir or abacavir. 9. Besides K65R after virologic failure with the PTO, two other patterns can be detected mutacionales. Mutations of resistance to nucleoside analogues (NAMs) with the presence of at least mutations M41L and L210W, with the pattern mutacional (M41L, D67N, L210W and T215Y) observed mainly, and to a lesser extent by other sets mutacionales.

Author: DIAZ MORENO VERÓNICA.
Year: 2004.
University: SEVILLA [www.us.es].
Place of defense: FACULTAD DE MEDICINA.
Place of preparation: FACULTAD DE MEDICINA.

Summary: Despite the good level of control achieved and the growing awareness of health personnel, nosocomial infections remain a significant problem in hospitals Spaniards. This is due to many factors, including the increased frequency of patients with high susceptibility to infections, increased complexity in interventions and performing invasive procedures and the problem of antibiotic resistant organisms. According to the results of the Study of the Prevalence of Infection Nosocomiales in Spain (EPINE), the annual prevalence data during the study period 1990-2002 tended to decrease, but since 1995 is not experiencing a significant reduction. It is also a fact that there are major differences between a hospital and another, and specifically, within each hospital services, as the type of patient affects their susceptibility and the kind of aggressive procedures, antibiotics and therapies inmunodepresoras received. By focussing on Intensive Care Units, the occurrence of one or more hospital-acquired infections is one of the most serious complications to the patient faced severe entering a Intensive Care Unit (ICU). These critics patients admitted UCIs are characterized by a high propensity to acquire infections. This is mainly due to the aggressiveness of the disease that motivates their income, and multiple therapeutic assault, as well as microbial ecology and the physical characteristics and working in the UCIs. At times, this problem becomes the most important, possibly decisive influence on the prognosis of these patients, resulting in turn in a substantial increase in mortality, and lodging costs directly attributable to these infections. According to the survey results EPINE, infections are increasing their frequency in Intensive Care Units according to the study EPINE are respiratory addition, the infection has increased over time in a meaningful way. The second most common infection bacteremia was also an increase in successive studies EPINE. Overall, urinary tract infection was the first type of infection, but they have been losing this post, the reduced significantly. Finally, surgical infections have declined significantly, which certainly is related to the improvement in the prophylaxis perioeratoria. And this not only in Spain, internationally there has been a progressive increase in the incidence of nosocomial sepsis home in recent years. This increase is of utmost importance in UCIS, and it involves a number of factors: 1 - The change in the type, number and severity of underlying diseases in patients critics. 2 - The largest number of immunocompromised patients and the use of immunosuppressive drugs. 3 - The age progressively higher with entering these patients. 4 - The intense use of both maneuvers invasive diagnostic as therapeutic. 5 - The antibiotic exerted strong pressure on the microbial ecology of the Units. 6 - The use of special technical means which allow prolong the clinical course of some diseases. IMPORTANCE OF AGENTS CAUSALES The Gram negative bacilli aerobic microorganisms have been isolated more frequently in nosocomial bacteremia, making up 52% of microorganisms isolated from blood. The importance of Gram negative bacteria infections is the frequent development of resistance to multiple antimicrobials and their propensity to grow in contaminated products and solutions. ACINETOBACTER BAUMANNII Focusing on Acinetobacter Baumann 8 i, gé 1ff8 nero Acinetobacter consists of Gram negative bacilli, strictly aerobic, immobile, catalase positive, oxidase negative, and most importantly, widely distributed in nature. Despite that Acinetobacter possesses virulence factors as capsular polysaccharides, endotoxins, or fimbrias favoring his grip, his ability pathogenic depends critically on the characteristics of the infected host and character of nosocomial multidrug microorganism. The key features of nosocomial infections by Acinetobacter spp.son: 1 - The frequent involvement of critically ill patients, especially those with mechanical ventilation. The prognosis of these patients with bacteremia by Acinetobacter seems to depend on their basal conditions. 2-Their frequency resistance to multiple antibiotics, so what treatment options are often limited. 3 - Since this is so ubiquitous microorganism, assumes great importance pollution of the environment of the patient, creating a special reservoir for the transmission paciente-paciente, which act as a vehicle transmitter's own medical staff or medical equipment. In recent years have described a dramatic increase in the rate of infections caused by Acinetobacter in the UCIs, all with pathogens resistant to most commonly used antibiotics. The Acinetobacter baumannii infections have been associated with a high death rate, prolonged hospital stays. Although nosocomial bacteremia caused by strains of multidrug-resistant Acinetobacter baumannii apparently have a significant impact on the UCIs, their relationship with increased hospital stay, extra costs, and mortality from these infections in critically ill patients is still unknown. Therefore, the greatest impact, the potentially more serious consequences of the emergence of a bacteremic sepsis, and the added difficulties in dealing with them, makes this population of patients is of great interest for the development of a model to predict appropriate forms of the emergence of a bacteremia. SCENARIO 1, - bacteremia acquired during the stay of patients in intensive care units are a risk factor for mortality independent of other factors. 2 - The mortality bacteremia caused by Acinetobacter baumannii is greater than that of other bacteremia. 3 - The primary bacteremia constitute a risk factor for mortality among patients admitted to intensive care units independent of other factors. 4 - The bacteremia acquired during the stay of patients in Intensive Care Units causing an undue extension of stay and cost. 5 - The Acinetobacter baumannii bacteremia caused by an excess of generating and lodging costs that exceed those of bacteremia caused by other microorganisms. 6 - The primary bacteremia acquired during the stay of patients in Intensive Care Units causing an undue extension of stay and cost. SURVEY METHODOLOGY OF SCOPE OF THE STUDY This study has been carried out in the ICU of General Hospital and ICU of Orthopedics and Rehabilitation Hospital of University Hospitals complex Virgen del Rocio. The ICU General Hospital is a multipurpose unit médico which has 40 beds, which admitted patients with medical and surgical problems, except in the latter case, patients whose source of income is an injury or a problem Neurosurgical , where more than 1,800 patients are admitted each year, with a hospital stay half of 8.5 days. The ICU Hospital Orthopedics and Rehabilitation is a unit of 22 beds which receives patients with multiple trauma patients and for the recovery of neurosurgical procedures. More than 1,000 patients admitted each year with a hospital stay half of 5.5 days. DESIGN OF THE STUDY To verify the hypothesis proposals have been designed a cohort study nested in the prospective cohort study, with a matching each case of bacteremia (exposed) with a control (unexposed), ie matching 1:1 . In this design, the presence or absence of bacteremia is the independent variable (risk factor, variable exposure) and death and hospital stays are the dependent variables (outcomes). CALCULATING THE SAMPLE SIZE To calculate the size of the sample has been taken into account and the design matched the various subgroups who wished to study: all bacteremia, bacteremia by Acinetobacter baumanni and bacteremia primaries. The election outcome was the death of the participants, and for the calculations of the sample sizes (number of pairs required) were used in each case the results of mortality carried out in UCIs where he had spent the design matched. It was a calculation based on the worst situations, ie requiring more partners and these situations were: 1, alpha-An error of less than 5%, 2-Two tails ( 'two sided') 3, - A power of the study of 90%, 4-A difference between proporicones of 15%, 5-A percentage of discordant pairs of 30-40% These requirements required a minimum sample size of 129 or 178 pairs (depending on the percentage of discordant pairs) PARTICIPANTS Participants were defined as all patients admitted in both UCIs during the study period and were at risk of presenting a nosocomial bacteremia. IDENTIFICATION OF CASES were defined as cases of bateriemia those patients with one or more blood cultures positive for at least 72 hours after admission to one of the UCIs and that the blood was associated with clinical signs of sepsis. We excluded bacteremia related to an infection acquired fuer of the ICU. In those cases where the patient had more than one episode of nosocomial bacteremia, or more than one entry, only the first episode was seen. SELECTION OF CONTROLS AND CRITERIA EMPAREJAMIENTO was defined to a non-exposed to bacteremia as a patient during his stay in hospital had not presented evidence of suffering from a bacteremia. Arbitrariamente they were called by the term controls. The controls were selected according to the following criteria pairing: 1-Income in the same ICU during the same period of the study the case. 2-Age (+-5 years) 3-Sex 4-APACHE II score at the time of admission to the ICU (+-5 points) 5-Diagnosis primary income (based on the 9Â th Revision the International Classification of Diseases). 6-surgical procedure (encoded by 9Â th Revision of the International Classification of Diseases) 7-patient stay at least equal to the interval from him entry to the onset of bacteremia in cases (+ -10%) to insure the same duration of exposure. The list of potential checks was revised to make the best possible match, and those situations in which several controls were acceptable only one with the APACHE II score and age closer to the patient's case was selected. DEFINITIONS The primary bacteremia was defined as one for which there is no recognized source of infection with the same microorganism isolated from the blood into other anatomic location. In the case of bacteremia premiums coagulase negative Staphylococcus, Micrococcus sp. Corynebacterium sp. Bacillus sp, Propionibacterium sp and other Gram negative bacteria strictly aerobic (except Acinetobacter and Pseudomonas), it required the presence of these microorganisms in at least do 8 s hemocu 1ff8 ltivos, separated with each other by a minimum of two hours in a maximum period of 48 hours. The bacteremia secondary infection was defined as that post-already documented with the same microorganism and other different anatomic location, including episodes that prove catheter-related infections. As bacteremia polimicrobiana was felt any growth of two or more different species of microorganisms in the same blood or the growth of different species into two or more blood cultures obtained in a period of 48 hours. DEFINITION OF ACINETOBACTER BAUMANNII MULTIRRESISTENTE was defined as Acinetobacter baumanni nultirresistente to that in the antibiogram presented simultaneously to all antibiotics resistance of the following groups: 1-Penicillins and aminopenicillin 2-cephalosporins 1Â meetings, 2Â meetings, 3Â th and 4Â second generation 3, Quinolones STATISTICAL ANALYSIS - The extension of stay in hospital was defined as the difference between the length of stay in the incidence of bacteremia and the duration of stay of controls. The extra costs attributable to bacteremia were defined as the difference between the total cost and cases of bacteremia and controls. The costs were calculated by adding together the daily cost of hospitalization for each patient, considering whether the stay was in the ICU of General Hospital or in the ICU Hospital Orthopedics and Rehabilitation. This was done because, predictably, the daily cost were significantly different in each ICU. The cost calculation was carried out by the Economic and Administrative Unit of the hospital. It also compared the prolonged stays and extra costs in the subgroup of couples cases of bacteremia and no cases in which both survived. The comparisons were performed separately because it was hoped that both stays as costs are affected by the death of patients. The mortality from nosocomial bacteremia was determined by subtracting the death rate of Kurdish controls the crude mortality rate of cases of bacteremia paired. The hazard ratio for mortality was determined by dividing the crude mortality rate of cases of bacteremia by that of the controls. The odds McNemar was calculated by dividing the number of couples in which only the case of bacteremia died by the number of couples in which only died control. We used the Shapiro - Wilk test to determine whether the differences in hospital stays and costs between cases of bacteremia and controls have a normal distribution, but both scenarios were discarded (p less 0.0001). Therefore, we applied the Wilcoxon rank test ( 'wilcoxon signed rank test') to test the equality and placement costs between cases of bacteremia and matched controls. To determine whether the differences in mortality rates between the cases of bacteremia and matched controls. To determine whether the differences in mortality rates between the cases of bacteremia and matched controls were applied statistically significant evidence of 2 McNemar. The confidence limits (with a 95% margin) of the rates of mortality, the risk ratios and odds ratios were calculated using the McNemar standard error approximate method from the Taylor series. Multivariate analysis of risk factors for mortality in the cohort was drawn by conditional logistic regression analysis. To check cases of bacteremia excluding those listed was used with the Mann-Whitney test for continuous variables and Chi Square test of Pearson for categorical variables. The results were analyzed using the program STATA 8.0. DISCUSSION The results of this study show that the incidence of nosocomial bacteremia is similar or falls within the limits of those found in other studies in UCIs and, as could not be otherwise, is higher than that reported in other hospital services. MORTALITY ATRIBUIBLE TO BACTERIEMIA Pitter and cabbage (Arch Intern Med 1995) described a decline in crude mortality rate from about 51% in 1981 to about 29% in 1992. However, in this study included all nosocomial bacteremia, not only those of UCIs. The studies that have specifically investigated the death rates by Kurdish bacteremia in UCIs have described Kurdish mortality rates ranging from 31.5% to 82.4%. Among the results of investigaicón Spaniards, the Multicenter Study in UCIs sponsored by the Spanish Society of Critical Care Medicine and Coronary Units (Clin Infect Dis 1997) followed up consecutive prospective 590 episodes of nosocomial bacteremia in 30 UCIs and found a mortality rate Kurdish the 41.6%, and although the group of cases is not matched with controls, describing an average duration of stay between patients bacteriémicos of 34.6 days. Rello et al (Intensive Care Med 1994) analyzed the results of 111 consecutive patients in an ICU and found a crude mortality rate of 31.5%. In this study were paired with laos cases or controls was calculated prolonged stays or extra costs attributable to bacteremia The study of Forgacs and cabbage (QJ Med 1986) analyzed the results of 15 years of ICU and found a the 60.4% mortality in patients with bacteremia and 13.1% among those who did not show up. In this study were paired with the cases or controls was calculated prolonged stays or extra costs attributable to bacteremia. Smith et al (chest 1991) studied the mortality in 34 patients with 34 controls matched bacteriémicos without bacteremia according to their probability of death according to the value of APACHE II at the time of admission to the ICU. The mortality of patients with bacteremia was 82.4% and in the not bacteriémicos of 52.9% with a mortality of 29.5% Pitter and cabbage (JAMA 1994) in a cohort study in patients UCIs carried a study of cases of bacteremia and no cases nestled in a surgical ICU patients, and found mortality to 50% among patients with bacteremia and 15% in controls, with a mortality of 35%. Soufir and cabbage (Infect Control Hosp Epidemiol 1999) in a cohort study in an ICU médico en el que se paired exposed (Case bacteremia) and unexposed (without bacteremia) in a ratio 1:2 described a mortality rate from 50% in patients with bacteremia and a 21% in the unexposed, with a mortality of 29%. Renaud et al (Am J Respir Crit Care Med 2001) in the multicenter cohort study in 15 UCIs French, which paired 96 exposed and 96 unexposed, described a mortality of 52.1% in the exposed and 16, 7% in the exposed us, with a mortality of 35.4%. The differences found in studies are attributable to many reasons. On the one hand, the different composition of the patients in the UCIS of each study and its basic diseases and therapeutic inmunodepresoras, with forecasts very different, the criteria for membership in each ICU, and the environmental risks of exposure to hazardous agents more casual, among others. However, the comparability of results of the various studies are also other factors conditional: the procedures employed for the control of bias. The design of this study has sought to control three types of biases: the selection biases, biases of information and confounding biases that threaten the validity of the studies on mortality os, longer stays and costs in nosocomial infections. Although the design and matched cohorts have been widely used for assessing 8 the efec 1ff8 cough of nosocomial infections on mortality, longer stays and increased costs, this method has been criticized for selection bias that may occur from the excluding cases of nosocomial infection by not find appropriate controls for the match. Some authors have described cases of bacteremia excluded disease base most serious cases of bacteremia included in the study, with what in theory is sobrestimaría extension of stay, costs and mortality from nosocomial infection. In this study, the percentage of cases not accounted for 13.9% of all cases of bacteremia, which falls within the range of cases excluded from similar studies conducted in UCIs, such as: Soufir and cabbage (Infecte Control Hosp . Epidemiol 1999): 9.5%. Pittet et al (JAMA 1994): 10.4% García-Garmendia and cabbage (Crit Care Med 1999): 13.8% Kappstein and cabbage (Eur J Clin Microbiol Infect Dis 1992): 40.4% Renaud et al (Am J Respir Crit Care Med 2000) do not give specific figures, but commented that "less than 10% of the data of the participants were missing values' and that precluded UCI study since the 31% of participants had missing values. Delgado and cabbage (J ClinEpidmeiol 1997) discussed the selection bias that can occur in the cohort studies matched by not found appropriate controls for certain cases and excluded from the study without an analysis of the effects that might occur. Using the analysis of convarianza (ANCOVA) in the entire cohort, from what had been nestled cohort study showed that matched cohort study overstated the prolonged stay attributable to infections. The study Delgado and cabbage is an exception. Most of the articles published on prolonged stays and mortality from nosocomial infections have not analyzed the differences between those included and excluded, or at least, have not published. Another group whose bias control is important is the biases of information. Many of the studies presented results to be compared with caution because the determination of status if bacteremia and / or other variables have great variability. This is evidenced in the definitions of bacteremia and multidrug causative agent, and even in sepsis. The accuracy or lassitude of the definitions of bacterriemia by coagulase negative Staphylococcus and other organisms that typically colonize the skin can lead to compare studies with different exposures, in a case with a large proportion of bacteremia and others with a high percentage of the contaminations hemocultivo labeled bacteremia. To avoid bias information on the status of disease in the course of this study, has followed the standard definitions according to the criteria described by the Centers for Disease Control (CDC) in the USA. The third set of biases that threatens the validity of these studies is the bias of confusion. These biases have tried monitored in the design stage, primarily through matching techniques, and in the analysis phase through multivariate analysis. Age and Sex. No conclusive data on the age and sex as independent predictors of mortality in nosocomial infections in patients admitted to UCIs However, in all the studies I have reviewed, and in other hospital studies in non-critical patients have been included both variables in the pairing of nosocomial infections with controls. Because of the seriousness of the disease as a basis for the sick entered the ICU can be the source of confusion in relations between bacteremia (and other nosocomial infections) and mortality, some researchers have tried to control in various ways. For example, Pitter and cabbage (JAMA 1994) paired cases of bacteremia with controls based on age, sex, residence prior to infection, the diagnosis of income, and the number of diagnoses at discharge. Subsequently, comparing cases of bacteremia and controls according to the distribution of prognostic patients based on the classification of McCabe and Jackson. Other studies also have used the matching number of diagnoses at discharge as a technique for controlling the severity of illness based patient, but some researchers as DiGiovine et al (Am J Respir Crit Care Med 1999), have questioned its use as test match since, according to them, bacteremia (or other nosocomial infections in critically ill patients) could influence the course of the disease and in the final number of diagnoses at discharge, and thereby confuse the relationship. However, there is no published analysis to verify or disprove this hypothesis. It has been suggested that quantitative forecasting systems such as APACHE II are better suited to monitor the severity of illness in studies that evaluate mortality attributable to nosocomial bacteremia. Smith et al (Chest 1991) and García-Garmendia and cabbage (Crit CareMed 1999) used APACHE II on the day of admission to the ICU for the matching of controls, on the other hand, Soufir and cabbage (Infect Control Hosp Epidemiol 1999) and Renaud et al (respir Am J Crit Care Med 2001) used SAPS II at the time of admission. Some researchers as DiGiovine et al (Am J Respir Crit Care Med 1999), have questioned the use of APACHE II Income patient in the ICU as a variable pairing. The argument focuses on the criticism that since bacteremia I could see many days after the date of entry, farvedad of the disease may have changed significantly during this interval. However, the use of the value of a prognostic indicator as APCHE II or another immediately before the start date of bacteremia (which was the strategy followed by these researchers), is accompanied by the possibility of another bias confusion: that the value of APACHE II at this time is influenced by the bacteremia and septic table that is starting. This sobrevaloraría the seriousness of the disease and subestimaría mortality from bacteremia. EXTRA COSTS RESULTING FROM THE EXTENSION OF STAY In this study to explore the extra costs arising from prolonged hospital stay due to all and bacteremia caused specifically by ABMR, got results as extra costs total more than 1 million euros could be attributed annually to all bacteremia, which affected some of the 4% of the population admitted to both UCIs. In the case of ABMR the results show that we can give a total extra cost of more than 600,000 euros to these bacteremia, which affects less than 1% of the population that enters both UCls. Overall, the extra costs were even higher survivor and an estimated 15,273 euros per patient for all bacteremia compared with 24,315 euros per patient for those bacteremia caused specifically by ABMR. The method of calculating costs used in this study has been the most widely used internationally published studies on UCIs [Pittet et al (JAMA 1994) and DiGiovine et al (Am J Respir Crit Care Med 1999)], but there are other options that have investigated in Spain. Diaz Molina and cabbage (Med Clin 1993) in a study on all nosocomial infections in an ICU made an estimate of costs from the fixed costs for each bed, which joined the variable costs of each patient (analytical chemist, fungible). Such approaches to the calculation of costs requires an exhaustive study of what is used specifically for each patient, and usually only used in case studies or match between the two methodologies. ACINETOBACTER BAUM 8 ANNII MU 18f5 LTIRRESISTENTE The incidence of infections caused by Acinetobcter baumannii multidrug has increased in a manner indicted in Spain in recent years, particularly among critically ill patients. A co-existing phenomenon has been the dramatic increase in resistance to multiple antibiotics in Spain during this period. Of repeatedly has been found that the use of antimicrobial therapy is a factor that predisposes the acquisition of Acinetobacter buamannii with or without the development of a new infection, and that the use of broad-spectrum antimicrobial is more common in UCIs, especially where there is not enough staff. In a study conducted by García-Garmendia and cabbage (Clin Infect Dis 2001) on the risk factors of bacteremia caused by Acinetobacter baumannii in the ICU médico in the same hospital where he has developed this study, it was found that a prior antimicrobial therapy involved an increased risk of bacteremia by Acinetobacter baumannii among these critically ill patients. Important measures such as preventive and control policies and the use of antimicrobial aseptic techniques that could reduce the incidence of these infections and mortality and associated costs, the main interest for clinical ICU. BACTERIEMIAS PRIMARY In this study, the primary bacteremia had a mortality of 19.2%, lower than the rest of bacteremia, and the estimators magnitude of the causal association (reason Risk and Odds Ratio) showed some confidence limits that approach to the value of invalidity. Some studies have described that bacteremia secondary produced higher mortality than primary bacteremia [Roberts and cabbage (Rev Infect Dis 1991) Pittet et al (Eur J Clin Micoribol Infect Dis 1993)]. Estudios previos han demostrado que las bacteriemias por Staphylococcus coagulasa negativa presentan una mortalidad atribuible más baja [artín y col (Ann Inteern Med 1989)], mientras que las producidas por Candida están asociadas a una mortalidad atribuible del 38% [Web y col (Arch Inern Med 1988)]. Ya que en este estudio predominaron las bacteriemias primarias pro Staphylococcus coagulasa negativa, los resultados apoyarían las conclusiones de estos estudios. Otra alternativa es que se hubiesen incluido falsos positivos (colonizaciones en lugar de bacteriemias), pero el criterio de incluir en el estudio únicamente bacteriemias con signos de sepssis clínica y los criterios de definición de bacteriemias por Staphylococcus coagulasa negativa, disminuye sensiblemente la posibilidad de ese sesgo de información. Otros investigadores como DiGiovine y col (Am J Respir Crit Care Med 1999) no han encontrado diferencias de mortalidad entre ambos agentes causales y sus resultados indican que las bacteriemias primarias no presentan una mortalidad atribuible estadísticamente significativa. En cambio, en el estudio de Reanaud y col (Am J Respir Crit Care Med 2001) la mortalidad atribuible a las bacteriemias primarias fue de 28,6% y la de las bacteriemias secundarias fue de 54,8%. Los resultados de este estudio permiten hacer un futuro análisis de coste-efectividad no sólo de procedimientos preventivos específicos, sino también de las distintas estrategias de los programas de prevención y control de las bacteriemias nosocomiales en pacientes ingresados en UCIs. Aún mas, facilitan información para evaluar programas dirigidos a gentes causales específicos como Acinetobacter baumannii, de efectos devastadores en estos pacientes críticos, y sin embargo, ya que su multirressitencia presenta factores causales comunes con los de muchos otros microroganismos de UCIs, los resultados de los programas preventivos podrían tener efectos multiplicadores. El estudio de la prolongación de estancias y los costes extra atribuibles a las infecciones nosocomiales aportan una información de particular interés para los gestores de los hospitales y para los responsables de la planificación asistencial. Finalmente, este trabajo facilita la iniciación de otro tipo de estudios complementarios, ya que además de los costes hospitalarios, la prolongación de estancia y la mortalidad atribuibles a las infecciones, éstas representan otros costes a la sociedad, como los dais de trabajo perdidos por los enfermos como consecuencia de la prolongación de hospitalización (en la UCI y posteriormente en otros servicios hospitalarias) y los años de vida perdidos como consecuencias de la defunción atribuible a la infección. CONCLUSIONES 1,- Las bacteriemias adquiridas por pacientes durante su estancia en Unidades de Cuidados Intensivos, constituyen un factor de riesgo de mortalidad independiente de otros factores. 2,- La mortalidad atribuible a las bacteriemias ocasionadas por Acinetobacter baumannii es mayor que la atribuible a bacteriemias causadas por otros microorganismos. 3,- Las bacteriemias primarias adquiridas entre los pacientes ingresados en Unidades de Cuidados Intensivos, constituyen un factor de riesgo de mortalidad independiente de otros factores. 4,- Las bacteriemias que los pacientes adquieren durante su estancia en Unidades de Cuidados Intensivos, ocasionan un considerable aumento de costes hospitalarios y prolongación e estancias. 5,- Las bacteriemias producida por Acinetobacter baumannii conllevan a un exceso de estancias y costes hospitalarios que supera a los de las bacteriemias causadas por otros microorganismos. 6,- Las bacteriemias primarias adquiridas durante la estancia de los pacientes en Unidades de Cuidados Intensivos, ocasionan un importante aumento de costes y prolongación de estancias. 7,- Los resultados mostraron en este estudio apoyan la necesidad de realizar un análisis coste-efectividad de las distintas estrategias de prevención y control de las bacteriemias nosocomiales en pacientes que ingresan en Unidades de Cuidados Intensivos.

Author: RODRÍGUEZ MEDINA CARMEN.
Year: 2005.
University: VALLADOLID [www.uva.es].
Place of defense: FACULTAD DE MEDICINA.
Place of preparation: FACULTAD DE MEDICINA.

Summary: Our lab focuses on the study of community treatment of the right to protection of health, taking into account its two components, which will help to structure the doctoral thesis. On the one hand, the field of so-called public health and otherwise, actions to be taken to ensure health care that every citizen can arrive at clarifying. The European Union, as has been recognized in the art. 152 TEC must strive to ensure the highest level of protection of human health, which manifests itself in that it is protected in the European territory with the same levels of quality and quantity in the country itself. As was demonstrated in our study, following several developments have emerged in recent years such as bovine spongiform encephalopathy, the dioxin crisis and more recently acute respiratory syndrome or fever chicken, the European Union has increased its powers in the field of health protection. Because although health issues have been present in the various treaties since the beginning of the construction of Europe, has been with the Treaty of Maastricht in the first place and then to Amsterdam, which have helped develop a real strategy on public health . Trying to cover in a job like ours European regulation of the right to health protection is a difficult and complex challenge because this law covers many facets and is intertwined with other rights and policies that could set a field infinite, Hence, the first task that we had to consider was to outline the topics to be developed. We started by the delimitation of the scope of action available to the European Union on the issue at hand, to turn to the Community actions in public health and in health care, emphasizing those we consider most important both for his present, as for his greatest impact. And all without forgetting Community Action Program in the field of public health (2003-2008) which today constitutes the cornerstone of the existing Community rules. Finally, we wish to put on record that we made references to cooperation with third countries and international organizations on public health, as well as the challenge posed by recent accessions carried out within the Union, since health problems presenting these countries are substantially different and often more difficult to treat than those in the rest of the Member States.

Author: SÁNCHEZ MAGRO ISABEL.
Year: 2005.
University: REY JUAN CARLOS [www.urjc.es].
Place of defense: FACULTAD DE CIENCIAS DE LA SALUD.
Place of preparation: UNIVERSIDAD DE SALMANCA.

Summary: 1 .- A cross-sectional study of pain prevailed by interviewing a sample of patients in consultations of rheumatology. Its objectives were to estimate the predominance of pain, describe the pain as the patient characteristics (gender, age, socio-cultural level, marital status, etc..), The characteristics of pain in terms of intensity, location, speed, frequency. Evaluating the quality of life of patients and their relationship to pain. The study shows that 79% of patients who come to the consultations of rheumatology suffer from chronic pain rate (more than six weeks) for chronic inflammatory arthropathy, arthritis and rheumatism estraarticular. The type of pain, a 58% of total patients suffering in the spine, a 52% in the upper extremities of the body and a 59% on the lower limbs. The pain intensity measured with the eva (virtual analogue scale) has been a 55.7%, being higher in females (57.3%), and of them, which showed greater intensity was in the range of 46-65 years (57.7%). In terms of the association with depression, work sample (by the scale of zung) that up to 41% a mild depression, 40% moderate and 15% serious. These figures translate into a 96% of people with pain have some type of depression. Data on use of different medications available from the study suggest that opioid analgesics are used only in about 3% of patients newly diagnosed. The 70% " 'dela population thinks that the degree of relief from their symptoms were found between the size buena-regular. Addition, 48% think that the treatment he receives is not enough to deal with their grief. 2 .- Study, prospective not controlled, multicenter observational of 3 months of treatment. Objectives: To evaluate the safety and effectiveness of buprenorphine given in patch transdémico in its usual conditions of use. 1223 patients participated (67.66% females) (mean age of 64 , 86 more or less 12.89), the percentage of patients with pain relief bueno-muy good on the scale categorical verbal passage of a 3.57% at baseline (n, like 1205) to a 85.82% the third month of treatment (n, like 677), this being a significant increase (p less 0001). score thermometer euroqol were statistically significantly increased (p less 0,001), from an average of 40.25 more or less 19.52 to 64.38 more or less 19.88 (No, just 655). adverse events (aa) Frequently were: nausea (11%), vomiting (9.2%), constipation (7.8% ), dizziness (7.5%), dizziness (4.0%), arcades (3.7%), pruritus (2.0%) and cefaléa (1.6%). on 6.21% of patients presented aa premises, the most frequent pruritus (1.4%), dermatistis (1.3%) and erythema (1.3%).

Author: MAYO MONTERO ELGA.
Year: 2005.
University: REY JUAN CARLOS [www.urjc.es].
Place of defense: FACULTAD DE CIENCIAS DE LA SALUD.
Place of preparation: FACULTAD DE CIENCIAS DE LA SALUD.

Summary: Introduction: influenza is a disease with a high morbidity and resulting in a high cost health, which also has an effective vaccine. Main objectives: to assess the progress and predictors of vaccination antigripal in Spain on the basis of data from national health surveys conducted in Spain in the years 1993, 1995, 1997 y2001. Methodology: A descriptive study was conducted on cross-coverage antigripal in adult subjects (over 15 years) Spaniards. Data will be used side individuallzados provided by the national health surveys in Spain (enss) for the years 1993, 1995, 1997 and 2001. Surveys for the years 1993 and 2001 include each a total of 21,120 adults and surveys of 1995 and 1997 included 6,400 adults. As a dependent variable is considered the answer (yes or no) to the question "have been vaccinated for influenza in the last campaign." As independent variables (predictors) will analyze why vaccination, perceived health status, demographic variables partner, presence of associated chronic diseases and lifestyles. Been analyzed using multivariate logistic regression models, temporal evolution of the hedge vacúnales over the period 1993-2003 and the independent effect adjusted to each of the predictive variables for receiving influenza vaccination for the total the sample for subgroups at risk. Also examine the temporal evolution in antigripal vaccination coverage in the adult population in Spain and autonomous community between the years 1993 and 2001 and the temporal evolution and the factors that are associated with vaccination in subgroups of patients with a high risk of suffer from the complications of influenza such as: diabetes and chronic respiratory illness. Results: for the total sample is estimated vaccination coverage in 1993 to 17.94% (lc 95% 17.42-18.46) and 19.30% (18.77-19.83) in 2001. In logistic regression model, adjusted for age, gender and associated chronic illness, there are significant improvements in the coverage of the group older than 64 years (or equal to 1.28 ic 95% 1.10-1.50) for the total Spain and five of the 17 autonomous communities between 1993 and 2001. However, we found no significant changes in coverage for the group under 65 years with chronic illness associated reflecting an indication for the vaccination. For the total sample of the autonomous region of Madrid, an estimated vaccination coverage in 1993 to 18.57% and 19.8% in 2001. In the multivariate model showed a significant improvement between 1993 and 2001 in the coverage group more than 65 years. However, we found no significant changes for the group of less than 65 years with clónica associated disease. Conclusions: antigripal vaccination coverage in the adult population obtained from the data 'of the self-declared national health surveys have been 18.02% (ic 95% 17.49-18.55) for the year 1993: 17 , 89 (ic 95% 16.95-18.83) for the year 1995, 17.09% (ic 95% 16.16-18.02) for the year 1997 and 19.31% (18,78-19,84 ) for the year 2001. We found significant improvements but insufficient coverage antigripales in subjects with an indication of the influenza vaccine. Improving coverage has been more important for subjects with age greater than or equal to 65 years. Subjects under that age who suffer from chronic illnesses have not improved their levels of vaccination in perrodo analyzed. Age and comorbidad are the factors that most strongly predictive constants associated with a greater likelihood of being vaccinated in Spain. Subjects also declared a healthier lifestyle as not smoking or not drinking is more likely to receive influenza vaccination. We found vaccination coverage antigripal very different between the autonomous communities in Spain. Antigripal vaccination coverage has been below the desired levels among adults Spaniards with diabetes mellltus or respiratory diseases cr 8 ónicas. 721 after controlling confounding variables we have not found improvements estadlsticamente significant coverage of vaccine against influenza in diabetics and Spanish subjects with diseases. Repiratorias chronic between 1993 and 2001. Between 1993 and 2001, there are no significant changes in coverage or vaccine antigripales totals according to belong to groups at risk in adults residing in the autonomous region of Madrid. The use of combined strategies proven to improve the use of the influenza vaccine, aimed at both patients and health personnel as health education, the memories, increased accessibility to the vaccine or capacitac-lón of health personnel can to be very useful to improve vaccination coverage in groups where levels achieved are not appropriate. The lack of effectiveness to improve coverage in high-risk groups under the age of 64 years could make considering the option of lowering the age limit of the current recommendations for the indication of influenza vaccine in spain.

Author: MARTIN CANTERA CARLOS.
Year: 2005.
University: AUTÓNOMA DE BARCELONA [www.uab.es].
Place of defense: FACULTAT DE MEDICINA. UNITAT DOCENT VALL HEBRO.
Place of preparation: CENTRO ATENCIÓN PRIMARIA PASSEIG DE SANT JOAN.

Summary: Introduction: Traffic Accidents (TA) is an important health problem by mortality, morbidity and disability originate. There are three groups most at risk. Population 15-24 years users of motorcycles, people of 18-34 years occupants of cars at the roadside and pedestrians increased 65 years in urban areas. As part of preventive activities and as a key element of labor delos professionals Primary Care (PA) is health education in lifestyles or behavior that directly affect the health status. For the prevention of the TA is important health education and is responsible for health professionals (PS) providing advice on preventive road safety. Objectives and Assumptions: 1. To determine the level of knowledge and attitudes of professional advice on the PA preventive AT concerning: Epidemiology (data incidence and / or prevalence), the most common injuries resulting from the AT, using measures of active and passive safety to recommend the population, consumption of alcoholic beverages, use of medicines and other hazardous substances in the driving-related diseases and the ability to drive. 2. To determine the facitibilidad council on preventive road safety from the PA in terms a. The degree of responsibility of each PS (general practitioners, pediatricians and nurses), facilitators and elements barrier. Assumptions: 1. The level of knowledge on the prevention of TA is insufficient for a council preventive. 2. The level of knowledge and attitude on road safety of the profession (doctor or nurse), experience in emergency services and personal experience in AT. 3. Professionals AP considered unlikely the council preventive TA for lack of time. Method: Design. This was done through a combination of quantitative and qualitative methodology. The study is descriptive quantitative and qualitative cross through the technique of focus groups. The period for conducting both studies was October 2000 to March 2001. Scope: Primary Care Centers of the city of Barcelona. Subjects of study, doctors (pediatricians and general) and nurses AP in Barcelona city. Measuring instruments: Survey autoadministrada knowledge and attitudes about road safety council preventive and analysis of focus groups. Variables. According to the two tools will work, age, sex, marital status, number of children, occupation, place of work, graph knowledge about preventive advice, degree of responsibility, facilitators and barrier elements (time, incentives and motivation, and level self-confidence). Results. Quantitative Study. Response Rate to cuesetionario of 54.8% (187/341). Responses 74.6% female and 25.4% male, mean age 41.3 years (8.3), range 23-64 [95% CI 40,1-42,5] years. They carried an average of 11.6 years (of 7.6), range 1-43 years of practice [95% CI 10,5-11,7]. Declare have had personal experience or family related to any AT the 59.9% [95% CI 52,9-66,9]. The primary endpoint (puntiación of total test) showed an average of 11.3 (95% CI 10.9-11.7). The total score of the test was related in a manner inversely with age and statistically significant (r = -0344, r2 = 0118, p higher 0001) and years of experience (r = -0194, r2 = 0038, p = 0009). Overcoming the knowledge test was related to the medical profession (OR 3.7 95% 1,5-9), age group until 45 years (OR 3.1, 95% CI 1.3-7.6) and be driver (OR 2.9, 95% CI 1.04-8.3). Estuio qualitative. We 4 group interviews (focus groups), 3 segmented by type of health professional, and the fourth involving all professionals. The AT perceived as a serious problem, but not priorita 8 river. It 8b3 identifies a significant lack of coordinated efforts to reduce the AT from various fields. The degree of sensibilidzación of PS to the TA is variable depending on whether they worked in an emergency department, which have had direct experiences with AT or having children. The main barriers to the viability of their application are: lack of time, training, information about the effectiveness of preventive interventions, lack of resources and motivation related to the ignorance of the effectiveness of these boards. Among the elements that could facilitate the implementation of this program: to have information on interventions implemented, help manuals, support materials in consultation, awareness among professionals PA prior to the start of program implementation and coordination of efforts with other areas to strengthen this program. Conclusions. 1. Health professionals have an AP intermediate level of knowledge, which requires educational activities. 2. The PS believe the council preventive TA is an important activity, but not a priority. 3. The main barriers to implementing the council preventive detected by the AP professionals are: lack of time, lack of material resources (education and support), poor training and low motivation. 4. The elements that provide advice on preventive AT are: Information on effectiveness of the intervention, supporting material in consultations, awareness campaigns and increased time for this function. 5. Health professionals need to believe by the administration health and scientific societies, are engaged awareness among PS and coordination with other stakeholders involved.

Author: SANCHIS CIENFUEGOS JOVELLANOS RICARDO.
Year: 2005.
University: OVIEDO [www.uniovi.es].
Place of defense: FACULTAD DE MEDICINA DE LA UNIVERSIDAD DE OVIEDO.
Place of preparation: FACULTAD DE MEDICINA DE LA UNIVERSIDAD DE OVIEDO.

Summary: OBJECTIVE AND RATIONALE The overall objectives of the study were aware of the prevalence of dementia in the population aged 65 and over living in the city of Oviedo and determine the cost of the patient's condition insane. In addition, to determine the most significant components in the cost of dementia. METHODS We conducted a cross-sectional descriptive epidemiological study on a sample of people aged 65 and over. The study cost of the disease was made by comparison of two populations of the same features, a people without dementia and another for people with dementia. Through an interview guided by a questionnaire consisting of two parties select subjects with suspected dementia and information was collected on the use of health care resources and not health. In a second phase is the confirmation of clinical diagnosis of Dementia in people who have low levels of test scores Mini Mental State Examination of Folstein, in the last general questionnaire and the evaluation of the entire population to study, assigning a cost to resource consumption recorded in the questionnaires. RESULTS The sample consisted of 763 people, with an average age of 75.08 years, 50.98 women and 49.02 men. The prevalence of dementia has been obtained from 7.47%. The prevalence increases with age, and passes a rate of 2.05% in the group of 65 to 69 years, a 21.14% in the group of patients older than 85 years. Dementia-type alzheimer has been the predominant, with a 73.68% of the cases, followed by vascular with 14%. Only 2.1% of the sample of people living in an institution. The use of informal caregiver is 82.5% in the group with dementia and 28.6 in the non-dementia, with an average of hours of care weekly 35.5 and 3.85 pm in each group. The average annual cost per person with dementia was 22,062 euros delos that correspond to the 68.1% and 31.9% indirect costs to the direct costs direct and indirect costs were respectively 3.4 and 10.6 times higher than the group for people without dementia. The estimated annual cost of the test scores according MMSE was greater 18 11,778 euros from 12 to 18 22,407 euros and lower 12 38,808 euros. CONCLUSIONS Insanity is confirmed as a disease with high health and social costs. It involves some 375 million euros in all Asturias. There is a clear relationship between the disease with age. There is a relationship of the seriousness with increased costs. Indirect costs are the most important part of the same due to these informal caregivers.

Author: IGLESIAS SANMARTIN JOSE MANUEL.
Year: 2005.
University: OVIEDO [www.uniovi.es].
Place of defense: EDIFICIO SANTIAGO GASCON.
Place of preparation: FACULTAD DE MEDICINA DE LA UNIVERSIDAD DE OVIEDO.

Summary: Summary: Edit multiple risk behavior is a promising approach to reduce the risk of cancer. The Councils primary prevention of the European Code Against Cancer were included in an educational intervention (EI) used theories cognitivo-sociales to motivate families with experience of cancer, in order to take six acts of cancer prevention. Method. We conducted a randomized controlled trial that enrolled 3,031 patients in primary care, including relatives of cancer patients. The intervention group (GI) received four IE, once every six months, on snuff, alcohol, diet, weight, sun and work based on models cognitivo- social. The impact of EI was calculated by measuring at the beginning and after 18 months of follow-up: a) The percentage of people with each risk behavior, b) scores achieved in the indicator Behavioral Risk Total (RCT), c) " Odds Ratio "in the post-test. Results. Five risk behaviors decreased significantly more

Author: MARTINEZ CIFUENTES SILVIA.
Year: 2005.
University: AUTÓNOMA DE MADRID [www.uam.es].
Place of defense: FACULTAD DE MEDICINA.
Place of preparation: FACULTAD DE MEDICINA.

Summary: BACKGROUND AND OBJECTIVES OF THE ISSUE patients with acute myocardial infarction have a high risk of cardiovascular and other events, but the evidence suggests that the modification of cardiovascular risk factors could achieve significant reductions in coronary disease recurring and the mortality in these patients, follow-up studies in the long term have shown that a high percentage of patients maintaining these factors after an acute cardiac event, and it is not known the extent of monitoring and controlling them. Similarly, which is also not known whether there is a patient profile that identifies who performs an inadequate monitoring and control of their cardiovascular risk factors. Nor is known about the incidence of long-term cardiovascular events after acute myocardial infarction and whether it is related to the control of different risk factors. The situation was described which led us to initiate this investigation from a record population of patients with acute myocardial infarction in the province of Albacete, in order to obtain information on tertiary prevention of cardiovascular disease and the evolution of these patients in the long run, posing targets appropriate and relevant. DEVELOPMENT OF WORK AND METHODOLOGY We designed a prospective cohort study in which they followed 655 patients with acute myocardial infarction who survived the 28-day event. The cases are collected from registration IBERICA Albacete from September 1, 1997 to January 1, 2001, tracking between January 1, 2004 and June 1, 2005. To see the evolution of the patients, initially reviewed the databases of public health centers in the province of Albacete (hospitals and specialty centers), which experienced cardiovascular events occurred as some diagnostic previously established (the codes CIE_9Â th edition). And then, we contacted patients, relatives or family doctors to ascertain vital status, degree of monitoring and control of cardiovascular risk factors (high cholesterol, hypertension, diabetes mellitus, obesity, and smoking), educational attainment, employment status at the time of acute myocardial infarction and in the monitoring, and if there was return to work, according to an informal survey conducted through a telephone or personal interview. Statistical analysis was used descriptive and comparative bivariate and multivariate appropriate to the goals. RESULTS During the study period, 59 patients unable to obtain complete information on cardiovascular risk factors or cardiovascular events (9%). The prevalence of cardiovascular risk factors was high at the time of the stroke, increasing during follow-up, being cholesterol and hypertension factors more prevalent at the end of follow-up (72%). Moreover, the prevalence of diabetes mellitus and obesity was 36% and smoking of 13% (33% of smokers in acute myocardial infarction were still smoking). The 69% of patients were on a proper monitoring of cardiovascular risk factors, while only 54% get adequate control. The profile of patients who performed an inadequate monitoring the patient would be young, unemployed graduates with, smoker, obese and without hypertension, while the profile of patients who maintains an inadequate control of their cardiovascular risk factors would be, the patient smoker , diabetic and unemployed. Of the 638 patients with information about the events cardiovasculare 8 s on 47, 6e1 5% had any cardiac event being the most frequent angina, and the vascular acute stroke. The presence of these cardiovascular events was related to inadequate control of cardiovascular risk factors, mostly with diabetes mellitus and hypertension. The overall mortality was 17% and was related to inadequate control of cardiovascular risk factors. So, hypertension and diabetes mellitus uncontrolled posed an increased risk of death from any cause, and even more on cardiovascular mortality. CONTRIBUTIONS FROM NATURE GENERIC OR PILOT This paper provides valuable information to advance the effectiveness of tertiary prevention of cardiovascular disease and long-term treatment in patients with acute myocardial infarction, not just for the clinician that handles this kind of sick, but for other health institutions larger, and thereby achieve a better health care and adequacy of the resources available for such patients.

Author: SAZ PARKINSON ZULEIKA.
Year: 2005.
University: COMPLUTENSE DE MADRID [www.ucm.es].
Place of defense: MEDICINA.
Place of preparation: FACULTAD DE MEDICINAS.

Summary: The perinatal screening is practiced for years to detect those disorders that have an effective treatment. The possibilities of prevention open these screening programs were expanded today with the introduction of genetic testing. To determine the economic viability of a genetic screening is necessary to know, among others, the costs of carrying out such screening as the treatment of diseases or disorders that it is intended to prevent. Moreover, it is necessary to know the prevalence of the disease in question and the illnesses it causes. To design a generic model that incorporates variables determinants, it is advisable to select a prototype known genetic disease on which to design a model for assessing specific costs which then can be applied to other pathologies. The disease is the elected hereditary Hemochromatosis, an autosomal recessive disease is among the most common inherited metabolic abnormalities and characterized by an abnormal intestinal absorption of iron leads to a progressive increase in the total iron stored, and ultimately to clinical complications. After selecting a center of study, analyzed the medical histories of patients referred to the Center between 1999-2003 to detect mutations prevalent in the HH (C282Y and H63D), and to determine the penetration of the disease in Spain and perform economic study of genetic screening. The main conclusions are: The elevation of biochemical parameters studied does not necessarily mean mutations in the HFE gene, or vice versa, is critical to know the exact origin of the sample populations to determine the penetrance of a pathology, the penetrance real HH between population Spanish is much weaker than initially estimated, the neonatal screening HH in Spain is not economically relevant as a preventive measure in Public Health. KEYWORDS Analysis of costs, health policy, health technology assessment.

Author: BRAVO PORTELA MARIA JOSÉ.
Year: 2005.
University: COMPLUTENSE DE MADRID [www.ucm.es].
Place of defense: FACULTAD DE MEDICINA.
Place of preparation: FACULTAD DE MEDICINA - UNIVERSIDAD COMPLUTENSE DE MADRID.

Summary: OBJECTIVE Knowing practices risk for HIV transmission and prevalence of the virus in heroin users in Spain and evaluate a historical perspective health policy to control the epidemic of infection in this population, with special attention to the use of injecting . METHODOLOGY Cross-sectional studies of prevalence. Review of public health policies. CONCLUSIONS In 1994-95 confirmed the persistence of high HIV prevalence and risk behaviors for transmission injectors in Madrid, Seville and Valencia. In 1994-96, the differential evolution of risk-taking behavior among HIV-positive and HIV negative with potential adverse consequences for health. In 1998-2000, the existence of higher prevalences of sharing injection equipment indirectly to injection syringes used outside in the cities identified and Galicia. In this context the reasons for choosing the path of consumption in Madrid, Barcelona and Sevilla were influenced by the context or social pressure (injected, smoked or esnifada), the efficiency of the route (injected), concern about the health consequences (smoked or esnifada) and the fear of blood (injected), consumers did not perceive the reasons for availability of the type of substance. The prevalence of HIV and risky behavior varies as deemed in heroin users or only injections. Among the main factors that contributed to the evolution of HIV infection in Spain highlighted the early introduction of HIV into networks injectors with high risk behavior and the delay in making public health decisions. In fact, the territorial differences in the evolution of the prevalence of HIV infection in Barcelona, Madrid and Seville among young injectors from 1995 until 2003 could be explained by differences in the implementation of preventive policies among different regions.

Author: PAUL GARASA MARIA PILAR.
Year: 2005.
University: ZARAGOZA [www.unizar.es].
Place of defense: FACULTAD DE MEDICINA.
Place of preparation: FACULTAD DE MEDICINA.

Summary: It was part of the development of a methodology for assessing working conditions for jobs guards, auxiliaresde nursing and caretakers of a tertiary hospital. With the participation of almost 1000 employees and 93 working groups participadospor 638 workers, and with the supervision of 60 middle management, provides an assessment of the risks they are exposed ergonomic alos these workers in the performance of their duties in a hospital. The risk factors are consideranson: training, accountability, personal relationships, physical load and mental burden. The manual assessment puestosidentifica 88 posts nurse, 93, auxiliary nurses and 27 of warder. All of them graduate in three levels of risk (low, medium and high) in each of the risk factors are considered. Assumes that the conditions detrabajo are a risk factor for accidents, so that the higher the level of risk will increase the number of accidentes.El study is carried out in the University Hospital Miguel Servet in Zaragoza and has a retrospective registered losaccidentes occurred during the years 2001, 2002 and 2003. The study has considered accidents which have estadoimplicados risk factors that are within the area of jurisdiction of the specialty of ergonomics and psicosociología applied (23% of accidents), as specialty risk prevention work within the Prevention Service delreferidohospital. The accidents included in the study have been called accidents for cargo física.Los risk factors implicated as a cause of this type of accident, have been mobilizing sick, manipulaciónmanual loads, sobreesfuerzos, positions forzadss, Repetitive and desplazamientos.En total sample of accidents is 198 cases: 98 of warder, 74, auxiliary nurses and 26 of enfermera.El study design has been Caso-Control 1:1, where each case is defined by the because of the level of risk in which produceel accident by physical burden, in each one of the risk factors. The controls were selected randomly entreaquellos posts where there has been no accident. Treatment estadísitico is a univariate analysis (mean, incidence rates and densities) and a multivariate analysis (X2, using Fisher's exact test in the case of variablesbinarias and ODDS RATIO). The results show that 2 out of 3 accidents warders are loads of physics, 1 out of 3 in auxiliary deenfermería and that the nursing staff is the second leading cause of accident. Nearly 10% of Celadores, 7% deauxiliares and only 1% of nurses suffers an accident burden fisicaEl main risk factor involved in these accidents is the Manual Handling Charges (MMC) and the Mobilization deEnfermos (ME). The latter especially nurses and nursing assistants. The tasks of risk in the ME sonla attention to encamados, transfers and transfers (the latter warders). At the hospital 1 out of 5 accidents is porMMC or ME. A ODDS RATIO significantly to 95% shows that are risk factors for the accident by physical load, the following: 1) The risk factor burden physical nursing assistant positions. The 52.7% of the accidents occur in unnivel high load physical yen concrete in 9 of these posts, the main risk because of the Neurology Service, dondelos patients have a high dependency. 2) The risk factor burden physical positions warder. The 73.47% of accidentesocurren in the high risk factor burden physics. Specifically the 77.55% of accidents are concentrated in 8 posts, mainly health care. 3) Factor training and accountability are prognostic factor of accidents per load fisicaen celad 8 or, hech 6c9 or explain to the hearing that these posts were not required technical qualifications to access them ypor other hand there is a definition the skills required of him to the employee, who can guarantee unaprevención risk in the case of workers especially sensibles.En nurses have not been identified prognostic factors of risk of accident by physical burden, perhaps because alescaso sample size or the working conditions are not riesgo.Consideramos need to include the human factor as a risk factor of accident to explain those cases where no haycondiciones working risk unsafe behavior, lack of training, no-risk perception or missing motivational sonfactores risk. The attitudes of workers from prevention require intervention from a culturapreventiva in the organization, ensuring information and training of workers, their participation in the evaluation deriesgos and his involvement in preventive measures to take.

Author: HEREDERO GALVEZ EVA.
Year: 2005.
University: AUTÓNOMA DE MADRID [www.uam.es].
Place of defense: FACULTAD DE MEDICINA - UNVIERSIDAD AUTÓNOMA DE MADRID.
Place of preparation: AUTONOMA DE MADRID.

Summary: The overall objective was to assess the effect that the introduction of the nutrition unit is in the clinical course of patients and their complications. Specific objectives were to know the frequency of nosocomial infection, mortality and length of days in a cohort of patients with parenteral nutrition prior to the introduction of the nutrition unit regarding a cohort of patients with parenteral nutrition after nutrition that unit at the university hospital in Albacete. This is a cohort study with dual temporality: retrospective from January 1, 1998 until March 1, 2000 and prospectively from March 1, 2000 until December 31, 2002 for patients undergoing parenteral nutrition. The information is collected from the patient's medical history through a sheet of gathering information produced by themselves. The variables included were grouped into 4 sections: patient demographic data, those relating to revenue, related to parenteral nutrition and biochemical parameters.

Author: Folch Garcia Jose.
Year: 2006.
University: VALENCIA [www.uv.es].
Place of defense: Facultad de Medicina.
Place of preparation: Facultad de Farmacia.

Summary: It has been studied a sample of 600 workers (300 hombres/300 women), to determine the prevalence of cardiovascular risk factors: environmental, anthropometric variables, variable clinical and biochemical variables of lifestyle, and genetic polymorphisms . So it wanted the association between the different variables. This healthy working population has found a high prevalence of major intermediate phenotypes. Thus, the prevalence of hypertension, the hiperlipemias of atherogenic profile has been generally high and higher in the group of men than for women. Even with high prevalence, has also been very different for men and women, the prevalence of obesity and overweight. It has found a high prevalence of use of snuff in both sexes. Physical activity performed by the sample studied was low. Alcohol consumption was elevated in men (92%) and lowest among women (57%). Food consumption also presented some evidence of different pattern in men and women consuming their food healthier. Analysis of genetic polymorphisms in candidate genes studied showed a significant genetic contribution as a determinant of phenotypes analyzed. Thus, the APOE polymorphism was associated significantly with the concentration of LDL-C for both men and women. The genomes of the LPL two polymorphisms were analyzed, the LPL HindIII, and LPL Ser447Stop Both have been found in high imbalance of positive linkage, introducing more frequent allelic the H + allele. The minority have been associated with lower concentrations of triglycerides and higher concentrations of HDL-C. For variability in the concentrations of HDL-C, has been identified polymorphism CETP-Taq1B, contributing to a 5.7%, well above the estimated value for other environmental variables such as alcohol, the level of education and consumption of snuff that was followed in magnitude. The gene polymorphism SstI in the APOC3 had a minor impact on the concentrations of HDL-C and triglycerides perhaps due to the lower prevalence of the variant gene S2. Finally, the analysis of statistical interactions between genetic and environmental variables has enabled us to identify several of these interactions determine plasma concentrations of lipids. So we have identified a gene * environment interactions between APOE genotype and alcohol consumption determining concentrations of LDL-C; * gene environment interaction between APOE genotype and physical exercise by determining the concentrations of HDL-C, as well as a interaction gen-gen-ambiente among genotypes of the LPL, the APOE and consumption of snuff determining the concentrations of HDL-C. These results not only reflect the importance of the genetic variants as predictors of cardiovascular phenotypes, but also the modulation of these environmental effects and the consequent need to have this genetic information to make a more personalized cardiovascular prevention.

Author: LANZAS PRIETO JOSE MANUEL.
Year: 2006.
University: OVIEDO [www.uniovi.es].
Place of defense: CLINICA UNIVERSITARIA DE ODONTOLOGIA.
Place of preparation: UNIVERSIDAD DE OVIEDO.

Summary: Bladder cancer is the fourth most common tumor in men in developed countries and the tenth in women from the countries of southern Europe. In the United States and Europe, more than 90% of bladder tumors are derived from cells uroteliales. The 70-80% of carcinomas cells uroteliales are superficial at the time of diagnosis. From a clinical point of view bladder tumors can be classified into superficial and deep or infiltrantes. The superficial bladder tumors represent a heterogeneous group of tumors including those of papillary and nature limited to the mucosa (Ta of TNM classification of 2,002), those of high and confined to the epithelium (TIS), and those who invade lamina propria (T1). Transitional cell carcinoma (CST) bladder stadium T1 and grade 3, represents a 6-23% for superficial tumors. It is a tumor that affects the lamina propria, which is rich in lymphatic vessels and vascular injuries. Therefore, despite what some still classified as "superficial tumor, it can be considered a potentially invasive and metastatic tumor. Current treatment of VP of stadium T1 and grade 3 is a challenge for urólogos for his unpredictable natural history and the implications of sobretratamiento and infratratamiento. In the case of tumors T1G3 have studied changes in cell cycle proteins, especially proteins in cell proliferation and proteins involved in cell cycle progression from the phase G1 to phase S. The protein p21 was one of the first inhibitors of Cdks (Ciclin-Dependent Kinases) or CKIs (Cyclin-dependent kinase inhibitors) described. It is encoded by the gene WAF1 (wild-type p53-activated fragment 1), which is located on chromosome 6p21.2. The gene p21 is a major target of p53, which in response to DNA damage, resulting in the deletion of growth in stopping the cell cycle checkpoint G1, repairing DNA or leading to the cell apoptosis. The p21 is also involved in the processes of cell differentiation terminal, both in normal cells of the tumor as well as in the processes of cellular senescence. In this paper we built a TMA (tissue microarray), which represented 102 cases of a number of carcinomas of the urothelium bladder T1G3 collected prospectively and have made an assessment immunohistochemistry of the protein p21. Our objective was to assess the predictive ability of the protein p21 in tumor T1G3 in relation to the period of tumor recurrence, tumor progression and survival. He also studied the relationship of p21 with other known risk factors such as smoking tumors, the number of tumors and tumor size. We found an overexpression of p21 in 60.78% of cases. However, we found no relationship between the expression of p21 with any of the biological factors or clinical chosen. We demonstrate that tumors expressing p21 recur, progressing to a lesser number and later. But our study did not demonstrate that the expression of p21 influence mortality from bladder cancer.

Author: GUTIERREZ CIA ISABEL.
Year: 2006.
University: ZARAGOZA [www.unizar.es].
Place of defense: FACULTAD DE MEDICINA.
Place of preparation: FACULTAD DE MEDICINA.

Summary: Objectives: To identify the incidence of adverse events in a second-tier ICU. Knowing the influence that adverse effects (EA) have on the activity hospital care in the ICU. Analyzing the EA. Analyzing the impact that these have EA on the patient and unity. To analyze the possibilities for prevention Materials and methods: Prospective Cohort Study, conducted in an intensive care unit (ICU) of a second-tier hospital. It followed the methodology of the IDEA project, reviewing the medical records of patients admitted to the ICU Hospital Bishop Polanco over the year 2004. We used a screening questionnaire for the selection of patients at risk of side effects and a second questionnaire (MRF2) to describe the side effects and characteristics of the patients who presented. Results: We reviewed 416 stories of which 239 were selected by the guide screening. Of these 120 presented EA which provides the guide screening in our study a positive predictive value of 50%. The incidence of AD was 29%. Of the 120 patients who had EA in 47 cases the cause of her admission to the ICU (11.3%). The problems most often caused EA were related to the procedure (42%). The 36.5% were considered preventable. They were responsible for 22.5% of stays in the ICU. It related to the cause of death of 6% of patients. Conclusions: This study is a first approach to the problem of EA in the intensive care units of our country. While it is subject to certain limitations and biases highlights the importance of the EA and raises the need for new studies to know what impact that has on EA critically ill patients. The Spanish and European scientific societies aware of the seriousness and magnitude of the problem have begun multicentre studies devoted to the analysis of sentinel events. The SEMICYUC considers the registration of EA as one of the most important indicators of quality for our units. Multicenter studies are needed that include units of different sizes and characteristics and work using different data sources. The complexity of the problem requires that we aproximemos it from different perspectives. Using survey techniques individualized sentinel events and the most common EA by analyzing the root causes will help raise awareness and prevent the likelihood of EA. The incidence of AD in the year 2004 among critically ill patients was 29%. The incidence of AD as a cause of admission to the ICU was 11.3%. The incidence of AD during the ICU stay was 17.7%. Conducting epidemiological studies conducted to assess the incidence of AD in services and units can contribute to awareness among professionals and enhance their involvement in actions aimed at preventing problems that most often lead to EA are those relating to procedures ( involved in 42% of EA) and the use of medications (29.6%). The related procedures are not only more frequent but also more severe. Factors that have demonstrated their influence in the emergence of EA have been gravity, the risk factors extrinsic, the prolonged stay and readmission. Other factors that have shown their influence on the occurrence of EA are those relating to the training and motivation of workers in the ICU, the adequacy of equipment and factors relating to the organization, both in the service and the hospital. The EA is a particularly serious problem in the units of critics. They have great impact on the patient who suffers sometimes the deterioration of his health (59.3% of the EA were considered serious and in 6% of critically ill patients the cause of death is related to an EA), and almost always the need for new treatments and procedim 8 ientos q 941 ue They also could have been avoided a major economic problem for the increase of stay involved. They were responsible for 22.5% of stays in the ICU. If we avoid the EA on which it was felt that the possibility of prevention was high avoiding the 8% of placements. We identified a 36.5% EA avoidable. There is a need to raise awareness of both the problem and its potential for prevention, and that to avoid the EA requires the collaboration of all those involved in the process of critical patient care. We must preach responsibility for the guilt and introduce analysis of the EA and planning solutions as part of the work of the Critical units. The EA causing the patient's admission to the ICU are responsible for 10% of stays in the ICU, are serious, they relate to any proceedings in more than half the cases and in a very important impact on the patient's health. Despite this prognosis end of these patients was not worse than that of patients admitted to the ICU for his own pathology. It is possible that the proper handling of these situations contributes to mitigating their consequences. The guide screening is an effective tool for detecting EA ICU. The scales of gravity could be helpful in identifying patients at high risk for AD, but does not appear to be a good substitute for the road map. But always be a group of patients who do not have any screening test positive or are particularly severe. These will only be possible to detect EA through other techniques such as observation, monitoring clinic or voluntary statement.

Author: GONZALEZ GARCIA MARIA ESTHER.
Year: 2006.
University: OVIEDO [www.uniovi.es].
Place of defense: EDIFICIO SANTIAGO GASCON.
Place of preparation: UNIVERSIDAD DE OVIEDO.

Summary: For twelve years and two months, from January 1992 to February 2004, had been diagnosed 836 gammapatías belonging to the Health Area V of Asturias, covering a population of 300.000/habitantes. It was classified by diagnosis and follow-up in a computer file in the program Velasquez. These data were conducted an epidemiological study to describe the impact on the Area Health different gammapatías, separating the GM IgG, IgA IgM (including Disease Waldenstrà ¶ m), IgD and light chains of gammapatías of undetermined significance. We studied on the one hand the characteristics clínico-biológicas associated diagnostic and evolution of total GM, in order to determine the socio-demographic factors, clinical, analytical and pathologies associated with gammapatías monoclonal. Moreover attempted know the survival and mortality of different subgroups. With all the data has tried to develop a strategy for monitoring monoclonal a component in our area, knowing the gammapatías which evolves gammapatías malignant (GM, EW) and gammapatías disappearing along with the factors associated with them.

Author: TABOADA BLANCO YOLANDA.
Year: 2006.
University: A CORUÑA [www.udc.es].
Place of defense: FACULTAD DE CIENCIAS DE LA SALUD.
Place of preparation: FACULTAD DE CIENCIAS DE LA SALUD.

Summary: Objectives To determine the prevalence of peripheral arterial disease and cardiovascular risk in diabetic patients. MATERIALS AND METHODS SCOPE Health Center Cambre (A Coruna) PERIOD 2005 STUDY Prevalence criteria including patients with type 2 diabetes mellitus. Size shows n seventh 339 patients (Security 95%, accuracy +-2.94%), measurements age, sex, weight, height, BMI, analytical, blood pressure, creatinine clearance, smoking, ischemic heart disease, diabetic retinopathy, hypertrophy left ventrículo and index ankle / arm. QUANTIFICATION OF CARDIOVASCULAR RISK AS UKPDS, Framinghan, score, Regicar, Dorica. Statistical Analysis: aggression logistics analysis to determine variables associated with artery. Calculation of the sensitivity, specificity, production values and likelihood ratios, to study the values of claudication and mathematical models to predict arteropatía. RESULTS The highest prevalence of cardiovascular risk factors corresponds to ETS (59.9%) and hipercolesterdema (52.2%). The prevalence of aretriopatia peripheral (index ankle / brachial smaller 0.9) is of 29.2%. The symptom of intermittent claudication is 9.2%. The predictive variables of artery patía are age (OR = 1.15) and being exfumador (OR = 3.86) The sensitivity of capitulation to predict severe arteriopathy is 78.6% 49.4% of the patient have a high cardiovascular risk. CONCLUSIONS There is a high prevalence of modifiable risk factors. The age and to be exfumador predict probability artery. The sensitivity of clarification to predict arteriopathy and the ratio of probability increases with increasing severity of arteriopathy.

Author: ALVAREZ ALVAREZ MARIA BELEN.
Year: 2006.
University: OVIEDO [www.uniovi.es].
Place of defense: SEMI. DE BIOQUI. EDIF. SANTIAGO GASCON.
Place of preparation: UNIVERSIDAD DE OVIEDO.

Summary: Justification and assumptions: The current population increasingly demand better health and greater urgency as exponent of a position of greater social welfare, and emergency department hospital's main gateway to the health care system. Therefore, these services are currently of great interest to society and also the subject of numerous studies. The hypothesis that arises here is that there is a differential use of the emergency services in addition to health problems, other determinants that affect the perceived need for care, as an essential factor in the decision to seek care there. Objectives: The objective was to analyze the factors associated with the use of hospital emergency department Hospital Cabueñes by patients in the period between January 1, 2002 and November 30 of 2004.Y, the specific objectives , to study the demographic and health data of the users and meet the determinants of health status as a condition of the use of the service. Methods: We designed a study casos-controles matched and stratified by age and sex on a prospective basis. Through an interview directly, a questionnaire was used only for cases and controls. The number of people surveyed was 2,082: 1,041 cases and 1,041 controls. The variables included in the study were variable specific to the survey, demographic variables (age, sex, marital status, nationality), health variables (health coverage, use of health services), and variables related to the health status ( socioeconomic status, self-perception of health status, consumption of drugs, limited functional ability, mental state of the individual, and social and family situation). A descriptive study was conducted of all the variables, and to examine what factors were associated significantly to the use of the emergency department, it conducted a logistic regression analysis. Results: The average age of the cases surveyed was 60.75 years, we found a male in the median ages of life and female from 75 years. Most of those interviewed were married or had a partner. The likelihood of a foreigner was three times higher in those cases. The employment situation was further found retirement. Come previously in the past year to the emergency department reduced the risk of going back to service, and have a household income prior to a hospital in the past six months increased the risk. The middle class had a risk 1.3 times higher than go to the lower class. The social isolation increasing the risk, the existence of support from the social network decreased risk, live alone or part of the family environment increased 1.3 times the risk of going to emergencies and families functional decreased risk. Anxiety decreased the risk of going, and depression is increasing. The consumption of drugs increased the risk of going into 1243 times for each drug consumed. Conclusions: There is an increase in visits to the hospital emergency department, more than half of the patients treated at the service aged 65 and over. The condition of loneliness has become an aggravating factor of use. The immigrant population is more likely to go to the hospital emergency department. It is a different service use among different social classes. The polypharmacy found in this study, is directly related to the likelihood of service use. The family living in or within entrono family, the existence of a good social support, and functionality family diminished the risk of going to hospital emergency department. Keywords: Using emergency services, Determinants soc 8 ioeconóm 2b7 icos, Immigration, Social support.